Reflex Symptoms without Aural 
Disease. 
A w'al Disease Exciting Reflex Symptoms. 
BY 
C. J. BLAKE, M. D., 
Instrzictor in Diseases of the Ear, Harvard Medical School; Aural Surgeon to the 
Massachusetts Charitable Eye and Ear Infirmary; 
AND 
T. M. ROTCH, M. D., 
Instructor in Diseases of Children, Harvard Medical School; Physician to the 
Boston Dispensary. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES 
Octoiser, 1886. Extracted from the 
American Journal of the Medical Sciences for October, 1886. 
REFLEX AURAL SYMPTOMS WITHOUT AURAL DISEASE. 
AURAL DISEASE EXCITING REFLEX SYMPTOMS. 
By C. J. Blake, M.D.? 
INSTRUCTOR IN DISEASES OF THE EAR, HARVARD MEDICAL SCHOOL; AURAL SURGEON TO THE 
MASSACHUSETTS CHARITABLE EYE AND EAR INFIRMARY ; 
AND 
T. M. Rotch, M.D., 
INSTRUCTOR IN DISEASES OF CHILDREN, HARVARD MEDICAL SCHOOL ; PHYSICIAN TO THE 
BOSTON DISPENSARY. 
In the Annales des Maladies de V Oreille du Larynx et des Organes 
Connexes, September, 1884, an article appeared, entitled “ Aural Symp- 
toms occurring in Hysteria, and the Hysterical Element in Aural Dis- 
ease.” Two cases were reported : one of aural symptoms simulating 
inflammation of the mastoid, and caused by hysteria; the other, where 
slight hysterical symptoms were much increased by inflammation of the 
middle ear, with serous effusion. The report of these cases, which opens 
a wide field of research in the domain of hysteria, directs attention to 
another group of cases, occurring mostly in children, and which appa- 
rently is to be classed under the head of aural symptoms arising reflexly 
from trouble in other parts of the economy, and conversely reflex symp- 
toms of other organs caused by aural disease. 
This subject has, as yet, been very imperfectly recorded in the litera- 
ture of pediatrics, and yet is of considerable importance in the symptom- 
atology, prognosis, and treatment of children’s diseases; and in order 
that our meaning may be thoroughly understood by our readers, we 
will, before discussing the subject in detail and reporting our cases, pre- 
sent briefly the following examples, illustrating the two branches of the 
subject: 
Case I. Reflex aural symptoms; no aural disease.—A. D., aged four- 
teen months, has eight incisor teeth, and from general appearances is 
probably in the process of cutting the first four molars; frequently 
suffers from pain in both ears, partial temporary relief to the pain 2 
BLAKE, BOTCH, REFLEX AURAL SYMPTOMS. 
being obtained by inflation of the Eustachian tubes; careful examina- 
tion of the ears reveals nothing abnormal beyond, at times, an evanescent 
injection of the membrana tympani. 
The pain gradually grew less severe, and the attacks less frequent, but 
the trouble continued until the molars were well up under the gums. 
Diagnosis. Irritation of dental nerves in bone sockets; reflex irrita- 
tion and suspense of vasomotor inhibition through the otic ganglion, 
causing dilatation of tympanic vessels, pressure, and aural j>ain. 
Case II. Aural disease; reflex pulmonary symptoms.—B. C., three and 
a half years old, has for some months had purulent inflammation of left 
middle ear; sometimes a discharge being present, and again ceasing 
for several weeks; but perforation of the membrana tympani always 
remaining unclosed. 
