«*./-'»■*•..*•.'. 1 ! .' AAA' ,' ' •«*.* 2> ,., ,* > .' .• ..'Ail 9 . . *■■'•< ..• «L. : WU. .,.►*' »•'• 'I fc* .X -, . *. ■• fc* .-»\> . >* v ^. .,f.V.' t E V '••'' k. ..i4 *" i v,Wi ** ' 4 V* t\, < *,'•'* ' ,,*.' k *•» ' •.»-*' ^ .'/■it ,..!>.' .. r ' * ' V" '. V' r-;' r a** ■ ! V * '> .' 1. *- '.»-^'j o > r •: t ' . ' .■• IONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE N n inoiojw jo Aavaan ivnoiivn jnisiojw jo ab....... * ^4 V N 3NI3I01W JO ABVaBIl IVNOIIVN 3NI3IQ3W JO AaVIBIl IVNOIIVN INOIdiW JO *«»«lll 1VNOIJ n jNiDiaaw jo Aavaaii ivnoiivn inisiqjw jo Aavaaii ivnoiivn inoiqiw jo Aavaaii ivnoi I THE EAR; ITS ANATOMY, PHYSIOLOGY, AND DISEASES. A PRACTICAL TREATISE FOR THE USE OF MEDICAL STUDENTS AND PRACTITIONERS. BY CHARLES II. BURXETT, A.M., ALD., AURAL SURGEON TO THE PRESBYTERIAN HOSPITAL ; SURGEON IN CHARGE OF THE INFIRMARY FOR DISEASES OF THE EAR, PHILADELPHIA. WITH EIGHTY-SEVEN ILLUSTRATIONS. PHILADELPHIA: HENEY 0. LEA. 1877. Entered according to the Act of Congress, in the year 1877, by HENRY C. LEA, in the Office of the Librarian of Congress. All rights reserved. PHILADELPHIA: COLLINS, PRINTER, 70-3 Jayne Street. PREFACE. In view of the great advances which have been made of late years in Otology,, and of the increasing interest manifested in it, the Author has felt that the profession might welcome a new work which should present clearly but concisely its present aspect, and should indicate the direction in which further researches can be most profitably carried on. Such a work it has been the Author's aim to produce, and in accomplishing the task it will be seen that he has freely availed himself of the observations and discoveries of others. These he has, as far as practicable, tested by his own experience in the opportunities afforded by several years' special devotion to the study of the diseases of the ear. Considerable practice in teaching has shown him that the pathology and therapeutics of the ear cannot be properly under- stood without a more intimate acquaintance with its anatomy and physiology than is afforded by the ordinary text-books. In these departments much important work has recently been done abroad, especially in Germany, and the author is confident i V PREFACE. that the space which he has devoted to their consideration will not be considered as excessive. In conclusion, he trusts that, although the work is primarily designed for the student and general practitioner, it will not be found devoid of interest for the specialist. CHARLES H. BURNETT. No. 127 South Eighteenth Street, Philadelphia, September, 1S77. CONTENTS. PART I. ANATOMY AND PHYSIOLOGY. SECTION I. EXTERNAL EAR. PAGE Chapter I. The Auricle. Anatomy ........... 19 Cartilage. Muscles, extrinsic and intrinsic. Ligaments. Blood- vessels and lymphatics. Nerves. Integument. Glands and hairs. Physiology............23 Function of the muscles, voluntary and involuntary movements. Significance of size and shape of auricle. Comparative functions. Resonant functions. Temperature of the auditory canal. Chapter II. The External Auditory Canal. Anatomy............ . 38 The temporal bone—development. Styloid process ; origin and development. Temporal bone of infant. Development of bony auditory canal. Development of annulus tympanicus. Segment of Rivinus. The auditory canal. Ceruminous glands. Vessels and nerves. Physiology............45 The function in expelling cerumen by outward growth of skin and by shape of canal. Chapter III. Membrana Tympani. Anatomy.............47 The three layers. 1. The dermoid or outer layer. Epithelium. Shape of membrana tympaui. Color of membrana tympani. In- clinations of membrana tympani. Manubrium of the malleus. Umbo. Folds of membrana tympani. Pyramid of light. Cause of the pyramidal shape. Geometric divisions of the membrana tympani. Annulus tendinosus. Inner surface of the cartilaginous groove of the malleus. VI CONTEXTS. 2. Membrana propria or middle layer. The descending fibres o the membrana tympani. Dentiform fibrous structure of the mem- brana tympani. Constituent elements of the membrana propria 3. Mucous or internal layer. Fold of mucous membrane lor the chorda tympani. Pouches of the membrana tympani. Compaia- tive distribution of bloodvessels in the membrana tympani. PAGE SECTION II. MIDDLE EAR. Chapter I. Tympanic Cavity. 68 Anatomy...........■ Ossicles of hearing. Malleus—dimensions ; fixation—axial liga- ment. Incus—dimensions. Malleo-incudal joint. Stapes—dimen- sions. Joint between base of stapes and oval window. Dimensions of the ossicula auditus. The tympanum. Tegmen tympani. Malleo-incudal joint—sur- rounding parts viewed from above. Floor of the tympanum. Outer wall of tympanum. Pouches of membrana tympani. Inner wall of tympanum. Eminentia stapedii. Function of the stapedius muscle. Fixator baseos stapedis. Tensor tympani muscle. Anterior and posterior walls of tympanic cavity. Course of facial nerve. Development of the bony canals in and about the tympanic cavity. Lymphatic cavity in the facial canal. Chorda tympani nerve. Nerves supplying the mucous membrane of the tympanic cavity. Bloodvessels. Physiology............92 Innervation of the tensor tympani muscle. Physiological nature of certain tympanic bands, heretofore considered pathological. Function of round window and its membrane. Experimental re- searches—sources of sound. Artificial labyrinthine pressure. De- ductions. Power of muscular accommodation. Action of the tensor tympani and stapedius muscles. Bibliography. Chapter, II. Eustachian Tube and Mastoid Portion. Anatomy.............# 104 The tube—its name and dimensions. Bony portion of tube. Cartilaginous portion of tube. Tensor palati muscle. Inner ptery- goid muscle. Ligamenta salpingo-pharyngea. Mucous membrane. Tonsilla pharyngea. Differences in size and shape of tube. Blood- vessels and nerves of tube. The mastoid portion. Cells. Mastoid process and antrum. Limits of the mastoid cells. Physiology............116 The amount of constant patulence of the normal Eustachian tube Functions of the muscles of the tube. Conjoint physiology of the Eustachian tube, tympanic cavity, and the mastoid cells. CONTEXTS. SECTION III. INTERNAL EAR. Chapter I. Labyrinth and Auditory Nerve. Anatomy .... The vestibule. The ampullar mouths of the semicircular canals. Maculae cribrosse. The cochlea. The canal of the cochlea. The modiolus—lamina spiralis ossea and scala?. The semicircular canals —dimensions, ampullar enlargement, and planes. Soft parts of the cochlea and lamina spiralis. Crista spiralis. Habenula perforata and zona?. Ductus cochlearis. Organ of Corti. Pillars and arches of Corti. Inner and outer ciliated cells. Mem- brana reticularis—the surface. Membrana tectoria. The auditory nerve ; origin and distribution. Vestibular and cochlear branches. Inner and outer ends of cochlear branch. Soft parts of vestibule and semicircular canals ; the membranous labyrinth. The sacculi. Membranous semicircular canals. Sac- culi and ampulla?—inner surface. Planum semilunare. The oto- liths. Topographical arrangement of the soft parts of the internal ear. The endo- and perilymph. Physiological functions. Physiology...... Audition in the cochlea. Function of the semicircular canals. Experimental researches. Chapter II. Scheme of Relationship between the Middle and the Internal Ear. Description of the Middle Ear, of the Internal Ear, and of the relation they bear to each other..... The tympanic cavity, the foramen ovale and foramen rotundum or fenestra?. The ossicles and their supports ; their connection with the membrana tympani and the inner wall of tympanum. The tympanum with the Eustachian tube in front and the mastoid cells behind. The internal ear, a water-containing cavity. The vestibule, with the cochlea in front and the semicircular canals behind. The mode of entrance of the nerve of hearing. Vlll CONTEXTS. PART II. DISEASES AND TREATMENT. SECTION I. EXAMINATION OF PATIENTS. PAGE Chapter I. Instruments, and Methods of their Employ- ment. Examination of the Ear..........165 Examination of the ear by polarized light. Otoscopes, or aural specula, Gruber's, Politzer's, Toynbee's, and Bonnafont's. Sigle's, and Voltolini's pneumatic specula. Blake's operating otoscope. De Rossi's binocular otoscope. Blake's middle ear-mirror. Posi- tion of patient's body and head. Position of surgeon. Insertion of ear-speculum. Removal of obstacles to a view of the membrana tympani. Forceps and cotton-holder. Basin and towel. Syringes and syringing. Examination of the Nares and Fauces, Throat and Eustachian Tube . 177 Tobold's apparatus. Forehead-mirror and small laryngeal mir- rors. Rhinoscopy and rhinoscopic examination of the mouth of the Eustachian tube. Eustachian Catheters..........180 Forms of catheters. Auscultation tube. Air-bag or hand-bal- loon. Catheterization of the Eustachian tube ; insertion and fix- ation. Other methods of catheterization. Politzer's air-bag and method of inflation of the Eustachian tube and tympanic cavity. Chapter II. Sound, Hearing, and Tests of the latter. Sound and Hearing..........192 Definition of sound and hearing. Intensity, pitch, and quality. Partial or overtones. The so-called deaf points of the ear. Sound and color. Tests of Hearing.......... 19g 1. Aerial and bone-conduction of sound. Normal hearing. The watch. Record of hearing. The stop-watch. Tuning-forks. Tuning-fork in bone-conduction. Three-limbed auscultation tube. Interference-otoscope. Tuning-fork vibrating on a parietal pro- tuberance in a normal case. 2. Speech. Perception of high musical tones. Acoustic charac- ter of vowels and consonants. Whispering and loud tones. Vari- able hearing. Hearing low tones better than high ones. Effects of position and extent of perforation in the membrana tympani on the hearing. Testing the hearing in one-sided deafness. Entotic application of the ear-trumpet. CONTEXTS. IX SECTION II AURICLE. PAt'B Chapter I. Organic Defects and Cutaneous Diseases. Organic Defects...........220 Absence of auricle. Plurality and abnormal position. Mal- formations. Congenital fistula of the ear. Cutaneous Diseases...........223 Simple erythema. Erysipelas. Intertrigo. Frost-bite. Pem- phigus gangrenosis. Eczema. Subacute ezcema. Acute phleg- mon. Chronic phlegmon. Circumscribed inflammation of the cellular tissue. Cornu cutaneum auricula?. Secondary syphilitic eruptions. Tubercular syphiloderm. Idiopathic herpes zoster auricularis. Herpes zoster of the tragus. Chapter II. Morbid Growths and Injuries. Morbid Growths '.........238 Cysts, atheromatous and sebaceous. Angioma. Vascular na?vus maternus. Fibrous or fibro-sarcomatous tumors of the lobule. Sarcoma of the lobule. Glandular hypertrophy of the lobule. Epithelial cancer. Othematoma—idiopathic and traumatic. Injuries.............2oo Traumatic cleft of lobule. Knapp's operation. SECTION III EXTERNAL AUDITORY CANAL. Chapter I. Circumscribed and Diffuse Inflammation. Circumscribed Inflammation.........258 Symptoms. Etiology. Treatment—general and local. Diffuse Inflammation..........20j Symptoms. Various forms. Causes. Treatment. Otomycosis............277 Forms of fungi found in the ear. Myringomycosis aspergillina. Symptoms. Etiology. Treatment. Chapter II. Foreign Bodies in the Enternal Ear. Foreign Bodies originating within the Ear......288 Collections of cerumen in the ear. Etiology of rapid formation of cerumen. Treatment. Cretaceous bodies in the external audi- tory canal. Treatment. Laminated epithelial plug in the external auditory canal. Etiology. Treatment. Ingrowing hairs from the tragus, resting on the membrana tympani. Treatment. X COXTEXTS. PAGE Foreign Bodies from without.........* Inanimate objects in the ear. Cases. Animate objects in the ear. Cases. Treatment. Foreign bodies in the Eustachian tube and middle ear. Removal of foreign bodies from the ear. Chapter III. Results of Inflammation and Injury. Results of Inflammation..........315 Chronic circumscribed ulceration in the external auditory canal. Etiology and treatment. Cholesteatomatous tumors in the auditory canal. Treatment. Exostoses in the canal. Etiology. Osseous closure of the auditory canal. Etiology and treatment. Cutaneous closure of the auditory canal. Results of Injury...........326 Epileptiform manifestations from irritation in the auditory canal. Ear-cough—nature and history. Dr. Fox's conclusions. Bleeding from the meatus externus. SECTION IV. M E M B R A NA TYMPANI. Chapter I. Acute and Chronic Inflammation, Injuries and Morbid Growths. Acute Inflammation.......... 329 Acute myringitis. Symptoms. Differential diagnosis between acute myringitis and acute otitis media. Etiology. Treatment. Chronic Inflammation..........333 Ulcers in the dermoid layer. Symptoms. Etiology. Treat- ment. Perforation of the membrana flaccida. Cases. Treatment. Traumatic Injuries...........342 Perforating wounds. Cases. Fracture of handle of malleus. Reproduction of the membrana tympani. Medico-legal significance of traumatic injuries of the drum-head. Morbid Growths ........ Wart-like bodies on the drum-head. Endothelial cholesteatoma of the membrana tympani. Cholesteatoma of the drum-head. 348 SECTION V. MIDDLE EAR. Chapter I. Acute Catarrhal Inflammation. Subjective Symptoms ....... os0 Pain. Vacuum in the tympanum. Effects of talking, couch- ing, sneezing, and eructation. Hardness of hearing. Tinnitus aurinm. Double hearing, or subjective echo-like sensation ; para- cusis duplicata; subjective alteration in pitch. Cases. Intra-tym- panic pressure during phonation. Acute aural catarrh in infants. CONTENTS. XI Objective Symptoms...........369 Retraction of the membrana tympani. Spontaneous rupture of the membrana tympani. Course. Etiology. Earache from teeth- ing, and from whooping-cough. Diagnosis and prognosis. Treatment............377 Anodynes. Irrigation of the naso-pharynx. Paracentesis of the membrana tympani. Chapter II. Chronic Catarrhal Inflammation. Subjective Symptoms..........381 Tinnitus aurium. Hardness of hearing. Pain. Throat symp- toms. Condition of Eustachian tube. Vertigo. Hearing better in a noise. Hereditary tendency. Odor. Objective Symptoms...........387 Appearances in external auditory canal. Membrana tympani, changes in color. Calcareous deposits. Changes in position of membrana tympani. Implication of the sympathetic and other nerves; flushing of the cutaneous surface adjacent to the ear. Cases. Condition of the pharynx and throat. Loss of function in the velum. Changes in the voice. Changes in the Eustachian tube. Adenoid growths and granulations in the naso-pharynx. Inflation and auscultation-symptoms revealed in Eustachian tube and tympanum. Effects of inflation on the membrana tympani. Etiology. Chapter III. Treatment of Chronic Catarrhal Inflamma- tion. Constitutional and Local Remedies........404 1. Introductory remarks. Constitutional remedies and hygiene. Applications to the nares, naso pharynx, and throat. Irrigation of the naso-pharynx by means of the nasal douche. 2. Applications to the Eustachian tube. Excision of the tonsils. Clipping the uvula. Applications to the cavity of the drum. 3. Operations with the knife on the drum-head. Permanent open- ings in the drum-head. Methods, eyelets, rings, etc. Tenotomy of the tensor tympani. Operations of Weber-Liel, Gruber, J. Orne Green, and others. Forms of tenotomes. 4. Removal of fluid and inspissated matter from the cavity of the drum and Eustachian tube. Cases. Electricity in Aural Diseases.........433 Historical Sketch. Mode of application of electricity to the organ of hearing. Brenner's normal formula of the reaction of the audi- tory nerve. Investigations of Erb, Moos, and Hagen, and of Scliwartze, Schulz, and Benedikt. Intra-tubal electrization. Xll CONTENTS. PAGE Chapter IV. Unusual Diseases of the Middle Ear. Functional Disturbances.........439 Objective snapping noises in the ear. Historical sketch. Simul- taneous spasm in the soft palate and elsewhere. Cases. The author's observations of a case. Etiology. Treatment. Organic Disturbances..........447 Extravasation of blood into the tympanum in Bright's disease of the kidneys. Otitis media hemorrhagica (Roosa). Tubercular dis- ease of the ear. Desquamative inflammation of the middle ear; cholesteatoma of the petrous bone. New formed membranes and bands in the middle ear. The corpuscles of Politzer and Kessel; Prof. Wendt's examination. Embolism in the mucous membrane of the tympanic cavity. Primary cancer of the middle ear. History, course, and symp- toms. Etiology. Treatment. Cancer of the mastoid process. Emphysematous tumor over the mastoid portion. Hairs in the mastoid cells. Chapter V. Acute Purulent Inflammation. Subjective Symptoms..........457 Itching in throat and ear. Pain. Alteration in hearing. Ver- tigo, fever, and delirium. Objective Symptoms..........459 Membrana tympani; changes in color, spontaneous rupture. Course.............4gl Possible fatality of the acute form of purulent inflammation of the middle ear. Cases. Etiology.............464 Cold bathing ; its effects on the middle ear. Acute inflammation of the tympanic cavity produced by concussion. Diagnosis ......... . 