December 2J/.. For some days has been having an offensive purulent 
discharge from the ear, with a temperature varying from 99° to 101° F.; 
was out of doors in the morning and exposed to a cold easterly wiud; did 
not seem well in the middle of the day; loss of appetite, chilly sensations 
and pains in limbs; throat slightly reddened; in the night, symptoms 
grew worse ; the temperature went up to 105°, the pulse to 160, and the 
respirations to 75; nothing abnormal was found in the lung or larynx, 
and yet the quickened respirations were of a pulmonary type; examina- 
tion of the ears showed nothing to account for the severity of the symp- 
toms but the same purulent offensive discharge; temporary relief to the 
respirations and a reduction of temperature were obtained by inflating 
the Eustachian tubes and syringing the ear; the symptoms, however, 
returned on the following day, and when seen by another physician in 
consultation (respirations 75; temperature 104°; pulse 160) were pro- 
nounced to be those of pneumonia, until repeated and careful physical 
examination proved that the respiratory tract was not involved, and 
inflation and syringing were followed in a few hours by reduction of the 
respiration to 25, and the temperature to 98.2° ; no further trouble arose 
in the case. 
Diagnosis. Purulent inflammation of middle ear; reflex symptoms 
simulating pneumonia. 
The intimate association of the filaments of the pneumogastric nerve 
with the ganglia of the sympathetic system, will suffice for the present 
as an explanation of the marked pulmonary symptoms existing in this 
case, where the source of the disease was evidently aural; we shall, how- 
ever, later refer again to these pulmonary symptoms in a case somewhat 
more complicated than the one just cited; our first example also will be 
more clearly explained when we come to speak of the connection be- 
tween the teeth and the ears. 
One point especially to be urged in these cases of aural lesion of reflex 
origin is that the preliminary congestion occurs, in the great majority, 
in the upper portion of the tympanic cavity, and upper portion of the 
membrana tympani. The more immediate source of the blood supply of 
this region is a tympanic branch of the carotid, sometimes two or three 
branches, passing through openings in that portion of the bony wall of BLAKE, ROTCH, REFLEX AURAL SYMPTOMS. 
3 
the carotid canal which forms a part of the anterior inferior wall of the 
tympanic cavity. 
These branches are necessarily short, of considerable size as compared 
with other sources of blood supply, proceed directly to their point of dis- 
tribution, and have not, according to Politzer, the usual capillary termi- 
nations ; these facts, taken in connection with the force of their circula- 
tion derived so directly from the carotid, make them especially liable to 
sudden and extreme dilatation on the suspense of vasomotor inhibition, 
and that the nervi-vasorum constituting the carotid. plexus at this part 
of its course come largely from the otic ganglion (Woakes), and are 
hence placed in direct communication with distant parts, is the second 
of the important factors which explain the sudden and often unexpected 
implication of the middle ear in the diseases of other organs. 
The sympathetic nerves of the lining membrane of the middle ear 
spring from the sympathetic plexus which accompanies the carotid 
artery in its canal. By means of orifices in the canal, several small 
branches of this plexus enter the tympanic cavity as nervi-carotico-tym- 
panales, to form in its anterior portion together with the ramifications of 
Jacobson’s nerve, and the nervus petrosus superficialis minor, the plexus 
tympanicus. From this proceed the finer nerves for the whole lining 
membrane of the middle ear. 
The important influence exerted by the sympathetic nerves upon the 
vessels of the tympanic cavity is shown by Prussak’s experiments on 
dogs.1 The tympanum was opened, and while the portion of the sympa- 
thetic in the neck was galvanized, the vessels of the promontory and of 
the membrana tympani were examined by a magnifying glass. Shortly 
after the beginning of the irritation, the vessels became smaller, dimin- 
ishing so as to be almost invisible; when the irritation ceased a consider- 
able expansion of the vessels took place.2 
We shall confine ourselves, for the sake of brevity, to cases implicating 
the middle ear, leaving out of consideration that large group of symptoms 
connected with disease of the internal ear which has already been in- 
vestigated, and also not attempting to cover the whole ground of reflex 
middle ear affections, merely citing such illustrative cases as have hap- 
pened in our practice. 
A few words regarding the general mechanism of the phenomena rep- 
resented in these cases, and so admirably spoken of by Woakes in his 
article on “ Sources of Ear Affections in Infancy and Childhood,” may 
be of aid in fully appreciating the otherwise inextricable complex of 
symptoms which we are about to describe, and we can then take up the 
1 Prussak. Ueber Anastomosen zwischen den Gefassbezirken des Mittelohrs und des Labyrinths. 
Archiv f Olirenheilkunde, xi. 
2 Pulitzer. Diseases of the Ear. English edition, p. 50. 4 
BLAKE, ROTCH, REFLEX AURAL SYMPTOMS. 
especial anatomical connections which serve to elucidate the individual 
case. Woakes says, ‘‘ The anatomical mechanism, to the consideration 
of which these remarks lead, will be found in that portion of the nervous 
system constituted by the ganglia of the sympathetic chain and its afferent 
and efferent branches.” 
By far the most important fact in connection with the sympathetic 
system is that, with one or two exceptions, all sensori-motor nerves in- 
clude fibres belonging to it. These sympathetic fibrillse proceed to their 
companion cerebral or spinal nerve from that ganglion which is nearest 
to the latter when it issues from the spinal canal, or that join it from 
ganglia near which it passes in its course. 
These sympathetic fibres are afferent in their function as regards the 
ganglion—i. e., they convey impressions from the tissues to which they 
are distributed to the ganglion, or. beyond it, to centres within the spinal 
cord. They may be looked on as taking this ganglion in their course 
to the general vasomotor centre, hypothetically seated in the medulla 
oblongata, but it must not be forgotten that when these fibres thus enter 
a ganglion, they communicate with its caudate cells. This important 
fact brings them into communication with another set of nerves coming 
from very different directions to the same ganglion. 
The second set of fibrillse referred to as entering the ganglion, pro- 
ceed by a similar course from the general centre, to join a given sym- 
pathetic ganglion; they then, similarly to the afferent sympathetic 
fibrillse, mingle with the caudate cells of the ganglion, after which they 
quit it to seek their several destinations on the coats of the arteries. 
They are efferent or centrifugal in their function, conveying impressions 
from the general centre or the sub-centre constituted by their ganglion, 
to the arteries whose calibre it is their function to regulate; hence they 
are usually called vasomotor nerves. It will probably be found a not 
incorrect inference to regard these centres, whether primary or second- 
ary, as playing a subservient part to the tissues which animate them. 
From this point of view, they will be reduced to the level of stations for 
receiving and transmitting impressions originating in the vital work of 
the areas with which they communicate, and, therefore, devoid of any 
power of originating such impressions, though they do undoubtedly 
modify the impulses passing through them, according as their vigor or 
vital energy is less or more than normal. We may conclude then that 
the sympathetic ganglia not only play the part of secondary centres or 
sub-centres, receiving and transmitting impressions quite independently 
of the general centre, but that they are also correlating organs, by 
means of which afferent tissue impressions from one direction are reflexly 
referred to a totally different tract, where they find expression as modi- 
fications of vessel calibre in that tract, the afferent impressions being BLAKE, ROTCH, REFLEX AURAL SYMPTOMS. 
5 
manifested through their medium as efferent impulses in the area to 
which they are thus reflected. In other words, the sympathetic ganglia 
are to be regarded as so many stations situated on the lines traversed 
by vasomotor impressions, in which the “ points,” so to speak, are man- 
aged and by means of which impulses are transferred from one line to 
another. 
The following diagram will illustrate, in a general way, the foregoing 
remarks. 
Fig 1. 
A, sympathetic ganglion. 
B, sensori-motor nerve. 
C, afferent sympathetic fibres from sheath of B. 
I), caudate cells. 
E, efferent sympathetic fibres proceeding to artery F. 
F, artery dilated. 
f, normal size of artery beyond the sympathetic influence. 
G-, general vasomotor centre. 
HH, the dotted lines indicating the course of the fibres forming the roots of the ganglion 
in the spinal cord to the general vasomotor centre G. 
We can now report a class of cases which represent the reflex con- 
nection between the ear and the larynx, and we will first indicate simply, 
by means of Fig. 2, the anatomical relations between the organs. 