453 General remarks. Earache from decayed teeth. Appearances of the membrana tympani, differential diagnosis. Prognosis and Treatment....... 4™ Nature and object of treatment. Depletion and anodynes. Para- centesis of the drum-head. Chapter VI. Chronic Purulent Inflammation. Etiology and Symptoms....... *», Introductory remarks. Diphtheria as a cause. Chief symp- toms, hardness of hearing and persistent discharge. Appearances of external auditory canal. Appearances of the drum-head and the tympanic cavity. Treatment..... .„. T .........481 Introductory remarks. Chief remedies to check the chronic dis- charge. Mode of instilling nitrate of silver. Powdered substances for insufflation. Alum and other astringents used in chronic otitis media purulenta. CONTENTS. Xlil Chapter VII. Course and Consequences of Chronic Puru- lent Inflammation of the Middle Ear. Hardness of Hearing and Deaf ness.......492 The artificial membrana tympani, history and forms. Mode of application of the artificial membrana tympani. Action of the arti- ficial membrana tympani. Its protective function. Paper disks of Blake. Epileptiform Manifestations and other Nervous Phenomena . . .500 Introductory remarks. Etiology and treatment. Various nervous phenomena produced by chronic purulent inflammation of the middle ear. Paralysis of the facial nerve. Cases. Alterations in gait. Irritation of the chorda tympani. Anomalies of taste and salivary secretion in chronic purulent disease of the tympanum. Vertigo and reflex psychoses from chronic purulent inflammation of the middle ear. Granulations and Polypi ......... 510 Polypoid hypertrophy of the mucous membrane of the middle ear. Treatment of granulations. Aural polypi. Classification and histology ; fibromata, myxomata, angioma. Organized vesicular polypus, containing necrosed long process of the incus. Symptoms of polypus in the ear. Spontaneous detachment of polypi. Treatment of aural polypi. Forms of in- struments for the removal of polypi. Treatment of ear after re- moval of aural polypi. Chapter VIII. Course and Consequences of Chronic Puru- lent Inflammation—Continued. Ulceration of the Mucous Membrane of the Tympanic Cavity, Perios- titis and Caries of various parts of the Temporal Bone, and their results.............526 Exfoliation of the cochlea. Exfoliation of the cochlea, vestibule, semicircular canals, and deeper parts. History and treatment. Mastoid disease ; symptoms and course. Periostitis of the outer surface of the mastoid portion of the temporal bone. Congestion and inflammation of the mucous membrane lining the air-cells of the mastoid cavity. Caries and necrosis ; followed by meningitis, thrombus in the lateral and other sinuses of the brain, embolism, pya?mia, and cerebral abscess. Cases. Treatment of mastoid dis- ease. Artificial perforation of the mastoid portion of the temporal bone. History. Modes of perforating trephining the mastoid. The point to be chosen for the operation. Instruments to be used. Bibliography. XIV CONTENTS. SECTION VI. DISEASES OF THE INTERNAL EAR. PAGE Chapter I. Primary and Secondary Inflammation. Introductory Remarks.........• Anomalies of formation. Anaemia, hyperemia, and inflammation of the internal ear. Hypersemia of the labyrinth. Primary Inflammation of the Internal Ear......553 History, observations of Deleau and Meniere. Meniere's disease, or labyrinthine vertigo of Hinton. Observations of Brunner, Knapp, Moos, and others. Otitis labyrinthica of Voltolini. Etiology and treatment of primary inflammatory disease of the labyrinth. Trau- matic injuries. Fracture of the base of the skull. Cases. Symp- toms. Secondary Inflammation of the Internal Ear ..... 562 Deafness from concussion. Cases. Hardness of hearing, and total deafness after cerebro-spinal meningitis. Observations of various authorities. Prognosis and treatment. Disease of the in- ternal ear from syphilis ; from typhoid fever. Aural vertigo from chronic catarrh of the middle ear. Cases. Aural vertigo with variable hearing. Aural vertigo resulting from secondary inflam- mation of the labyrinth. Apparent motion during vertigo. Vertigo from cerebral tumors. Chapter II. Morbid Growths of the Auditory Nerve. Fibrous Tumors...........581 Cases of Landiforth, Leveque-Lasource, Boyer, Carre, and others. Sarcoma........... . 581 Cases of Voltolini and Forster, Cruveilhier, Moos, and Boettcher. Symptoms. Tumor of each auditory nerve, case with ante and post mortem notes. Microscopical examination of both cochlea?. Case of probable cerebral tumor, aural notes. Pathological changes found by Moos in the organ of Corti in a case of cerebral tumor. Fibro-Sarcoma ......... 591 Observations of Boettcher. Case of tumor involving common trunk of auditory and facial nerve. Changes in the vestibule and semicircular canals. Glioma of the auditory nerve. The Labyrinth in Ileo-Typhus...... ggo Fatty metamorphosis of the organ of Corti. Amyloid defenera- tion. Corpora amylacea, observations of Luca? and Riidinger. Morbid States of the Auditory Nerve ..... rrq4 Hallucinations of hearing in the insane. Nervous deafness. The effects of quinine on the ear. Observations of Roosa and Hammond CONTENTS. XV SECTION VII. DEAF MUTES AND PARTIALLY DEAF CHILDREN. PAKE Chapter I. Methods of Relief and Education. Deaf-Dumbness...........599 Introductory remarks. Congenital and acquired forms of deaf- dumbness. Modes of instruction by dactylology and lip-reading. Bell's system of visible speech. Partially Deaf Children.........604 Remarks and statistics. Methods to be adopted in teaching par- tially deaf children. Suggestions of Blake. Ear-trumpets. LIST OF ILLUSTRATIONS. PAGE 19 FIR. 1. The auricle ••..... 2. Muscles of the auricle, outer surface . . . (Henle) 20 3. Cartilage and muscles of auricle, posterior view . (Henle) 21 4 Diagram representing the topographical relation of the component resonant cavities of the external ear . . . . .34 5. Centres of development of the temporal bone . . (Gray) 38 6. Outer surface of left temporal bone . . (Smith and Horner) 39 7. Inner surface of left temporal bone . . (Smith and Horner) 39 8. Under surface of left temporal bone . . . (Gray) 41 9. Transverse section of the entire auditory apparatus of the right side (Gray) 44 10. View of outer surface of membrana tympani . . (Gruber) 47 " i Diagram of section of stretched membrane ... r>l 12. ) 13. Geometric divisions of the membrana tympani . . (Kessel) 57 14. View of inner surface of membrana tympani . . (Gruber) 63 15. Membrana tympani of dog . . . . .Go 16. Malleus ....... (Henle) 69 17. Ligamentous support of ossicles viewed from above (Helmholtz) 73 18. Incus ....... (Henle) 74 19. Stapes ....... (Henle) 76 20. Right tympanic cavity viewed from above ; malleo-incudal and incudo- stapedial joints ..... (Henle) 80 21. Inner side of outer wall of the right tympanic cavity. Hammer and Anvil in situ; canalis musculo-tubarius laid open . (Henle) 80 22. Section through the long axis of malleus at right angles to the mem- brana tympani, from an adult .... (Brunner) 82 23. Inner wall of tympanic cavity .... (Gray) 83 24. Nerves in and about the tympanum . . . (Heath) 89 25. Transverse section of the cartilaginous part of the Eustachian tube near the foramen ovale .... (Henle) 106 26. Palatal muscles viewed from behind . . . (Gray) 108 27. Mastoid portion of the left temporal bone, laid open and viewed from behind ......... 114 28. View of the entire right middle ear, laid open by incision from above downward, through the centre of the cavity, parallel to the long axis (Gruber) 121 B xviii LIST OF ILLUSTRATIONS. fig. 29. External view of a cast of the left labyrinth . • (Henle) 30. Section of the pyramidal portion of the right temporal bone through the vestibulum, parallel with the outer wall of latter; view of inner wall......• (Henle) 31. Osseous cochlea laid open .... (Henle) 32. Transverse section of the first coil of the cochlea of a child one and a half years old......(Waldeyer) 33. Transverse section of the organ of Corti . . (Waldeyer) 34. Membranous labyrinth of man .... (Riidinger) 35. Transverse section of the bony and the membranous semicircular canal of man . . . . . . . (Riidinger) 36. Transverse section of an ampulla of a fish : floor and wall (Riidinger) 37. Otoliths from various animals .... (Riidinger) 38. Scheme of the membranous labyrinth of mammals . (Waldeyer) 39. Auditory ossicles in connection; viewed from in front; right side (Henle) 40. Ear-mirror ...... 41. Gruber's aural specula ..... 42. Bonnafont's otoscope • . 43. Sigle's pneumatic otoscope .... 44. Kramer's ear-speculum ..... 45. Blake's middle ear-mirror .... 46. Delicate forceps for removing foreign bodies from the ear 47. Cotton holder ...... 48. Ear syringe and olive-shaped nose-piece 49. Tin basin used in syringing ear .... 50. Tobold's laryngeal apparatus .... 51. Forehead mirror ...... 52. Eustachian catheters of hard rubber 53. Bonnafont's nose-clamp ..... 54. Auscultation tube . ' . 55. Insertion of the Eustachian catheter 56. Inner view of the right half of the head; antero-posterior section ; Eustachian catheter in situ .... (Gruber) 57. Fixation ofthe Eustachian catheter in position, preparatory to inflation 58. Politzer's air-bag for inflating the middle ear .... 59. Blake's tuning-fork ' . 60. Clinical tuning-fork 61. Konig's rod as modified by Blake 62. Othaematoma and resultant deformity . . . (Gruber) 63. Delineation of operation on cleft lobule . . . (Knapp) 64. Forms of aspergillus flavescens removed from the human ear 65. Forceps for removal of foreign bodies from the ear 66. Aural douche of Clarke ..... 67. Paracentesis-knife . . . . . 68. Weber-Liel's graduated metallic Eustachian catheter and bougie catheter of gummed silk .... 69. Politzer's eyelet and eyelet forceps 70. Weber-Liel's tenotome .... PA3E 124 125 127 130 134 138 139 141 142 143 160 166 167 168 169 169 171 173 174 175 176 177 178 181 182 183 185 186 187 190 200 200 210 248 257 279 297 378 379 411 418 422 LIST OF ILLUSTRATIONS. XIX Fill PAGE 71. Grnber's, J. 0. Green's, and Hartmann's tenotomes . 424 72. Politzer's monometer ..... 444 73. Toynbee's artificial membrana tympani . 494 74. Wilde's snare ...... 519 75. Blake's Wilde's snare with adjustable paracentesis-needle 519 76. Silver probe for manipulating polypi 520 77. Permanent platinum-wire loop on flexible shaft 520 78. Polypus scissors . . . . . , 521 79. Polypus hook ...... 522 80. Toynbee's lever-ring forceps .... 523 81. Forceps for removal of a polypus or a foreign body situate near the mouth of the external auditory canal . 523 82. Mastoid sequestrum, outer surface 534 83. Mastoid sequestrum, inner surface 534 84. Mastoid sequestrum, outer surface 536 85. Mastoid sequestrum, inner surface 536 86. Strong knife for incising softened outer mastoid table . 543 87, Drill and bit for perforating the mastoid portion of the temporal bone. (A. H Buck) 544 errata. Page 73, 13th line from bottom, for Fig. 18, e, read Fig. 17, e. "310,20th " " top, for Dr. C. T. Blake, read Dr. C. J. Blake. PART I. ANATOMY AND PHYSIOLOGY. SECTION I. EXTERNAL EAR, CHAPTER I. THE AURICLE. Fig. 1. ANATOMY. The external ear comprises the auricle and the external audi- tory canal. The auricle, or ear of common language, is formed of a cartilaginous sheet, from one to two millimetres thick, with various depressions and elevations. Extrinsic and intrinsic ligaments and muscles are inserted into it; it is well supplied with bloodvessels, lymphatics, and nerves: and it is covered with skin. The auricular cartilage is of the reticular variety, and the various depressions and elevations into which it is twisted have received the following names: helix, antihelix, fossa of the helix, fossa of the antihelix, the tragus, the antitragus, the lobule, and the concha. The entire auricle is also called the pinna. These portions of the auricle have received other names from some authors, but those given here are, perhaps, the most commonly used in English. Henle' and others give to the fossa helicis the name of fossa navicu- laris or scapha, and to the fossa antihe- licis the name of fossa triangularis. I prefer, however, the names suggested by Antiheiix. &. Fossa of the heiix. Grav, because tlicv will natural]v occur d- Fossa of the aauheiix. e- J ' %" . " Tragus, f. Antitragus. h. Lo- to any one acquainted with the anatomy bale. g. concha. 20 EXTERNAL EAR. of the auricle, and the combination of a few words will supply the terms necessary in the designation of the various parts oi the pinna. Fig. 2. Muscles of the Auricle, Outer Surface. (Henle.)—b. Incisura auris. e. Spina helicis. h. M. auricularis superior, g. M. helicis major. /. M. helicis minor, c. M. tragicus. a. M. anti- tragicus. Muscles of the Auricle.—The extrinsic muscles of the auricle are those which move it as a whole, and are the I. Attollens aurem. II. Atrahens aurem. III. Retrahens aurem. The intrinsic muscles of the auricle, or " proper muscles of the ear," are seven in number. These have also been denominated vestigia, a name well chosen as indicative of their condition in man. Henle says:1 "These muscles, with one exception, run between the various portions of the auricular cartilage and the external auditory canal. They are all muscles of animal life; but on 1 Eingeweidelehre, s. 726. THE AURICLE. 21 account of their extreme thinness are pale, and lie immediately upon the cartilage, into the fibrous layer of which they are in- serted by means of short tendinous fibres. They are not equally persistent; whether they are all equally developed at first and finally become atrophied through disease, can only be decided by a statistical comparison of the ears of adults and children." Five of the proper muscles of the auricle are on the anterior surface and two are on the posterior surface of the organ. Those on the anterior surface of the auricle are the tragicus, the antitra- gicus, helicis major, helicis minor, and the two on the posterior surface are the transversus auriculas, and the obliquus .auricidce. Fig. 3. d Cartilage and Muscles of Auricle, Posterior View. (Henle.)—/. Cartilage of externa auditory canal, e. Surface of attachment of same to the edge of the boDy canal, d. Cartilage of the pinna, c. Cauda helicis, I. Eminentia scaphw. g. Eminentia fossa conch«. h. Transverse muscle of the auricle, b. Oblique muscle of the auricle. In some rare cases, a third muscle is found in the auditory canal, and is called the 31. incisures Santorini. It lies below, and further in the auditory canal than, the M. tragicus. Ligaments of the Auricle.—The ligaments of the auricle may also be divided into an extrinsic and intrinsic set: The first con- nect the auricle with the side of the head, and the second con- nect the various parts of the cartilage together. The former, the most important, are two in number, anterior and posterior. 22 EXTERNAL EAR. The anterior ligament extends from the process of the helix to the root of the zygoma. The posterior ligament passes from the posterior surface of the concha to the outer surface of the mastoid process of the temporal bone. A few fibres connect the tragus to the root of the zygoma. " Those connecting the various parts of the cartilage together are also two in number. Of these, one is a strong fibrous band, stretching across from the tragus to the commencement of the helix, completing the meatus in front, and partly encircling the boundary of the concha; the other extends between the concha and the processus caudatus."1 Bloodvessels and Lymphatics of the Auricle.—-The arteries sup- plying the auricle are, the posterior auricular, from the external carotid; the anterior auricular, from the temporal; and the (utricular branch, from the occipital. The veins follow the arte- ries in their general distribution. The auricle is supplied with a beautiful and very rich net- work of capillary lymphatics, an important consideration in aural disease. Nerves of the Auricle.