The irritation of the sensitive fibres of the auriculo-pneumogastricus 
distributed in the meatus, and to the membrana tympani, is reflected 
along the motor fibres of the superior laryngeal nerve, exciting in the 
larynx the act of coughing, by causing contraction of the crico-thyroid 
muscle. Now, where the original irritant, either in the meatus or in the 
membrana tympani, by its continued presence involves the vasomotor 
fibres associated with the auricular nerve, they conduct their impression 
to the ganglion of the pneumogastric, and thence it is deflected through 
a sympathetic fasciculus proceeding from it to the first cervical ganglion, 
this again through the nervi molles carries the impression to the external 
carotid artery and by its branches to the mucous membrane of the 
larynx, and as a result of reflected vasodilator impressions we may have 
congestion of the vessels supplying the mucous membrane of the larynx 
and perhaps effusion from these vessels. 6 
BLAKE, ROTCH, REFLEX AURAL SYMPTOMS. 
As examples of reflex irritation, having their origin in this way, may 
be mentioned the hoarseness which sometimes accompanies the impac- 
tion of cerumen, and which disappears almost immediately after the 
removal of the mass, and the case of a young girl who was relieved of a 
Fig. 2. 
A, auditory canal, membrana tympani, and middle ear. 
B, second ganglion of vagus. 
C, first cervical ganglion of sympathetic. 
I), auriculo-pneumogastric nerve 
E, sympathetic fasciculus connecting B and 0. 
F, nervi molles vasomotor connection with external carotid. 
G, external carotid. 
H, laryngeal artery. 
S, superior laryngeal nerve. 
L, larynx. 
persistent laryngeal cough of several months’ duration, accompanied by 
excessive expectoration, producing extreme emaciation, by the removal 
of a bead from the external auditory canal. The reverse of these laryn- 
geal symptoms reflex from the ear, is represented by that class of cases 
noticed by Troltsch and others, in which long-standing laryngeal disease 
is followed by deafness, and Gerhardt’s case of severe pain in the ear, 
apparently depending on ulcerative destruction of the epiglottis. 
The following is an interesting case of middle ear disease causing 
reflex laryngeal cough. 
Case III.—A child, five years old, who had been under our care for 
various diseases, and had developed purulent inflammation of the mid- 
dle ear, was noticed, when under treatment for the otitis, to have a spas- 
modic, apparently laryngeal, cough, not to be accounted for by any 
abnormal condition of the air-passages. Whenever the discharge was 
checked, the cough was persistent, and resisted all the remedies which 
were employed to control it, but always grew less and frequently disap- 
peared entirely, whenever the ear began to discharge again. This 
sequence of symptoms happened so frequently that there seemed to be 
no doubt that there was a connection of dependence between the dis- 
charge and the cough, and many an amusing appeal was made by the 
writers of this paper to each other, to allow the especial part to which 
they were directing their remedies, to remain quiescent, which only BLAKE, ROTCH, REFLEX AURAL SYMPTOMS. 
7 
ended by the baffled physicians sending the despairing parents abroad 
with the child, to a climate where a more complete cure could take place 
in the ear. 
We will next report the reversal of the impressions conveyed by the 
filaments of the pneumogastric and the allied sympathetic fibrillse, oc- 
curring in the second case described in this paper, in which aural disease 
was followed by pulmonary symptoms. This case is an illustration of 
the primary implication of the middle ear in pulmonary tuberculosis. 
Case IV.—A young man, twenty-three years of age, with marked 
tuberculosis of the right lung, complained of tinnitus aurium, and espe- 
cially of a sense of fulness in the right ear, accompanied by decided im- 
pairment of hearing. 
Examination of the ear showed congestion and oedema of the upper 
portion of the membrana tvmpani which was followed by perforation of 
the membrane of Shrapnell, and a serous discharge which soon became 
purulent, and was accompanied by a rapid breaking down of the tissues. 