—The nerves are most numerous on the posterior surface of the auricle, while the concave surface and the lobule are comparatively poorly supplied with nerves. In some of the lower animals, the mole variety especially, the nervous supply of the auricle is so rich and so peculiar in its development, as to endow the auricle with valuable tactile powers.2 The nerves of the auricle are derived from the auricu- laris magnus, from the cervical plexus; the posterior auricular, from the facial; the auricular branch of the pneumogastric ; and the auriculotemporal branch of the inferior maxillary nerve. Integument of the Auricle—The cutis of the auricle is a con- tinuation of that of the face and head, which, after covering the cartilage, forms a fold at its base, called the lobule. In some rare instances the cartilage of the auricle may extend into the lobule, and then the usually harmless operation of piercing it for purposes of adornment may give rise to serious chondritis. » Gray"s Anatomy, p. 629. 2 ^jax Schultze's Archiv, 1870. THE AURICLE. 23 The auricle is abundantly supplied with sebaceous glands from 0.5 to 2.0 mm. in diameter, which are most numerous and highly developed in the concha. The entire surface of the pinna or auricle is covered with downy hairs, which attain their most luxuriant growth near the meatus and on the tragus, to which fact the latter spot owes its name of "goat" or tragus. Sudoriferous Glands.—The sudoriferous glands are most abun- dant on the posterior surface of the auricle, an important con- sideration in the management of the ears of infants, for if their auricles are pressed constantly against the head, as is too apt to be the case, chafing of the parts must be the inevitable result. The modified sudoriferous glands of the cutis of the external ear are developed into ceruminous glands in the external audi- tory meatus.1 PHYSIOLOGY. The use of the extrinsic auricular muscles is usually very imperfectly developed in man, although the ability to move the auricle is now and then met with even in the most cultivated. It has, however, been supposed, that as civilization has elevated man above a merely animal existence, the power to move the auricle freely and voluntarily, has diminished as the necessity of such a function would cease with a less savage life. Such indeed seems to be the rational view to take of the use of these muscles. That they are capable, however, of culti- vation does not seem to be an uncommon observation. All are familiar with the story of Albinus, the anatomist of the eighteenth century, who could move his auricles so well, that he was in the habit of removing his wig in order to demon- strate to his class the power he possessed over them. Sir Astley Cooper has recorded a case2 in which the auricles were in constant motion whenever great attention was necessary. Two physicians of my acquaintance can move the auricles markedly with ease. I have very often seen the auricles move unconsciously in my patients, when standing behind them, and they were obliged to be more than usually attentive. But this motion was not continual; it appeared to me to be an entirely 1 Kessel, Strieker's Handbuch, p. 841. 2 Phil. Trans., London, 1800. 24 EXTERNAL EAR. involuntary endeavor at an adjustment of the auricle in the most advantageous position for hearing. When suddenly surprised by an unusual or loud noise, I am sensible of a very marked movement, entirely involuntary, of my own auricles. I have seen marked contraction in the region of the tragicus and anti-tragicus muscles, during the application of the constant electric current by means of a ball-electrode. The general opinion is that a small ear, well shaped, is a sign of careful breeding, whereas the large elephantine auricle is accepted as a type of vulgarity ;x however, the unfortunate possessor of a large auricle is compensated for his so-called misfortune, by the popular belief that the large auricle is a sign of good nature and generosity. This may be the modern idea, but Giotto, in his drawing of Envy, in the chapel of the Arena at Padua, represents the auricle as superhuman in size, its long axis as a continuation of that of the horizontal ramus of the inferior maxillary bone, and without a lobule. It is also a matter of interest that the position and shape of the auricle are national peculiarities, as seen on the ancient Egyptians, the trait being carefully preserved even in the rude attempts at works of art made by the artists of the age and country. It is also said that the Egyptians, even in the present day, possess this peculiarity of high-placed auricles, and as late as 1840 there was in " Paris a teacher of Arabic—a Copt of Upper Egypt—who possessed this conformation in a most decided degree."2 However significant the shape of the auricle may be, it is probably not so significant of caste as the shape and texture of the hand, although, without doubt, it has a great significance. Prof. Meyer3 states, that it has already been noted by previous observers that malformations of the external ear are found in the greatest number in connection with arrested development in the region of the first (Kiemenspalte) branchial or visceral fissure, viz., with cleft palate, and other forms of retarded development in the bones of the head and face. The explana- 1 Parvse malos mores docent, magnse et erectse indices sunt stultitise aut loquacitatis. Opera Galeni, iv. 797. Kuhn, Leipsic, 1833. 2 J. Williams, Treatise on the Ear, London, 1840, p. 80. 3 Ludwig Meyer, Ueberdas Darwinische Spitzohr. Virchow's Archiv Band 53, Heft 4. THE AURICLE. 25 tion of Virchow, that these changes are due to inflammatory processes in the earlier days of foetal development, seemed sufficient to Meyer, until, as he says, he instituted a careful examination of the form and position of the external ear, in a number of insane people, manifesting those peculiarities de- scribed and called by -him cranium progenicum. In all these cases there was a relative arrest of development of the bones of the face, especially a malformation of the inferior maxilla, and it should be borne in mind that the inferior maxilla is formed through ossification in the membrane of the visceral arch. The expectation of finding, in just such cases, characteristic forms of the ear, was not realized, and the theory appeared the less tenable, the further the investigation was extended to numerous cases of both the insane and the sane. Patholosn- cally, the result of the investigation is considered by Meyer to be unimportant, but he expresses a belief that the significance of the form and position of the external ear is purely of a physiog- nomical character. In connection with a beautiful, well-formed face, we usually find a round, well-formed, small, and close-lying ear; whereas, in macrocephalic heads we find large massive ears, in some cases real elephantine ears ; while the narrow ear, directed backward, the so-called Faun's ear, accompanies a low, retreating forehead, sharp nose, and narrowT chin. A comparative examination of normal male heads seems to indicate that the position of the ear possesses a certain and constant relation to the architecture of the skull, for female heads,-with a large facial angle, show a more vertical position of the concha than is usually seen in females and in children who possess, as a rule, small facial angles. In women and children we often find, in connection with a large facial angle, obliquely placed ears, so that the upper part of the helix points backward, and the posterior portion is directed downwards. The cause of this is to be sought for in the relation of the ramus to the body of the inferior maxilla rather than in the relations of the superior maxilla and the frontal bones to each other. The explanation of the connection between the position of the ramus of the inferior maxilla and the external ears is to be referred to the development of those portions of the face from the same part of the branchial arch. 26 EXTERNAL EAR. Kot only the position of the ears, but the elevations and depres- sions ofthe auricle, vary even in the same individual. Mr. Darwin's ideas of the significance of certain prominences in the helix are thus given by that distinguished observer: "The celebrated Mr. Woolner informs me of one little pecu- liarity in the external ear (i. c, auricle) which he has often observed both in men and women, and of which he perceived the full signification. His attention was first called to the subject while at work on his figure of Puck, to which he has given pointed ears. He was thus led to examine the ears of monkeys, and subsequently, more carefully, those of man. The peculiarity consists in a little blunt point, projecting from the inwardly-folded margin, or helix .... These points not only project inward, but often a little outward, so that they are visible when the head is viewed from directly in front or behind. They are variable in size and somewhat in position, standing either a little higher or a little lower; and they sometimes occur in one ear and not in the other. ISTow, the meaning of these projections is not, I think, doubtful; but it may be thought that they offer too trifling a character to be worth notice. This thought, however, is as false as it is natural. Every character, however slight, must be the result of some definite cause ; and if it occurs in many individuals, deserves consideration. The helix obviously consists of the extreme margin of the ear folded inward, and this folding appears to be in some manner con- nected with the whole external ear being permanently pressed backward. In many monkeys which do not stand hio-h in the order, as baboons and some species of maccaus,1 the upper portion of the ear is slightly pointed, and the margin is not all folded inward; but if the margin were to be thus folded, a slight point would necessarily project inward and probably a little outward. This could actually be observed in a specimen of the Ateles beelzebuth in the Zoological Gardens ; and we may safely conclude that it is a similar structure—a vestige of formerly-pointed ears —which occasionally reappears in man."2 1 See also some remarks and the drawings of the ears of the Lemuroide - Messrs. Muril's and Mivart's excellent paper in Transact. Zool. Soc vol ^ pp. 6 and 90, 1869. '' ' V11" 2 Darwin, Descent of Man, vol. i. pp. 21 and 22. THE AURICLE. 27 Prof. Ludwig Meyer,1 in an article referring especially to Darwin's idea, that the common, small projections in the helix of the ear are remnants of the pointed ear of certain Simian races, says that too much importance has been attached to the deviations in the form of the auricle, but he admits that fre- quently we find irregularities in the edge of the helix. To one of these, more prominent than the others, Darwin has attached the significance already alluded to. Xow, the edge of the helix is rarely completely smooth, and even when any slight ine- quality of the concha escapes the eye, the finger can readily detect it. These are really deficiencies and not absolute promi- nences, and the wider the loss of substance in the helix carti- lage, the more prominent will the remaining portions appear. If, in an ear where one or two such prominent remnants of the helix occur, a line be drawn joining them, it will corre- spond with the outline of the normal helix. That these promi- nences are nothing more than remnants of the helix, is proven by the fact that their inclination and curve correspond entirely with the curve of the helix. That part of the helix which affords the most examples of the peculiarity referred to by Darwin, is most adapted to producing the longest points, since it is the widest portion of the curved helix. These changes in the ear are doubtless not produced during life, but are congenital. They are found in perfection in little children, and are more apt to occur in males than in females. According to Kollman, the helix is not a separate point of development. The auricle consists originally of those formative parts which can be distinctly recognized at the end of the sixth week of fcetal life, as tragus, antitragus, and antihe- lix. From the latter the helix is developed. Hence we see that as interferences in the development of the tragus may cause the presence of a cleft in it, so may disturbances in the development ofthe antihelix cause deficiencies in the helix. Prof. Laycock says:2 "Men of high intellectual attainments, great capacity for mental labor, and great force of character, have a full, perfectly ovoid ear, the helix well developed, the 1 Ludwig Meyer, Ueber das Darwinische Spitzohr. Virchow's Archiv, Band 53, Heft 4. 2 Med. Times and Gazette, March 22, 18G2. London. 28 EXTERNAL EAR. lobule plump, pendent, and unattached to the cheek at its ante- rior margin. These characteristics are seen in all portraits ot great men which Lavater gives, and are easily observed in liv- ing celebrities." The same writer also says : " In a perfect ear the ovoid lobule han°;s from the cartilage with a rounded lower margin, which, at its inner border, is not confluent with the face. Now, if this inner margin be adherent to the cheek, and at the same time the lobule be only a segment of an ellipse, there is more or less tendency to imperfect cerebral action. A more import- ant form is seen when the lobe is not only soldered to the cheek, but its posterior half cut away, as it were, and the helix defective." A knowledge of these peculiarities in the ear of an individual may become of great legal value, as in the Tichborne case, in which it was shown that the " claimant's" ears were altogether different from those ofthe lost heir. Comparative Functions of the Auricle.—The functions of the auricle are modified by the habits of the animal, and, since in most four-footed mammals the external ear is well developed, we have an opportunity of observing in them a variety of func- tions, acoustic and otherwise, acquired by the auricle. The large, long, and easily moved auricles are found in animals that are timid and often pursued by stronger and sagacious animals, while those which pursue, as lions, tigers, etc., possess auricles which are short and directed forwards. AYe have no positive means of finding out how sounds are modified by these peculiarities in the auricles of these animals. However, by applying a variety of speaking trumpets to our ears, and by alterations in the position of these artificial auri- cles, as well as of our own by manipulation, we may form at least an approximate idea of the modification in hearino- pro- duced by the size, shape, and position of the auricle. By such experiments we see that it is highly probable that ordinary sounds are augmented, and faint sounds rendered very audible to animals with largely developed auricles, by the increased resonance such organs produce, a function of the auricle us f 1 to animals which are rapacious as well as to timid ones wh" h are pursued. THE AURICLE. 29 The auricle is small in seals, walruses, moles, and the manis, but largely developed in some species of the bat, and " is so con- structed as to prevent air from rushing in while flying."1 In birds, the auricle is wanting, as it would probably greatly impede their flight, but in night birds, the power to elevate the feathers around the ear seems to indicate that they can supply themselves at will with a kind of auricle, and that their hearing is thereby augmented, a necessity due to their nocturnal pur- suits. The auricles of the mouse2 and of the hedgehog3 are developed into organs of touch, and the auricles of marine mammals seem to become almost useless; as in the narwhal "the opening of the ear is of the diameter of a knitting-needle,4 and in the leopard seal the ears are merely openings in the surface of the skin, which are placed one and a half inches behind the eye,"5 while in the sea-otter6 the " ears are less than an inch in length," the animal being at least five feet long. In the water-shrew, an aquatic mammal, the anti-tragus serves as an operculum to the auricle, which fact seems to indicate that the auricle is no longer needed for hearing as soon as the animal ceases to live in the air. In the crocodile, also, the auricle acts as an operculum, and in the whale it is practically absent. Therefore, the fully developed auricle is needed by and found in mammals whose life and condition are aerial, and we find that it ceases to exist, or its functions are altered, in mammals inhabiting the water or living underground. So much influence on hearing was attributed to the auricle by the first Dionysius of Syracuse, that he is said to have con- structed a subterranean cave in a rock, in the form of a human ear, which measured eighty feet in height and two hundred and fifty feet in length; the sounds of this cave were then directed to a common tympanum, which had a communication with an adjoining room, where Dionysius spent the greatest 1 J. Williams, Treatise on the Ear, London, 1840, p. 35. 2 J. Schobl, Max Schultze's Archiv f. Mic. Anat., 1871, p. 260, four plates. 3 Ibid., 1872, p. 295. 4 Marine Mammalia of North America, by Chas. M. Scammon, U. S. Rev. Marine, p. 108. s Ibid., p. 165. 6 Ibid., p. 168. 30 EXTERNAL EAR. part of his time, to hear whatever was said by those whom Ins suspicions and cruelty had imprisoned. Resonant Functions of the Human Auricle.—As early as 1840, J. Williams, M.D., of London, attributed to the "configura- tion and tension of the auricle" the function of determining the " finesse of hearing." This author was led to such a con- clusion by the augmentation of sound obtained by pressing forward the auricle, and surrounding it by the hand, but he mistakenly referred the improved hearing which ensued to the overcoming of what he termed a relaxed condition of the auricle by the support of the hand. It was, on the contrary, due to the augmented resonance of the auricle, brought about by the relative lengthening of the external ear, by pushing the auricle out from the head, and adding to it the resonance of the hand. It is evident, therefore, that writers on the ear long ago noted the phenomena of alteration in the resonant functions of the external auditory apparatus caused by increase or diminution of its depth and position; but that these phenomena depended upon the power of the auricle and the external auditory meatus to act as resonators was not suggested nor proven until Hem- holtz's experiments in acoustics had rendered the subject of resonators clearer, and experiments on the human ear demon- strated that the most probable function of the auricle is that of a resonator, adapted to augment just those high notes or sounds most likely to be of interest and importance to man. According to Dr. Kiipper,1 the auricle can reflect sound into the auditory canal only to a limited extent, " because that part of the auricle which would reflect the sound-wave falling on it, into the auditory canal, is very small." Nor does he believe that it is concerned in the direct collection and transmission of sound as the drum-head is, for it is neither so elastic as the latter, nor is it inserted into a bony frame. He also denies it the function of determining the direction of sound, which, he thinks, may be proven by inserting into the meatus, a tube of any kind, thus cutting off all participation of the auricle in the reception of sound, when it will be found that the direction of sound can still be told. 1 Archiv f. Ohrenh., vol. viii. 158. THE AURICLE. 31 This author appears to be wTrong in his assertion that the auricle can have no influence in hearing, for it is well known that with the altered shape of the auricle in othematoma, the hearing is altered. He furthermore argues that the auricle in man is useless, because birds have none ; but birds do not need an auricle, on account of the high resonance of their audi- tory canal, as well as the interference in flying such an appen- dage would entail. Dr. Kiipper, therefore, places the auricle of man in the " list of organs inherited, but no longer possessed of functions." He, however, ascribes an important part to the auricle in the lower animals, agreeing with Miiller1 that as it is supplied with so many (17) well-developed muscles, it is well adapted to catch sounds, but especially to express the passions of the animal, as is best seen in the horse. Dr. Kiipper, how- ever, apparently does not believe that the auricle of man, while losing the function so sharply seen in the lower animals, gains a higher and more delicate one, of resonator for the nobler tones of the human voice, as shown by the author. Prof. E. Mach2 considers the auricles in the lower animals, resonators for the higher tones of ordinary sounds, important for them to hear, such as the rustling of grass and leaves. This function depends partly upon the ability ofthe animals to place the auricles towards the direction of the sound, and thus to alter the clang-tint, which leads to a proximate knowledge of the direction of the sound. A remnant of such a function may still be found in the human auricle, according to Mach, which agrees with the theories advanced, previous to those of Mach, by the author.3 In the summer of 1873, while I was travelling and exposed to a great variety of powerful sounds, of nature and of com- merce, I made some experiments on my own external ears, respecting their power of receiving all or part of the component tones entering into such complex sounds, as the rustling of leaves, the roar of Niagara, the seething and hissing noise heard in the wake of a large steamer, or in the escape of steam from a powerful locomotive or steamboat. I found that by altering the position of my auricle, that is, by relatively lengthening 1 Physiologie der Hanssaugethiere. 2 Archiv f. Ohrenheilkunde, Bd. ix. p. 72, 19 June, 1874. s Phila. Med. Times, No. 101, Oct. 4, 1873 ; No. 127, April 4, 1874. 32 EXTERNAL EAR. thereby the depth of the external auditory canal, I could ana- lyze the composite sounds alluded to, for if I pressed my auricle firmly back against my head, I heard the higher sounds, i. e. the entire sound became to my ear apparently of a higher quality, whereas, if I pushed my auricle outward and forward, the deeper partial sounds became more pronounced, and the entire composite sound became louder and deeper. I joined my friends, Drs. Buck and Blake, and communicated to them what I had very easily found out, and as they are endowed with musical or analytical ears, I requested them to repeat these ex- periments upon themselves, which they did ; Dr. Buck while with me, and Dr. Blake subsequently after we parted, and they both have confirmed my discovery. In the autumn of 1873 I published my first paper, and in the spring of 1874 my second paper on what I had observed re- specting the function of the external ear, especially of the auricle, viz., that it is a resonator for high notes. The first paper contained chiefly a description of the pheno- mena I had observed ; and the second paper was devoted spe- cially to their physical explanation. The substance of the first paper was the following:— Before any further explanation of the functions of the auri- cle, let us briefly consider the acoustic nature of some of the ordinary sounds which are received by it. It is well known that every sound is composed of a collection of " partial tones" or " over-tones" which determine its timbre or clang-tint. Any one of the ordinary sounds of nature, as, for example, the roar of a cataract or of the surf, and the rustling of the leaves in a forest, is composed of a large number of partial tones, which, for the sake of simplicity, let us call deep, intermediate, and high partial tones. The ordinary normal ear does not isolate any of the partial tones of a composite sound, but perceives them as a whole. This is due to the fact that certain parts of the auricle re- sound best to the high partial tones, while other portions of it resound best to the intermediate and low partial tones thus insuring the complete reception by the auditory nerve of all the partial tones which compose any given sound falling on the auricle. I have discovered, by experiments upon my own ear that the region of the helix and its fossa resound to the deeper THE AURICLE. 33 notes, the antihelix and its fossa to the intermediate notes, and that the concha, "the deep concavity within the position ofthe antihelix, presenting a semi-spiral course towards the entrance of the auditory meatus," resounds best to the high partial tones. In order to prove this it is necessary to be in the presence of a sound possessing the characteristics of those already mentioned, when, by pressing the auricle at its outer edge gently forward, the sound instantly becomes a deeper one, from the augmenta- tion of the resonance for deep tones thus gained by the helix and its fossa. The deep tones, however, are immediately weakened or lost by placing the finger upon the helix and pressing it firmly against the head. Then it is found that the sound becomes one in which the intermediate and higher partial tones are prominent. By pressure upon the antihelix the intermediate tones become weaker, and the higher partial tones are most distinctly per- ceived, on account of their undisturbed resonance in the concha. Firm pressure upon the helix, antihelix, and concha will inter- fere with the resonance of all but the highest partial tones. In the latter instance the resonance of the meatus auditorius ex- ternus has full scope, for this part of the ear, according to Helmholtz, resounds best to notes of the fourth octave (e'v-gw). . Therefore, if any one of these portions of the auricle has its acoustic functions altered, either by disease or artificially, the tones to which it resounds will be weakened or lost, and the prominence of the other partial tones will change the timbre of the original sound. Experiment will show that by giving prominence to a certain portion ofthe auricle, viz., the helix and its fossa, a sound may be rendered fuller, and hence louder, from the increased reso- nance of the deeper notes which enter into its composition. This may explain the asserted increase of hearing in some cases of othematoma, when the swelling may have rendered these particular parts prominent, and thus have increased their reso- nant power. But if the disease advance and produce great swelling and rigidity of the auricle, as it usually does, we can also readily understand the impairment of hearing in these cases. One without an auricle, all the rest of the auditory ap- paratus being normal, can indeed hear sounds, practically very well, but they are altogether different, acoustically considered, 3 Fig. 4. 34 EXTERNAL EAR. from the complete composite sound heard by the V°^T. Bevelled edge of tHe squamous portion. 6. Zygomatic process. 7. Digastric fossa. 8. Occipital groove. 9. Groove for the lateral sinus. 10. Position of the superior petrous sinus. 11. Opening of the carotid canal. 12. Meatus audito- rius interims. 13. Aqujeductus vestibuli. 14. Styloid process. l."». Stylomastoid foramen. 16. Carotid foramen. 17. Spine separating the eighth pair of nerves from the jugular vein. The dark spot in front of the number 17 is the position of the opening of the aqueduct of the cochlea. IS. Points to the Vidian foramen on the anterior surface of the petrous portion. 19. Origin of the levator veli palatini, and of the tensor tympani muscles. demonstrable as a separate cartilaginous body, and that the upper end of the styloid process is not found at the externally visible base of the process, but that it extends upward as far as 1 Archiv f. Ohrcnh., Bel. ix. p. 164. 40 EXTERNAL EAR. the lower part of the eminentia stapedii, along the posterior limit of the tympanic cavity, from which it is separated by a thin osseous lamella. Space forbids a lengthy consideration of the developed tempo- ral bone, but a few prominent features deserve notice here, as, that under the floor of the tympanic cavity is part of the jugu- lar fossa; that the anterior wall is part of the carotid canal; that the roof of the tympanic cavity is a thin bony septum be- tween the brain and the middle ear; and that the mastoid cells are separated by a thin partition of bone, from the sigmoid fossa, in which runs the lateral or transverse sinus of the dura mater. In addition to these facts may be mentioned that the entire internal ear, or labyrinth, lies in the petrous pyramid of the temporal bone, that the middle ear is formed by the union of the squamous, petrous, and mastoid portions of the temporal bone, and that the osseous portion of the Eustachian tube lies in the inner end of the petrous portion ofthe temporal bone, through which the tensor tympani muscle maybe said to run on its way to the tympanum. Its more detailed arrangement will be ex- plained when alluding to the soft parts of the Eustachian tube. Furthermore, the levator palati, an important" tubal muscle, originates at the under surface of the temporal bone, near the inner end of the petrous part; the carotid canal passes through this part of the bone, and the jugular fossa is partly formed by the temporal bone; the facial nerve passes through this bone from the brain to the face, and the aquseductus cochleae, the im- portant exit for the perilymph of the labyrinth, is placed near the carotid canal on the under surface of the temporal bone. It is also important for the aurist to bear in mind that on the upper and cerebral surface of the petrous portion are the petro- sal sinuses, and that these are closely connected with the cavern- ous sinus, which in turn is emptied into by the ophthalmic vein, a relationship which may often explain facial and ocular symptoms in obstruction of the sinuses from aural disease. The small opening of the aqueeductus vestibuli, on the pos- terior surface of the pyramidal petrous part of the temporal bone, near the entrance of the auditory nerve, must not be for- gotten, as at this point purulent disease may often be found to have entered the cranial cavity from the tympanum and vestibule. The anterior wall of the bony auditory canal forms part of THE AUDITORY CANAL. 41 the glenoid fossa, and it can thus be seen how, in certain inflam- mations about the ear, movements of the jaw are exceedingly painful. Fig. 8. Under Surface of Left Temporal Bone. (Gray.) At birth the bony auditory canal does not exist; the ring from which it is developed is deficient at the upper fourth, and the canal is represented at that point by the curved lower edge of the squama. The aforesaid ring grows at last into a tube which forms the posterior, inferior, and anterior wall of the osseous external auditory canal, to which the name of tympanic bone is also given. In the new born child the mastoid portion is also rudimentary and not fully united with the squama. At the line of imperfect union between these two parts of the temporal bone, quite large deficiencies are found in early child- hood and in some cases persist even into adult life. 42 EXTERNAL EAR. Development of the Bony Auditory Canal.—The osseous audi- tory canal, i. e. the inner and major portion of the entire audi- tory passage, is developed from the so-called drum ring, annulus tympanicus or processus auditorius. This ring, which is open or interrupted (for 1-2 mm.) at a point in its postero-superior periphery, has a furrow on its inner edge called the sulcus tym- panicus. This ring, united to the squamous and petrous portions of the temporal bone, gradually grows outward, and forms the antero-superior, anterior and anteroinferior wall of the bony auditory canal. The two prominent points (see Fig. 5) on the anterior and upper part of the ring are called by Henle' spina tympanica antica and postica, and are the terminal points of a ridge forming the upper boundary of a furrow called the sulcus malleolaris, which finally becomes the posterior boundary of the petrotympanic fissure for the reception of the long process, processus folianus of the mal- leus, and the various soft parts which pass through the afore- said fissure, also called the Glaserian fissure. Development of the Annulus Tympanicus.—The spina tympanica antica unites with the tegmen tympani and thus completes the petrotympanic fissure posteriorly, but the spina tympanica pos- tica projects beyond or behind the tympanic margin of the squamous portion of the temporal bone, and also behind and above the drum-head, and inserts itself at last into the depression between the head and the handle of the mallet, called the neck, as shown by Henle. Considered as anatomical points these are quite insignificant, but when taken in their physiological rela- tions with the support they give to the malleus they are of great importance. As the bone develops the spina tympanica antica grows away, as it were, from the spina tympanica postica, and is finally seen at a point far down on the superior wall of the bony portion of the canal, in the fully developed broad tympanic bone. As, however, the spina tympanica postica of Henle, in the foetal bone, becomes of so much importance as the anterior point of insertion for the ligaments supporting the malleus in the developed organ, Helmholtz has given to it in its physiological relations, the name spina tympanica major ; and to a less prominent point on the postero-superior portion of the ring in which the drum-head is inserted, he gives the name of THE AUDITORY CANAL. 