A week later the same symptoms occurred in the left ear, with the same 
appearances, and the transition within four days to a well-established 
purulent otorrhoea. The left lung was also affected. In this, as in simi- 
lar cases, a marked symptom is the absence of the severe pain which 
usually accompanies the inflammatory affections of the middle ear and 
membrana tympani. The anatomical connection of the parts is obviously 
through the pneumogastric ganglion B, Fig. 2, by means of the auriculo- 
pneumogastric nerve. 
We can now, guided by the principles which we have above endeavored 
to elucidate, return to the study of those especial ear cases illustrated 
Fig. 3. 
A, tympanic cavity. 
B, otic ganglion. 
C, tooth. 
I), internal carotid. 
E, tympanal branch. 
F, auriculo-temporal nerve. 
G, auricular branch of auriculo-temporal nerve. 
by the first case reported in this paper, in which there is congestion of the 
auditory structure arising from the irritation of teething, and we have 8 
BLAKE, ROTCH, REFLEX AURAL SYMPTOMS. 
to ascertain how a congestion of the ear sufficient to give rise to severe 
pain can be caused in a reflex way by irritation connected with the 
teeth and gums, for clinically the occurrence of this phenomenon is 
quite frequently met with in infants during the dental periods. Woakes 
says: 
“A considerable portion of the blood supply of the membrane of the drum 
is derived from an artery that leaves the internal carotid in the carotid canal 
and proceeds by a very short course directly to its destination. Being thus 
closely connected with a large arterial trunk, this small tympanal branch is 
very favorably situated for a speedy augmentation of its blood supply. Now 
the nervi-vasorum constituting the carotid plexus at this part of its course 
come largely from the otic ganglion. On the other hand, the inferior dental 
nerve supplying gums and teeth also communicates with this ganglion.” 
We thus arrive at a direct channel of nerve communication between 
the source of irritation, the tooth, and the vascular supply of the drum- 
head. The vessels of the membrana tympani become largely distended, 
and the attendant stretching of the tense and sensitive tissue in which 
this occurs occasions the pain constituting “ earache.” 
Fig. 4. 
A, tooth in bone socket. 
B, jaw. 
C, gum, soft, not inflamed or swollen. 
I), dental nerves. 
Incidentally to the discussion of this subject of “ dental earache,” it 
does not seem entirely out of place to say a few words about gum lancing 
— a procedure which in former years was so universal, and at the present 
time is discountenanced to an equal degree by certain writers of authority 
in pediatrics. 
Fig. 5. 
A, tooth in bone socket. 
B, jaw bone. 
C, gum, tense, inflamed, swollen. 
D, dental nerves. 
During the dental periods two classes of irritation are met with: (1) 
Irritation of the dental nerves from pressure in the bone socket caused 
by pressure at the root of the growing tooth, and the accompanying BLAKE, ROTCH, REFLEX AURAL SYMPTOMS. 
9 
symptoms commonly spoken of as “teething;” in this class of cases we 
especially have the reflex earache spoken of above. (2) Irritation of 
the gum over the crown of the tooth from pressure, with symptoms of 
local irritation causing fever, and with general nervous symptoms. 
Now we have here two exactly opposite conditions: 
1. Pain from pressure at root of growing tooth. 
2. Pain from pressure at crown of growing tooth. 
To relieve the symptoms of (1), we can easily see that lancing the 
flat, soft, unirritated gum C, in Fig. 4, can be of no possible use; while 
what better treatment can there be for the symptoms of (2) than freely 
to lance the hot, swollen, and tense gum C, in Fig. 5, as we would 
where it is possible in any part of the economy to relieve symptoms of 
pressure by abolishing the cause of the pressure? Lance, then, not as 
formerly in every case, but knowingly in the class of cases in which our 
common sense tells us that the gum is crying out for the lancet as plainly 
as the felon demands the bistoury. 
The relationship of superficial cutaneous disturbances of the face to 
congestions of the upper portion of the membrana tympani and tym- 
panic cavity, as is sometimes observed in the facial eruption of measles 
and in the cases of which the following is a type, is somewhat complex, 
the arterial supply of the tympanic cavity being derived from various 
vessels. The anterior and middle portions are supplied : 1, by branches 
of the ascending pharyngeal artery (from the external carotid) ; 2, by 
branches of the middle meningeal artery which penetrate through the 
hiatus canalis Fallopiae and the fissurse petroso squamoso into the tym- 
panic cavity; and, 3, by the internal carotid which sends branches 
through the bony Avails of its canal. 