43 spina tympanica minor. The latter forms the posterior point of insertion for the suspensory ligaments of the malleus. The neck of the malleus fits in between these two points in such a manner that the anterior almost touches it. In the perfect bone this relation is not visible from without. The line of attachment of the membrana tympani also shows a slight and ill-defined depression where it passes near and beneath these points, i. e., at its upper periphery above the short process of the hammer. Here the line of insertion of the drum- head is less sharply defined than it is lower down the periphery. At this ill-defined point in the upper part of the periphery of the membrana tympani, " slight pressure with a blunt instru- ment will loosen the membrane from its attachments. In fact it is more truly attached to the cutis than to the bone.'*1 Segment of Iiivinus.—This segment in the upper border ofthe drum-head is called the segment of Rivinus, since it includes the foramen described by Iiivinus, an opening which in some in- stances represents the last trace of the first visceral cleft, but which really has no existence in the majority of normally devel- oped adults. The Auditory Canal.—The external auditory canal extends from the bottom of the concha to the drum head, and consists of a cartilaginous and a bony portion, the former being about one-third and the latter about two-thirds ofthe passage. The length of the auditory canal is about one inch and a quarter, and its average width is about a quarter of an inch.2 The canal gradually narrows to the middle of the bony portion, where it widens again gradually to the drum-head. A hori- zontal section, therefore, of this canal will be proximately repre- sented by that of two detruncated cones placed together at their points of detruncation. The auditory canal is lined with skin, a continuation of that of the auricle, and not with mucous membrane. The skin of the canal is extended over the drum- head, forming its dermoid or outer layer, so that a glove-finger ' Mechanism of the Ossicles of the Ear and the Membrana Tympani. H. llclmholtz, Bonn, 18G9. English translation by A. H. Buck and Normand Smith, New York, 1873. 2 Richet, eight to nine mm. at the opening, and from six to seven mm. at the fundus of the canal. (Hyrtl.) 44 EXTERNAL EAR, will represent very well the shape of the cutaneous lining of the canal, the finger-tip being the position of the drum-head. In the bony portion of the canal, the skin is thin and closely adherent, its silvery lustre having probably led earlier observers Fig. 9. Incus Malleus Sttape .iSTirm-oi-rnwlar Cabals Cochlui Transverse Section of the entire Auditory Apparatus of the Right Side. (Gray.) to call it a mucous membrane; but there is no such membrane in the external ear. In the inferior wall of the meatus there are deficiencies in the cartilage called the incisures Santorini, and there is a cleft in the upper wall of the cartilaginous part of the canal. The general course of the external auditory canal may be described as sigmoid, or as a spiral turning anteriorly inward and downward, though there are many individuals in whom the auditory canal is so straight that their drum-heads may be seen very easily by direct inspection and without dilation of the cartilaginous part of the passage. I have frequently inspected the drum-head in such cases without the knowledge of the person examined, sometimes while riding in a street car. Such straight canals are invariably wide ones; and much more com- mon in the black than in the white race. Although the external auditory canal is usually spoken of as tortuous, I have observed that in the negro it is usually wide and straight, so much so, in fact, that in most cases in this race, I have been able to see the membrana tympani without THE AUDITORY CANAL. 45 the aid of speculum and reflected light, being able to look directly down upon the drum-head. I have sometimes, though very rarely, seen the same kind of a wide and straight auditory canal in the white man. Could the large auricle and auditory canal have any connec- tion with the musical talent universally found in the negro race in this country ? In the white race, the wide and straight meatus, according to my observation, is found in individuals more than ordinaril}' endowed with the so-called musical ear. Upon the entire free surface of the cutis of this canal are found epidermis and soft short hairs, together with the sebaceous glands usually found in connection with them. Throughout the canal, especially in the bony portion, are found vascular papillae arranged in parallel rows, and glandular structures closely resem- bling sudoriferous glands, but which in their modified form are called ceruminous glands. Ceruminous Glands.—These glands begin about two mm. from the opening of the auditory canal, and extend to within two to three mm. of the drum-head; they are found in the bony as well as in the cartilaginous part of the canal. They are most numerous at the junction of the cartilaginous with the bony canal, where they average as many as ten to the square milli- metre. According to Buchanan, there are from one thousand to two thousand in an auditory canal. The thickness of the skin in the cartilaginous part of the auditory canal is one and a half mm. thick. Vessels and Nerves.—The arteries supplying the auditory canal are branches from the posterior auricular, internal maxil- lary, and temporal. The nerves are chiefly derived from the temporo-auricular branch of the inferior maxillary nerve. There is also an auricular branch of the pneumogastric nerve. PHYSIOLOGY. The acoustic physiology of the external auditory canal has been alluded to in speaking of the functions of the external ear as a resonator. There is one function it possesses, that of causing the ear-wax and some small foreign bodies to fall out from it, which is not fully explained. 46 EXTERNAL EAR. Voltolini1 has shown, that if a foreign body is wedged in a swollen auditory meatus, and the former be made smaller by any means, but especially by the galvano-caustic, the body thus reduced will be pressed out by the swollen walls of the auditory canal. This he claims to be an invariable physical process. Perhaps we may explain the natural escape of cerumen from the ear in some such way as the following : The ear-wax is mostly formed in the wide end of a detruncated cone, i. e., near the outer end of the auditory canal. Therefore, as the wax forms, it presses upon the walls of the auditory canal, and the latter being widest towards the mouth, i.e., freest on the outer side of the gradually growing mass of cerumen, the latter meets with the least obstruction just in the direction of its only escape; hence it will be acted upon very much as if it remained a constant quantity, which is being continually pressed upon from behind, and pushed outward by a gradually narrowing auditory canal; for, as the mass accretes, it must necessarily, with its naturally lubricated surface, slip into a broader, which is an outer, plane in the external auditory meatus, and thus at last it may be found at the mouth of the auditor}" canal. Unfortunately, this delicate function is constantly interfered with by those who, in en- deavoring to clean out wax, push in more than they bring out, and thus, in a short time, form obstructive plugs of cerumen. Another mode by which cerumen is aided to fall out of the auditory canal, if let alone, has been suggested to me by watch- ing the gradual outward movement of a scab on the membrana tympani, and of a similar object on the wall ofthe auditory canal. If a little fleck of blood forming on the membrana tympani, or on the wall of the external auditory canal, be watched for some days, it will be observed to change its position by moving out- ward, strongly suggestive of the manner in which a spot over the matrix of the finger nail will gradually grow to the edo-e of the nail and disappear. I have watched little scabs of blood thus move from the drum membrane to the wall of the canal and from the inner part of the latter similar substances mav be seen to move outward to the mouth of the meatus. In some such way, I believe the outward growth of the skin of the auditory canal helps to force out the superabundant ear-wax. 1 Monatsschr. f. Ohrenh., No. 9, 1872, and elsewhere. MEMBRANA TYMPANI. 47 CHAPTER III. MEMBRANA TYMPANI. ANATOMY. The membrana tympani, or drum-head, is composed of three layers, viz.: the external or dermoid layer; the middle or fibrous layer, also called the membrana propria; and the internal or mucous layer. The Dermoid Layer.—The dermoid layer of the membrana tympani is a continuation of the cutis of the external auditory canal. This may be seen if the skin of the canal be macerated properly, when the entire cutaneous lining may be removed in the shape of a glove-finger, the tip of which will represent the dermoid layer of the drum-head. In this layer there are, how- ever, no hairs nor follicles such as are found elsewhere in the cutis of the auditory canal. In other respects, it is true skin, but extremely thin and transparent. The Outer Surface of the 31embrana Tympani.—The dermoid layer is the only one of three layers composing the membrana tympani, which can be inspected directly from without. When the ear is illuminated and a normal membrana tympani examined from without, there are several prominent features in it, which at once attract attention, viz.: its almost circular shape and peculiar polish and color; its vertical and horizontal inclination ; the manubrium of the malleus; the short process of the latter; the folds of the membrana tympani; the flaccid portion of the drum head above these folds, called the membrana flaccida or Fig. 10. IRFACEOF JlEM- (G ruber.) — a. View of outers brana Tympani. Malleus ; manubrium. B. Short pro- cess; c. The tip of the manubrium. D. Posterior fold. 48 EXTERNAL EAR. Shrapnell's membrane: and the bright triangular reflection of light in its anteroinferior quadrant, called the "pyramid ot light." Shape of the Membrana Tympani.-For purposes of conven- ience in description, the outline represented by the periphery ot the membrana tympani is called circular. This form, however, varies between that of an ellipse and an irregular oval, while in some cases where the lateral portions of the annulus tympanicus are especially curved outward, it assumes a heart shape. It may be strictly considered an ellipse, the long diameter of which, amounting to 9-10 mm., runs from above and in front, downward and backward, and the diameter of greatest width of which runs from below and in front, upward and backward. These measurements are those given by v. Trceltsch, and are nearly in accordance with those of Hyrtl, according to whom the proportion between the diameters is as 4.3//'-4.0"'. Since the difference between them is so slight, and their in- clinations are so nearly vertical and horizontal, the outline of the membrana tympani may be considered circular, and the long diameter is spoken of as the vertical diameter, while the dia- meter of greatest width is considered the horizontal diameter. The membrana tympani is therefore divided into quadrants, which greatly aid in locating any point to be described. Color of Membrana Tympani.—The normal color of the mem- brana tympani is never fixed. Just as some normal teeth are bluish or yellowish-white, so it is with the drum-head, which though perfectly normal may be bluish or yellowish-gray, though more frequently it is found to be the former. The normal color of the drum-head is usually spoken and written of as " pearl gray," but whatever color the membrana tympani may be said to have, that color must cdwa.ys be modified by the physical condi- tions brought about by stretching a slightly transparent mem- brane over a darkened cavity. And this is a modification not sufficiently taken into account by observers. There is there- fore, from the cause just mentioned, an admixture of black with the delicate gray of the membrane, but it is very difficult to paint a transparent or translucent object, and therefore very diffi- cult to ascribe even a name to the color of a normal membrana MEMBRANA TYMPANI. 49 tympani, since its appearance is partly due to the color which its own substance reflects and partly to the color it transmits from the cavity of the drum, the latter feature of course being modified in every imaginable degree by the thickness or thin- ness of the membrana tympani, as well as by the various condi- tions and colors of the contents and lining of the tympanic cavity. Modifications of color similar to those in the membrana tym- pani can be in a measure produced artificially, if we stretch a piece of gold-beater's skin, delicate tissue paper, or sheet gutta percha over a rather shallow cavity rendered dark by covering it in this manner. The color of the membrane thus formed will be composed of the latter's own peculiar tint as an opaque substance and the color of the cavity over which it is stretched and which it transmits. Just such conditions of coloring due to the fact that the membrana tympani is a slightly opaque substance and to the fact that it transmits color from the tympanic cavity must be borne in mind, in any attempt at naming its color, which therefore will ever be composed of the tint of the membrane modified by the color it transmits. Prof. Politzer defines the color of the normal membrana tym- pani, as " a neutral gray tint, with an admixture of violet and light brown." " That part of the membrana tympani, just behind the lower end of the manubrium, and over the promontory ofthe cochlea, is rendered yellowish-gray by the rays of light reflected from the yellow bone of the inner wall of the tympanic cavity." Of course all these shades of color vary a little, even in the normal state; but greatly during pathological processes in any part of the structures entering into the formation ofthe drum-head. The membrana tympani owes its peculiar lustre to the delicate and shining epithelium of the dermoid layer. If a fresh membrana tympani be placed in a solution of nitrate of silver the peculiar cement-like substance between the scales of this epithelium will become tinged, while the scales them- selves will remain uncolored, and thus a distinctly marked pre- paration will be made in which the various shapes of the epithe- lialscales become demonstrable under the microscope. 4 50 EXTERNAL EAR. The slightest maceration or exfoliation of this delicate epi- thelium deprives the membrana tympani of its beautiful gloss. The dermis of the drum-head is thickest in children. The Inclinations of the Membrana Tympani.—Another impor- tant feature which attracts the attention of one examining the ear is, that the membrana tympani, in its normal condition, is inclined at an angle of 45° in its vertical plane, and in its horizontal plane is inclined 10° towards the right on the right side and 10° towards the left on the left side. If the planes of both membranse be extended downward until they intersect each other, the angle which they will thus form will be equal to about 130°-135°. Of still greater importance than this, however, is the direction ofthe walls of the auditory canal from the plane of the mem- brana tympani. Thus if a perpendicular be drawn from the upper pole of the drum-head to the inferior wall of the auditory canal, it will strike the latter about 6 mm. from the inferior pole of the mem- brane. A similar result will be obtained by drawing a perpendicular from the middle of the posterior periphery of the drum-head to the anterior wall of the auditory canal, from which fact it becomes very evident that the anteroinferior part of the mem- bana tympani is further removed from the external opening of the auditory canal than the postero-superior part.1 The membrana tympani is inclined the most in very young children, being in the early years of life, almost horizontal in position, and, on account of the shallowness of the auditory canal at that time, the membrane is very superficial, especially at its upper part. The Manubrium of the Malleus.—Running from above down- ward and backward, to the centre of the membrana tympani is seen the ridge formed by the manubrium of the malleus. This slightly elevated ridge, entirely opaque and decidedly whiter than the surrounding drum-head, divides the membrana tympani into two unequal parts, the anterior being the smaller and 1 Gruber, Studien uber das Trommelfell, p. 4. MEMBRANA TYMPANI. 