In the case in question, there was evidently a rapid congestion of the 
middle ear, vvith no other readily assignable cause than the one men- 
tioned, and the mechanism of the suspense of vasomotor inhibition in 
this and similar cases, is a question which it is intended to make the 
subject of further investigation. 
A stout, healthy man, about thirty years of age, without history or 
evidence of previous ear-trouble, Avas exposed for an hour or more while 
driving to a cold, raw wind in winter; his body, head, and face were 
thoroughly protected, Avith the exception of the right side of the face and 
cheek, Avhich surfaces were, of necessity, continuously exposed. 
On entering the house a sense of fulness was experienced in the right 
ear, folloAved, at the end of an hour in a warm room, by a slight pain, 
which, by the end of another hour, had become very severe. At this 
period examination of the ear showed the membrana tympani congested 
and swollen above, but transparent below, and bulging outward; para- 
centesis of the membrana tympani in the posterior inferior quadrant 
liberated, not fluid, but air, which escaped with a sharp hiss, and was 10 
BLAKE, ROTCH, REFLEX AURAL SYMPTOMS. 
followed, within another hour, by a serous fluid, the outflow of which 
rapidly increased for a time and then continued, gradually decreasing, 
for three days. 
The fact that the bulging outward of the membrana tympani was 
due to compressed air, and not to accumulated fluid, as was shown by 
the paracentesis, is a marked symptom in this case, and was probably 
due to rapid swelling of the mucous membrane, first closing the Eus- 
tachian tube and then encroaching upon the lumen of the tympanic 
cavity sufficiently to compress the imprisoned air, and force the mem- 
brana tympani outward, and would imply that the first impulse to con- 
gestion occurred in the Eustachian tube and anterior portion of the 
tympanic cavity. If this conclusion is correct, the mechanism of the 
suspended vasomotor inhibition would be explained by the distribution 
of the superior maxillary nerve, which, with Meckel’s ganglion, supplies 
the integument above and over the malar bone and that of the lower 
eyelid, side of the nose, and upper lip; while the connection with the 
ascending pharyngeal, tympanic branch, may be supplied, either by the 
pharyngeal nerve, which is sometimes given off from the ganglia, and 
sometimes directly from the Vidian, or by the small nasal branches of 
the Vidian which supply the membrane of the Eustachian tube. 
The possible reverse train of symptoms to those of this case is presented 
in the following instance of reflex irritation : A boy, eight years old, who, 
from time to time, had had inflammation of the middle ear, but who for 
some months had been free from ear-trouble, after being out in the 
morning (the day was mild) came home with the right side of his face 
swollen ; the swelling, which was neither red nor painful, and was not 
accompanied by fever, also affected the right eye, and extended over to 
the left eye; careful examination failed to detect any lesion to account 
for the symptoms, either in the mouth or elsewhere. Unfortunately the 
ear was not examined at this time. 
In the night the child complained of slight pain in the right ear, fol- 
lowed in a few hours by a mucopurulent discharge, and by morning the 
swelling of the face had entirely disappeared, and there was a well- 
established otorrhcea. 
In this connection we must now speak of an exceedingly important 
class of cases represented by the exanthemata, as here, also, there appears 
to be a reflex relationship between the face and the ear. 
The implication of the middle ear in scarlet fever, for instance, occurs 
in two distinct ways: the first, and by far the most frequent, is that in 
which an inflammatory process in the middle ear is the secondary result 
of the inflammation of the mucous membrane of the fauces and naso- 
pharynx, the first step in the mechanism of the aural implication being 
a more or less general congestion of the tympanic mucous membrane, 
blood stasis, due to the swelling of the mucous membrane of the Eus- 11 
BLAKE, ROTCH, REFLEX AURAL SYMPTOMS. 
tachian tube and the consequent closure of that passage, a condition 
which permits the rarefaction of the air in the tympanic cavity, and 
consequently still further favors congestion in addition to the inter- 
ference with the venous circulation. 