51 the posterior the larger. At the upper end of this ridge is the short process ofthe malleus, projecting sharply outward, somewhat above the general surface of the handle of the hammer. In gene- ral appearance it is not unlike a pimple with yellowish contents. The lower end or tip of the ridge, which curves slightly for- ward, is flatter, broader, and yellower than the rest of the outer covering of the manubrium. This is due to the fact that the bone proper is spade-shaped at this point, and also because the radial fibres of the membrana propria centre at this lower part of the bone. The lower end of the manubrium draws the membrana tym- pani inward very markedly, and forms that depressed spot in the centre called the umbo. The convex shape of the drum-head from the tip of the manu- brium outward towards the periphery is due to the compara- tively large number of circular fibres at a point between the umbo and periphery, which constrict, as it were, the radial fibres, so as to form a kind of funnel. Fig. 11. Fig. 13. a A B C A' A' Pressure or traction applied to the centre of a membrane stretched over a ring, tends to draw the former into a cone, a vertical section of which is represented by the line A u a' in Fig. 11. But if a smaller concentric ring be placed at b c so as to resist the indrawing force at u, the curve assumed by the membrane 52 EXTERNAL EAR. is represented by the line a u a' in Fig. 12, and the whole mem- brane is drawn into a concavo-convex shape. The Yellow Spot at the End ofthe Manubrium of the Malleus.— This spot is not a pathological appearance, but a purely physio- logical condition. It is part of the cartilaginous structure at the end ofthe hammer. Dr. Trautmann,1 who has made a special study of the spot, concludes that its physiological significance is the same as an epiphysis of a long bone. The diagnostic value of the yellow spot is considered by him to be apparent in cases of thickening of the membrana tympani, wdien the former will disappear much sooner than the sharp edge of malleus. 2. Opacities of the membrane with thickening change the color of the yellow spot. 3. When the malleus is twisted on its long axis the form of the spot will be altered. 4. If the spot does not move during alterations in the atmospheric pres- sure in the canal, by means of Sigle's speculum, it is fair to con- clude that either anchylosis of the malleus or its adhesion to the inner wall of the tympanic cavity has occurred. In the latter instance the differential diagnosis is aided by the neces- sary foreshortening of the handle of the hammer. Folds ofthe Membrana Tympani.—From the short process of the manubrium of the malleus two delicate ridges may be seen, one passing forward, the other backward to the periphery. These are the so-called folds of the membrana tympani. They are formed by the pressure from behind, produced by the short pro- cess of the malleus. They are important topographical as well as diagnostic points of the membrana tympani. Above these folds is the so-called membrane of Shrapnell,2 or membrana flaccida. It owes its flaccidity to the small amount of fibrous tissue entering into its composition, and to the loosely stretched cutaneous and mucous layers of the membrana tympani, which here come together. In this membrane somewhere, there is ' Archiv. f. O. B. xi. p. 99-113. 2 Henry Jones Shrapnell, not Odo Shrapnell, as several German authors have called him. This author's description of the membrana flaccida is found in London Med. Gazette, vol. x. p. 120. MEMBRANA TYMPANI. 53 said to be a normal opening, the foramen of Rivinus, named after the writer, who first called attention to its supposed existence in 1717. Ever since, the dispute has turned upon several points, viz., first, whether there is such an opening; secondly, is it nor- mal or pathological; and lastly, in what part of the membrane is it found. Although a number of distinguished observers, among whom may be quoted Patruban, Gruber, Politzer, and Hyrtl, have investigated this point in the anatomy of the membrana tym- pani, the question was for a long time an open one, until Hyrtl denied the existence of a normal opening in the membrana flaccida, either in the adult or in the infant cadaver. He, how- ever, admits that a want of development in the membrane in the neighborhood ofthe Rivinian segment may, in some cases, lead to the formation of a quasi foramen, but the normal existence of such a foramen is not proven. Such testimony as Hyrtl's is incontrovertible in the author's opinion, and can never be over- thrown by the assertion that the opening is so small, that the anatomist must look for hours with a magnifying glass, in order to find it ; nor can I understand how a foramen should be so small as to require such persistent search with a magnifying glass, and yet, when found, be large enough to allow a bristle to pass in and through it. I have surely never seen any opening in this part or any other part of the membrana tympani that was not purely pathological. The occurrence of any opening in the membrana flaccida is most rationally accounted for by Hyrtl's explanation, viz., by a want of normal development, or by a pathological loosening of the fibres of the flaccid mem- brane from their very loose connection wTith the horizontal edge of the squamous portion of the temporal bone, at that point known as the Rivinian segment of the periphery of the membrana tympani. Pyramid of Light.—The pyramid of light is a name applied to the beautiful triangular reflection of light emanating from the antero-inferior quadrant of the normal membrana tympani. The apex of this triangular reflection touches the tip of the manubrium of the malleus, and its base lies on the periphery of the membrana tympani. It forms with the handle of the malleus an obtuse angle anteriorly, which becomes greater as the 54 EXTERNAL EAR. inclination of the membrana tympani to the auditory canal di- minishes. Its average height is from 1J to 2 mm., and its average width at the base is from 1J to 2 mm. This reflection, which has been called an isosceles triangle from its general appearance, is strictly considered pyramidal in shape, and hence the name applied to it by most writers of the present day. Wilde, of Dublin, called it the " speck of light," and many of the Germans call it the " reflection of light." The causes of the formation of this pyramid of light, or, in other words, the optics of this important spot, have been variously explained by a number of careful observers. Wilde, the first to describe it, believed it to be due to the convexity of the membrane, but other observers since that time, among whom may be named Politzer,1 Gruber,2 Voltolini,3 and Trautmann,4 have most clearly shown that such a convexity is not the only cause of the formation of the pyramid of light. From the more recent investigations, it is most conclusively proven that there are three elements indispensable to the formation of this peculiar reflection of light, viz., a shining surface, the inclination of the membrane, and its peculiar funnel-like shape. In these three conditions may be found the solution of three very important questions, viz.: 1. Why do we see such or any reflection from the membrana tympani ? 2. Why do we see this one in the an- teroinferior quadrant? And, 3. Why is its shape pyramidal ? The first condition, viz., the reflecting surface, is supplied by the lustrous epithelium of the dermoid layer of the membrana tympani, and thus an answer is given to the first question. The second condition, viz., the peculiar inclination of the membrana tympani, so places the membrane that, by the modi- fications of its surface brought about by the traction inward at the umbo, the only possible spot from which light can be re- flected is just where the pyramid of light is seen. This point will be more fully explained further on. The third condition, viz., the funnel shape of the membrana 1 Die Beleuchtungsbilder des Trommelfells im kranken, und gesunden Zustande, Wien, I860. 2 Anatomisch. Physiologische Studien, uber das Trommelfell und die Gehor- knochelchen, Wien, 1867. 3 Monatsschr. f. Ohrenh. Jahrg. vi., No. 8. 4 Archiv f. Ohrenheilkuude, Band ii., N. F., 1873. MEMBRANA TYMPANI. 55 tympani, will explain the pyramidal shape of this reflection, upon the physical law pertaining to concavo-convex mirrors. ISTot one of these conditions is sufficient of itself to produce a normal pyramid of light on the drum-head. That the lustre of the dermoid layer is an important factor in producing this pecu- liar reflection, may be easily proven by syringing an ear in which the pyramid of light is seen in its normal condition. After a slight maceration of the dermoid layer has been thus produced, and its shining surface destroyed, the pyramid of light will be found to have disappeared or to have become dulled or distorted. In order to prove that the peculiar inclinations of the mem- brana tympani, respecting the walls of the auditory canal, have also their part in the formation of the pyramid of light at that point where it is normally found, viz., in the anteroinferior quadrant, it is only necessary to inspect a normal drum-head in which the reflection of light, in question, is found, during the inflation of the tympanic cavity by the Valsalvan or any other method. It will then be seen that the pyramid of light becomes altered in its position in respect to the malleus. That this reflection can come only from the anteroinferior quadrant, is further shown by an experiment of Politzer's, as follows:— If the auditory canal be removed from the membrana tym- pani, so that the latter is attached only to the annulus tympani- cus, and the membrane then be revolved, so that other parts of its surface successively assume the position of that from which the pyramidal reflection formerly came, we shall perceive on each of these parts a reflection almost exactly like the original pyramid of light, excepting behind the manubrium, where, owing to the different curve of the membrane, the reflection in question will be somewhat different, both in shape and brill- iancy. The third important condition in the formation of the pyra- mid of light, is the funnel shape of the membrana tympani, to which is due, according to Trautmann, the pyramidal shape of the reflection under consideration. The Cause ofthe Pyramidal Shape.—It is already known that the membrana tympani is drawn inward in such a way by the 56 EXTERNAL EAR manubrium of the malleus and the peculiar distribution of fibres in the membrana propria, that its general shape may be likened to that of a shallow funnel or the flower known as the " morn- ing-glory" or convolvulus.1 As its surface is very polished, it may be considered a convex mirror, which, for the sake of better explaining the pyramidal shape of the light spot of the membrana tympani, we may con- sider a convex mirror composed of an indefinite number of sec- tions of convex mirrors with radii varying from that of a mere point to that of the circle which the periphery forms. jSTow, since it is a law of physics that the image reflected from convex mirrors varies in size directly as the radius of the mirror, we shall have in the composite convex mirror represented by the drum-head, an image, which at the centre, i. e., at the point of the manubrium, is a mere point of light, but which gradually enlarges towards the periphery, until we perceive a triangular spot with its base on the periphery, the height of which depends on the distance of the centre of the mirror from the periphery, and the breadth of the base of which depends on the dimensions of the periphery ; the greater the latter the wider the base of the triangle of light. Dr. Trautmann thus sums up the causes of the pyramid of light: " The normal membrana tympani has quite a high-de- gree of superficial lustre, is inclined at an angle of 45° in its vertical plane, and in its horizontal plane it is inclined 10° to- wards the right on the right side, and 10° towards the left on the left side. Furthermore, it is drawn inward so as to form a funnel, the point or apex of which lies in the centre of the ante- rior periphery of the yellow, sickle-shaped expansion at the end of the anterior edge of the manubrium of the malleus, the angle at which the walls of the funnel meet is greater than a right angle, the depth of the funnel is equal to about 2 mm., and the distance from the apex to the periphery is 2£-3 mm. anteriorly, and 3 mm. posteriorly. "Therefore, a 'spot of light' or a reflection of light from the plane surfaces of the membrana tympani cannot reach the eye of an observer, because the rays of light from without, on ac- 1 Voltolini, loc. cit. MEMBRANA TYMPANI. 57 count of the inclination of the membrana tympani, fall upon the plane surfaces of the same, at a very acute angle, and since the angle of reflection is equal to the angle of incidence, the rays of light reflected from the planes of the membrane which has an inclination of 45°, must strike the inferior wall of the external auditory meatus, and are in consequence unable to reach the eye of the observer. "The relations are, however, different, when we consider the ' reflection of light' which is found in the funnel-shaped tract. On account of the vertical inclination of 45° of the membrana tympani and of its horizontal inclination of 10°, the antero-in- ferior quadrant of the membrana tympani is at right angles to the illuminating object. Since, now, the illuminating body and the eye are in the same line, or should be, in order to obtain the best possible illumination of the membrana tympani, only the rays of light which fall perpendicularly upon the antero- inferior quadrant can reach the eye, since all other rays are re- flected at such an angle that they strike the walls of the auditory canal; therefore, the only reflection of light seen by the observer comes from the antero-inferior quadrant of the membrana tym- pani."1 Geometric Divisions of the 3Iembrana Tympani.—Kessel2 has divided the membrana tympani into two grand divisions, one above, the other below the folds of the drum-head, ae, ed. The upper division is subdivided into three sec- tors, viz., aeb, bee, and ced, Fig. 13. The sectors are bounded below by the folds of the membrana tympani and above by the annulus tympanicus and the segment of Rivinus. be. The middle sector bee, is separated from the other two on each side by the two suspensory ligaments be, ec, of the ' Loc. cit., p. 28. 2 Ueber den Einfluss der Binnenmuskeln der Pankenhohle auf die Bewe- gungen und Schwingungen des Tronirnelfells am todten Ohre. Archiv f. Ohrenheilk. N. F., Band 2, 1874. 58 EXTERNAL EAR. handle of the hammer. Between the anterior suspensory liga- ment, be, and the anterior fold of the membrana tympani lies the anterior sector, and between the posterior suspensory ligament and the posterior fold of the membrana tympani lies the poste- rior segment. The inferior division of the membrana tympani, viz., that portion below the folds, is divided into an anterior segment beginning at the anterior fold of the membrana tympani and extending to the pyramid of light, and the posterior seg- ment extends from the pyramid of light to the posterior fold of the membrane. Dr. Kessel says: " Making the pyramid of light the inferior boundary between these segments is not arbitrary, but has a good reason in the fact that the radial fibres, running downward and forward, i. e., in the tract of the triangle of light, from the point of the manubrium of the malleus, in a drum-head of nor- mal position are shorter and therefore tenser and more retracted than those fibres which run directly backward and forward from the manubrium." Annulus Tendinosus.—Before considering the membrana pro- pria, the structure from which the fibres of this middle layer of the membrana tympani arise demands a short description. This is the so-called annulus tendinosus,1 or tendinous ring of Arnold. It is a mass of fibrous tissue arranged around the periphery of the membrana tympani, effecting the union between the latter and the inner edge of the external auditory canal. The annulus tendinosus is not found, however, at that part of the periphery of the membrana tympani corresponding to the Rivinian segment, nor is it always visible from without, even when present in its normal position, around the periphery close to the annulus tympanicus. The fibres of the membrana propria, the origin of which has just been explained, are not inserted directly into the bone of the manubrium, but into a cartilaginous groove which receives the manubrium and short process. This peculiar structure was discovered and has been fully described by Gruber.2 It presents in general the appearance of a deep groove, when 1 The annulus cartilagineus ofthe older writers. 2 Studien iiber das Trommelfell, u. s. w., pp. 20-27. MEMBRANA TYMPANI. 59 seen from behind after the removal of the malleus. As shown by Gruber, this groove is closed at its upper end so that it forms a cartilaginous cap, which covers in the short process on all sides; its lower end, on the contrary, is open behind, and it gradually becomes shallower, i.e., flatter, until it is at last lost in the sub- stance of the membrana tympani. It extends from a little above the short process to a point J mm. below the spade-like end of the manubrium. Inner Surface of the Cartilaginous Groove.—The inner surface of this cartilaginous groove, which is in contact with the malleus, is lined by a very delicate layer of connective tissue, between which and the malleus there is found a small amount of fluid resembling synovia. As this condition of discontinuity be- tween the malleus and the inner surface of the cartilaginous groove is considered normal by Gruber, it is fair to presume that, such being the case, the malleus can make a certain amount of motion in this groove, and that therefore there is here a kind of joint. I have seen in Prof. Gruber's clinic, a case which appeared to have two short processes projecting from the upper end of the manubrium. Such an appearance is explained by Prof. Gruber, as the result of a dislocation or slipping upward of the entire malleus, out of this cartilaginous groove ; the upper of the " two short processes" in such a case is the true bony short process, whereas, the lower one is the aforesaid cartilaginous cap, moulded over the short process and held in the original position of the true short process by the membrana tympani. This condition, Gruber calls subluxation of the cartilage from the short process. Kollicker1 regards this hyaline cartilage as a remnant of the cartilaginous malleus of foetal life, and he thinks it is very possible that the osseous malleus is formed about the cartilage, as is the case in the processus spinosus, in which instance the layer of connective tissue found by Gruber between the cartilaginous oroove and the malleus, and the comparatively easy separation of the two from each other, becomes perfectly explicable; but Kollicker does not admit that there is a normally developed and constant space between these two structures. 1 Gewebelehre, p. 707. 60 EXTERNAL EAR. The Membrana Propria: the fibrous or middle layer of the Mem- brana Tympani.—Having considered the anatomy and the inspec- tions of the outer or dermoid layer, the anatomy of the middle or fibrous layer of the membrana tympani demands attention. The membrana propria can be subdivided into two distinct and delicate layers, viz., an outer, composed entirely of radiate fibres intimately connected with the dermoid layer ofthe drum-head; and an inner layer composed entirely of circular fibres, in close relation with the mucous membrane composing the internal layer of the membrana tympani. These sub-layers of the membrana propria are named, briefly, the radial layer, and the circular layer. The fibres composing the former arise from the annulus tendinosus and the upper wall of the auditory canal, and are inserted into the manubrium of the malleus, centring for the most part at its spade-like tip. The fibres composing the circular layer arise partly from the annulus tendinosus, but the majority of them arise from the substance of the membrana tympani itself (von Trceltsch). Some of them are inserted into the malleus. Of the former kind, viz., those arising from the annulus tendinosus, Gruber says: " They form a very acute angle with the annulus tendinosus, assuming in their progress downward the course of the fibres of the circular layer." These fibres, Prof. Gruber thinks, have either been overlooked heretofore, or considered radial fibres. The circular fibres are most numerous a short distance from the periphery of the membrana tympani. The region of their greatest thickness is in the outer third of the membrane, where they are twice as numerous as the radial fibres; the thickness of the circular layer at this point being 0.026'", while that of the radial layer is equal to 0.018'" (Ger- lach). They are much less numerous at the middle third of the membrane, and almost wanting at the central part of the drum- head. A knowledge of the arrangement of these fibres is impor- tant when considering pathological changes which may have taken place in the membrana tympani. Prof. Helmholtz1 thus accounts for the peculiar concavo-con- vex shape of the drum-head : " If the radial fibres of the mem- brana tympani were not united by transverse ones, they would 1 Mechanism of the Ossicles of the Ear and the Membrana Tympani En"- transl. by Buck & Smith, New York, 1873. MEMBRANA TYMPANI. 61 be stretched in a straight line. In point of fact, however, they maintain a curved shape, with the convexity looking toward the meatus ; hence we conclude that the radial fibres are drawn toward one another by circular fibres, and that the latter are also made tense at the same time. There is, in fact, in the membrana tympani at rest, no other force capable of holding the radial fibres in a curved position, except the tension of the circular fibres." The Descending Fibres of the 3Iembrana Tympani.—-In addition to the two layers already described as forming the membrana propria, there is still another layer composed of descending fibres, first described by Gruber. These fibres are external to the radial fibres, and arise from the upper segment of the annulus tendinosus, and, lying very close to each other, are inserted into the sides and median line of the cartilaginous groove already described. •The various layers of the membrana propria, i. e., the three just described as the radial, circular, and descending fibres, are lightly bound together by a very delicate kind of connective tissue. On the other hand, they cling very firmly to the annulus tendinosus, cartilaginous groove, dermoid and mucous layers, as shown by Gruber. Dentiform Fibrous Structure of the Membrana Tympani.—There is in the membrana tympani a set of fibres arranged in a pecu- liar way and first described and named by Gruber the dentiform fibrous structure1 of the drum-head. " They arise near the periphery, about in the middle of the posterior segment, pretty far apart, but as they proceed on their upward course in the posterior segment they approach each other, in order to divide again, at some distance from the manu- brium ofthe malleus, into several branches, usually about three, which run in different directions, and are finally lost by inter- twining with the fibres of the membrana propria."2 These fibres are not confined to the posterior segment, but traces of them are found throughout the membrana tympani. At their peripheral portion they are between the two layers of fibres composing the membrana propria, but as they approach 1 Dentritisches Fasergebilde. 8 Gruber, Studien uber das Trommelfell, p. 35. 62 EXTERNAL EAR. the centre they are in intimate connection with the mucous layer of the membrana tympani. These fibres are of tense con- nective tissue, closely resembling tendon. When treated with acetic acid, they exhibit the peculiar connective tissue corpuscles already alluded to as being found in the membrana propria. Prof. Gruber further shows that the fibres entering into, the composition of this structure, become most beautifully manifest when viewed by polarized light, when they appear much more brilliantly illuminated than the other tissues of the membrana tympani. Respecting the function of this structure we are told that in all probability it is an apparatus for relaxing the mem- brane, although it cannot be shown as yet that it is a muscular structure. Constituent Elements of the Membrana Propria.—The labors of Toynbee, v. Troeltsch, Gerlach, and Gruber have added to the knowledge of the nature and dimensions of the constituent ele- ments of the membrana propria. It consists chiefly of connective tissue of that variety half- way between the ordinary fibrillated and the homogeneous con- nective tissue of Reichert as shown by Gerlach. The fibres are 0.004'" broad and 0.002'" thick, and on account of their ribbon-like shape they were once supposed to be un- striated muscle fibres, which they are not. On these fibres, certain peculiar spindle-shaped corpuscles are found. They were once supposed to be peculiar to the membrana tympani, and have been called " corpuscles of the membrana tympani," or the "corpuscles of v. Troeltsch," after the observer who first drew attention to their existence. They are, however, connective tissue corpuscles of Yirchow. They are about 0.002'" long and from 0.005 to 0.010'" wide at their broadest part, with from two to three processes. According to Gruber, these bodies are found in two varieties in the membrana tympani, viz., the spindle-shaped and the stellate variety. The Internal or Mucous Layer of the Membrana Tympani.__The internal layer of the membrana tympani is composed of mucous membrane, a reflection of that lining the tympanic cavity. It is thickest at that point where it leaves the cavity of the mid- MEMBRANA TYMPANI. 63 die ear and passes over the periphery of the drum-head. It grows gradually thinner as it approaches the centre of the mem- brana tympani, where it is extremely delicate. On the inner surface of this layer various observers among whom may be named Politzer, Gerlach, and Kessel, have found villi or papillae. They are said by Gruber to resemble intestinal villi in their appearance. They are usually found in delicate children. These villi may be globular or finger-shaped, the diameter of the former being from 0.10'" to 0.12'" and the length 0.12 to 0.14'"; the finger-shaped ones vary in length from 0.10 to 0.12'" and in width 0.06 to 0.08'". (Gerlach and Gruber.) Since Gerlach could not discover any nerves in these bodies, and as some of them are connected with the mucous membrane only by means of pedicles, he is disposed to regard them as villi rather than, as papilla3. Fold of Mucous Membrane for the Chorda Tympani.—-The mucous membrane of the tympanic cavity covers the entire inner surface of the membrana tympani; at its upper boundary it is reflected over the chorda tympani and back again to the drum-head. By this means a duplicative or fold of mucous membrane is formed, the opening of which is turned towards the surface of the membrana tympani, and in the cul-de-sac or inner edge of which the chorda tympani is found. Pockets or Pouches of the 3Iembrana Tympani.—This arrangement makes the so-called pockets or pouches of the membrana tympani, first de- scribed by v. Troeltsch. The mu- cous membrane, after passing over the chorda tympani and rejoining the drum-head forming these pouches, passes upward and is reflected in- ward over the roof of the tympanic cavity and the ossicles. Further ex- planation of the pouches will be given under the consideration of the contents of the tympanic cavity. View op Inner Surface of Mem- brana Tympani. (Gruber.)—a. Man- ubrium of malleus. B. The tip or lower end of manubrium, c. Head of malleus. D. Body of incus, e. Short process of incus. F. Processus lenticularis of incus, g. h. Chorda tympani. I. In- sertion of tensor tympani. 64 EXTERNAL EAR. . Comparative Distribution of Bloodvessels in the Membrana Tym- pani.—In a series of investigations upon the membrana tympani of the mammalia, I have found in the dog, the cat, the goat, and the rabbit, an arrangement of the bloodvessels not hereto- fore described, and totally different from that in man. Prussak,1 in his brochure upon the circulation of the blood in the tympanum of the dog, has represented the general topo- graphy of the vascular system in the membrana tympani of that animal, but it does not point out the ultimate loop-like arrangement of the vessels distributed over the surface of the membrane. The plate which accompanies his article seems to indicate that the delicate vascular loops have been broken by the force of injection, and thus escape the eye of the observer. In my investigations I have found that from the periphery of the membrane a series of vessels run directly towards the manubrium of the malleus ; then each vessel, a point from one- half to one-third of the distance between the periphery of the membrane and the manubrium of the malleus, turns abruptly upon itself and returns to the periphery, thus forming a series of vascular loops at nearly equal distances from each other around the edge of the membrane. A similar series of loops run both anteriorly and posteriorly from the manubrium of the malleus towards the periphery of the membrana tympani, a diagram of which may be seen in Fig. 15, representing the membrana tympani of a dog magnified eight diameters. This arrangement of vessels in the membrana tympani is con- stant in the dog, the cat, the goat, and the rabbit, in conse- quence of which a portion of the membrane between the annu- lus tympanicus and the manubrium of the malleus remains free from capillaries in its normal condition, and it is probable, though not yet proven, that ordinary disturbances in the circulation are likely to interfere with the vibrations of the membrane in these animals. These vascular loops do not exist in the guinea-pio-, an animal which has in its membrana tympani an arrangement of vessels peculiar to itself. The general appearance of the membrana 1 Verhandlungen der Koniglich Saecbsischen Gesellschaft der Wissenschaften zu Leipsic, 1868. MEMBRANA TYMPANI. 65 tympani of the guinea-pig, under the microscope, is much more transparent and delicate than that of any of the previously mentioned animals. Fig. 15. Membraxa Tympani of a Dog.—The wood-cut is from a drawing of a gold preparation made by and in the possession of the author, a, a. Vacancy left by manubrium of malleus, b, b, b, b. Vascular loops, c, c. Ordinary capillaries. The vessels are arranged in the form of a net, with coarse mesh of quadrangular or pentagonal shape. The radiate fibres are strongly developed in comparison with the circular fibres, which are sparsely distributed throughout the texture of the membrane. They are, however, readily seen, and present an appearance as peculiar to the membrana tympani of the guinea- pig, as the shape of the mesh of the network of bloodvessels in this animal. In no other membrane have I seen as distinctly the blood-corpuscles lying within the capillaries as in that of the guinea-pig. The membranes which show these loops and other vascular arrangements most distinctly are such as have been colored with a solution of the chloride of gold (J per cent). The vascu- lar arrangement can be seen, but not very satisfactorily, in membranes which have been treated with osmic acid or a solu- 5 66 EXTERNAL EAR. tion of carmine. The best specimens, showing not only blood- vessels, but in many cases the delicate nerves of the membrane, I have obtained by preparing the membrana tympani of the dog in the following manner: Remove the membrane from the animal as soon as possible after death. In the majority of my experiments, the animal had been dead but a few minutes. Steep the membrane a few seconds in concentrated acetic acid ; then lay it in a solution of chloride of gold, which should be kept at a temperature somewhat above that of the blood, for one-half hour. After this treatment, the membrane should remain twenty-four hours in glycerine, or water slightly acidu- lated with acetic acid, and exposed to the light till it assumes a delicate purple hue. The older the preparation becomes, the more distinctly are the vessels colored. I have some prepara- tions, mounted in glycerine, now almost a year old, which are better than the day they were made, since the gold has taken an increasing hold upon the tissues of the vessels and nerves. After a number of trials, I prefer leaving the membrane in gly- cerine acidulated with acetic acid, since it demands less care in respect to renewal, and I am never chagrined at finding my specimen destroyed by the evaporation of the water. By this process the loops, and the nerves accompanying them, are most likely to be rendered visible. The arrangement of the nerves, not represented in the wood- cut, is best described as fork-shaped. The prongs embrace the loop; the handle unites with a similar projection from the opposite series of loops. As a rule, the vessels color more readily under the action of chloride of gold than the nerves. How this might be in clear weather, I am not prepared to say, as all of my experiments were performed in the cloudy weather of a Vienna winter, notwithstanding which, the nerves frequently became richly colored. This method of coloring vessels and nerves I have applied only to the membrana tympani, and hence, I can claim no supe- riority for it in connection with other tissues. When it succeeds it is superior to any injection of this very delicate membrane, since the vessels and nerves are rendered visible with a distinct- ness characteristic of the action of chloride of o-old, a reaction to which attention was first called by Cohnheim. The bloodvessels are rendered distinct, without becoming MEMBRANA TYMPANI. 