In the second instance the primary congestion occurs principally in 
the upper portion of the tympanic cavity and membrana tympani, and 
is coincident with the facial eruption, a sequence explainable on the 
reflex hypothesis; the same sequence is still more frequently observable 
in the facial eruption of measles. 
An illustration of this second instance was beautifully represented in a 
patient coming under our notice with an intense efflorescence of measles 
on the face and no aural symptoms; on examining the ears, however, a 
marked congestion was found in the upper part of the membranse 
tympani. 
The next and last case of our series represents a rather more extended 
line of reflex symptoms, and though resembling some of the other cases, 
is interesting as presenting a combination of reflex phenomena from the 
face and throat to the ear and thence to the lung. 
A girl, aged nineteen months, well until March 6th, when she began 
to have cough, coryza, and lachrymation; these symptoms continued 
on the 7th, and an efflorescence of measles declared itself on the face. 
Temperature 104£° F., pulse 150, respiration 40; on the 8th there was 
no extension of the efflorescence, and at 4.30 p.m. there was a general 
eclamptic attack, but consciousness returned at 5 p.m., cough less and 
apparently caused by a catarrhal condition of the pharynx and larynx, 
lungs normal, efflorescence appearing on body and limbs; in the night 
great restlessness and apparently pain, which, however, could not be 
localized, though it was suspected to be in the chest, as the respirations 
began to increase and to be of a short grunting character; these symp- 
toms continued until at 5 A.M., March 9th, the respirations numbered 70 
to 80 in a minute, and the picture was that of a pneumonia; frequent 
auscultation and percussion revealed nothing abnormal in the lungs or 
heart; at 6 a.m. a slight mucopurulent discharge was noticed on the 
pillow, coming from the left ear; the temperature was then found to be 
a degree lower, but the rapid breathing continued. The left Eustachian 
tube was now inflated, and in about ten minutes the respiration was 
almost normal; in the further progress of the disease, the measles ran a 
normal course, but the right ear was also affected and both ears con- 
tinued to discharge. A number of times the rapid respiration returned, 
and was always promptly relieved by the use of the air douche. 
Rational treatment of these cases, then, can only be accomplished by 
a thoroughly scientific anatomical and physiological knowledge of the 
reflex phenomena, which, from the hypersensitive condition of the child’s 12 
BLAKE, ROTCH, REFLEX AURAL SYMPTOMS. 
nervous system, play a much greater role in childhood than in adult 
life and render a diagnosis much more difficult. 
Finally, from what has been said, we must admit the great importance 
of recognizing whether symptoms are real or reflex, tracing them from 
one end of the labyrinth of nerves to the other, and following them out 
with the minutest detail, for in this way only can we speedily reach the 
goal of recovery through definite and exact diagnosis, with resulting 
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The News and The Journal will be furnished together at a commutation rate of 
$9.00. Advance-paying subscribers to either or both of the above periodicals can obtain 
The Medical News Visiting List for 1887 for 75 cents per volume (regular price #1.25). 
It is issued in four styles: Dated, for 30 patients per week (1 vol.), for 60 patients 
(2 vols.), for 90 patients (3 vols.), and Undated (perpetual, 1 vol.). Or similarly they 
can obtain The Year-Book of Treatment for 1885, an epitome of the world’s therapeu- 
tical progress during 1885, from the pens of 23 eminent specialists, for 75 cents (regular 
price #1.25). 
The News and The Journal for one year, together with The Year-Book for 
1885 and any one volume of The Visiting List, will be sent post-paid to any address for 
#10 in advance. Subsequent volumes of The Visiting List, 75 cents. 
LEA BROTHERS & CO., PUBLISHERS, 
706 & 708 Sansom Street, Philadelphia.