67 opaque, so perfectly in most cases that we can detect the blood corpuscles lying within the capillary. The vessel, furthermore, retains its normal calibre and posi- tion, whereas, when we resort to injections, the vessels are apt to be unduly distended, are necessarily opaque, extravasation of coloring matter may take place, or the vessel may be ruptured. The method is more convenient than injection, and as no mechanical force is used, the field of the microscope must of necessity present a very true picture of the tissues as they are in their normal state. The application of this method of coloring to the membrana tympani of man shows the absence of the vascular loops already described, and reveals an arrangement of the vessels similar to that obtained by other observers with injections. The arrangement of the vessels is not unlike the vascular network in the membrana tympani of the guinea-pig. In man, however, the mesh is much finer, the vessels coarser. The fibrous layer is, on the other hand, very thick, and is more equally composed of radiate and circular fibres than the mem- brane in the guinea-pig. Since the membrana tympani of man is supplied by a dense network of vessels, the gold method of coloring it is superior to the usual method by injection, as the entire preparation is less opaque than -when the vessels are filled with Prussian blue, carmine, etc. It may, therefore, be concluded that:— 1. There is a distribution of vessels in the membrana tym- pani of man peculiar to him. 2. There is a distribution of vessels in the membrana tympani of the dog, the cat, the goat, and the rabbit, constant in, as well as peculiar to them. 3. A distribution of bloodvessels exists in the membrana tympani of the guinea-pig peculiar to it. SECTION II. MIDDLE EAR. CHAPTER I. TYMPANIC CAVITY. ANATOMY. Under the term Middle Ear are included the tympanic cavity and its two very important adjuncts—the Eustachian tube in front, and the mastoid portion of the temporal bone, and its cells, behind. Ossicles of Healing.—In the tympanic cavity of all mammals, are three small bones: the malleus or hammer; the incus or anvil; and the stapes or stirrup. Anatomists of a latter day have shown that the once so-called os orbiculare, or os Sylvii, does not exist as a separate ossicle. That which once received this name is the processus lenticularis of the long process of the incus, which fits into a corresponding depression in the head of the stapes. The Malleus.—The malleus, or mallet, received its name from Vesalius, and although some anatomists have failed to see the resemblance to this implement, the ossicle still retains its name, and is divided into head, neck, and handle. At the junction of the latter with the neck, are twTo important processes, viz.: the short process, which, when in its normal situation, pushes the membrana tympani ahead of it, and points towards the auditory canal, and the process of Rau or Folius, which passes anteriorly into the Glaserian fissure. In the foetus and new-born child, this process is about 3J lines long, and can then be removed whole. After birth it unites with the under wall of the Glase- rian fissure, and when the malleus is removed, only a short piece of the former long process is found attached to it. This TYMPANIC CAVITY. 69 remnant was all that was known of the long bony process, to the older anatomists, and it has been called the processus Foli- anus,1 after Folius, who, in describing this process, alluded only to the remnant. Fig. 1G. Right Malleus: A, from in front; B, from behind. (Magnified 4 diam.: Henle.)—a. Head. 6. Short process, c. Long process, d. Manubrium, e. Articular surface. /. The neck. This process, in its most perfect osseous state, was fully described by Jacob Rau2 in his lectures, and his pupils, Valen- tin3 and Boerhaave,4 call him the discoverer of it. Hence in its perfect state it is called the processus Ravii, since Rau or Ravius was the first to describe the broad end united to the G-laserian fissure. This process has also been called the processus longus seu spinosus. It is united to the Glaserian fissure, in adults only, by a mass of ligamentous tissue, which favors slight motion in any direction. The head and neck of the malleus project into the tympanic cavity, and are entirely free from the membrana tympani. The rounded, smooth surface of the head is directed anteriorly, while the surface which articulates with the incus is directed backward. The long diameter of its articular surface runs vertically, the short diameter horizontally. In the direction of the former, the articulating surface has been said to resemble a saddle, for the surface is divided a little below the middle by a horizontal ridge, and depressed on each 1 Caelius Folius, Venice, 1643. Nova amis internfe delineatio. 2 Jacobus Ravius, Professor of Anatomy and Surgery in the University of Leyden. 3 1719. 4 Prselectiones, p. 358. 70 MIDDLE EAR. side of it. This articulating surface is also concave in the di- rection of its short diameter, i. e., from without inward. ^ If a shallow oval basin, the long diameter of which is con- siderably greater than its short diameter, be placed across a ridge, and^then bent downward, and at the same time slightly twisted on itself, the cavity thus formed will fairly represent the articulating surface of the malleus. The neck of the malleus lies between the head and the manu- brium. It makes, with the former, an angle of about 135° when viewed from in front. It has three surfaces : a broad inner one directed towards the tympanic cavity, bounded in front by the processus Ravii, or long process, and behind by the long, low bony elevation for the insertion of the tendon of the tensor, tympani; an anterior surface, lying above the ridge joining the processus brevis and the processus longus, and extending to the angle made by the head of the malleus with the neck, and separated from the posterior surface by a sigmoid-shaped ridge for the insertion of the ligamentum mallei externum of Helmholtz. The posterior surface lies between the aforesaid sigmoid ridge in front, the edge of the articulating surface of the malleus above, the low, long process behind, and a line drawn from the insertion of the tensor tympani to the short process below7. Of all the surfaces of the neck, the posterior glides most gradually into the manubrium. The handle or the manubrium ofthe mal- leus, that part ofthe bone inserted into the membrana tympani, has also three surfaces, which may be considered prolongations downward of those of the neck. Since they all gradually approach each other and are united in the tip or point of the manubrium, the latter may be said to resemble a three-sided bayonet, one ridge of which passes from the short process di- rectly downward to the tip, and is consequently turned towards the external auditory canal. The point or lower end of the handle ofthe malleus is flattened into a small disk, one surface of which is turned towards the auditory canal. This spot is plainly visible as the pale, round centre of the umbo. The long axis of the handle of the hammer is convex poste- riorly and inward, so that when viewed from without the manubrium appears concave on its anterior and outer surfaces. This is especially marked at the lower third on the anterior surface, so that the manubrium normally appears curved de- TYMPANIC CAVITY. 71 cidedly forward near its lower end, of course in the plane of the membrana tympani. Along the ridge of the manubrium, directed towards the external auditory canal, several little node- like prominences are not uncommonly seen. These are not pathological, but purely normal. Their origin is obscure. Dr. A. H. Buck1 has described a hook-shaped termination anteriorly, ofthe manubrium mallei in a boy thirteen years old. The manubrium of the opposite side had been destroyed by otorrhcea, so that it was impossible to make a comparison be- tween the mallei in this case. Dimensions ofthe 3Ialleus —The malleus is nearly 9 mm. long; its manubrium is between 4 and 5 mm. long, and its head is 2| mm. thick. The latter is the greatest diameter of any part of the bone, which gradually tapers to the point of the handle. The long diameter of the articulating surface of the malleus is about 3 mm.; the short diameter is between 1J and 2 mm. Fixation of the Malleus.—The malleus is held in position by four ligaments, viz.: Ligamentum mallei anterius, ligamentum mallei superius, ligamentum mallei externum, and the liga- mentum mallei posterius. The ligamentum mallei anterius is a broad band of fibres which holds the processus Folianus against the spina tympanica major. This ligament may be said to arise from the spina tympanica major and to be inserted along the neck of the malleus all the wa}* from the processus Folianus to the head of the malleus. A part of it also runs from the processus Folianus to the short process of the malleus below, and the membrana tympani above, forming thereby the division between the anterior and posterior pockets of the mem- brana tympani ; another fold of the same ligament runs from the processus Folianus downward with a free margin, as far as the line corresponding with the insertion of the tensor tympani muscle. This makes the limit between the anterior pocket of the drum-head and the tympanic cavity. The round ligamentum mallei superius descends obliquely downward and outward from the tegmen tympani to the head of the hammer. Its function is to prevent the malleus from being forced outward. ' N. Y. Med. Record, Dec. 16, 1872. 72 MIDDLE EAR. The ligamentum mallei externum is a very important collection of satin-like, tendinous fibres, which radiate from the sigmoid crest on the front of the neck of the hammer and are inserted into the sharp edge of the segment of Rivinus on the temporal bone. It prevents the hammer from being forced inward, and being inserted above the axis of rotation of the hammer, it prevents the manubrium, which is below the axis of rotation, from moving too far outward towards the auditory canal. The ligamentum mallei postieum is really the posterior edge of the ligament just described as the external ligament of the hammer. As the line this bundle of fibres follows passes through the spina tympanica major, and as it represents pretty closely the axis of rotation of the hammer, Helmholtz has sug- gested it should be considered a separate ligament, and has given to it the name it bears. As this ligament and the ligamentum anterius are in a mecha- nical sense one ligament, although the hammer intervenes be- tween them, Helmholtz has called the two sets of fibres the axial ligament of the malleus. Axial Ligament of the Malleus.—The plane of this ligament is not quite horizontal, being a little higher in front than behind. In all its motion as a lever the hammer swings about this axis-ligament as a fixed point. All above the short process of the malleus is above, and all below the short process is below, the axis-ligament. The ligamentum mallei anterius of Arnold was once described as a muscle, the laxator tympani major.1 It is not, however, anything more than a ligament which originates from the spina angularis of the sphenoid, passes through the petro-tympanic fissure,2 and is inserted into the malleus. Under the name of ligamentum mallei postieum seu manubrii, the ligamentum mallei externum of Arnold, Lincke describes a ligament which passes from the upper edge of the end of the external auditory canal to the short process of the malleus and occupies the position of a supposed muscle, once called the M. laxator tympani minor, or M. mallei exterior seu Casserii. It is 1 Somniering. 2 Glaserian fissure. TYMPANIC CAVITY. 73 now universally acknowledged that muscular fibres do not exist here.1 Ligamentous support of Ossicles viewed from above. (Helmholtz.)—J-h. Attachment of the ligamentum mallei externum, k. Head of hammer, i. Body of incus. /. Point of its short process, a. Entrance to the Eustachian tube from the tympanum, e. Stapes, d. Tendon of its muscle, b. Tendon of the tensor tympani, leaving the cochlear process, g-g- Chorda tympani, marking the free edge of the folds of mucous membrane, boundiug the pouches, n. The upper tendinous fibres of the ligamentum mallei anterius, originating above the spina tym- panica major, m. j. Malleo-incudal joint. Incus or Anvil.—The middle one of the three auditory ossicles is the incus or anvil. The name is derived from the shape of its upper half. This small bone is divided into a body and two processes, viz., a short and long one. The former of these two processes is also called the horizontal process. It is held to the posterior and to the upper wall of the tympanic cavity by ligaments.2 (Fig. 18, e.) This is an important point in the mechanism of the auditory ossicles.3 The longer process is also called the descending ramus of the incus. It curves gradually outward, /. e., towards the external ear, away from the vertical plane of the body of the incus, assuming a slight sigmoid shape; at its tip it curves rather sharply inward, to unite with the head of the stapes by means of the processus lenticularis. 1 Henle, Eingeweidelehre, p. 745. 2 Ligamentum incudis posterius et ligamentum incudis superius. 3 Henle calls this the incus-tympanic joint, "an amphiarthrosis between the articulating surface of the short process of the incus, and a prominence on the posterior wall of the tympanic cavity. The articulating surface on the incus is covered with a thin layer of fibrous cartilage." 74 MIDDLE EAR. The narrowest part of the incus is at the middle of the body of the bone; beneath this part it widens out again anteriorly into the important tooth which locks with the malleus in all its inward movements, and posteriorly into the descending ramus or long process. The articulation between the. malleus and incus is a true joint, in which is found a meniscus.1 Fig. 18. Right Incus. (Magnified 4 diam.: Henle.)—A. Inner surface. B. View in front. An. and Be. Body. b. Short process, e. Long process, d. Processus lenticularis. /. Articular surface for the head of the malleus, c. Surface which lies in contact with wall of tympanic cavity. If this articulation is viewed on its outer surface, i. e. on that side towards the external auditory canal, it would seem that the incus quite overlapped or embraced the head of the malleus; wThen viewed from its tympanic side, however, it appears that the largest share in the joint belongs to the malleus. This is due to the wonderfully peculiar structure of this joint, the true nature and function of which were first pointed out and explained by Helmholtz in 1869.2 Dimensions of the Incus.—The greatest length of the incus is in a vertical line passing from the top of the body of the bone through the long process. It measures 7 mm. The horizontal upper edge of the body measures 5 mm. Its greatest thickness, 2J mm., is at its articulating surface for the malleus. Malleo-incudal Joint.—Before Helmholtz's investigations the shape of this articular surface was usually described as resem- bling a saddle. In order to gain a clearer idea of the mechanism 1 Riidinger. 2 Mechanik der Gehorknochelchen und des Trommelfells, Bonn* also PA" ger's Archiv f. Physiologie, 1 Jahrgang. TYMPANIC CAVITY. 75 of this joint, Helmholtz makes use of a different comparison. u It is, in fact, like the joint used in certain watch-keys, where the handle cannot be turned in one direction without carrying the steel shell with it, while in the opposite direction, it meets with only slight resistance. As in the watch-key, so here, the joint between hammer and anvil admits of a slight rotation about an axis drawn transversely through the head of the ham- mer toward the end of the short process of the anvil; a pair of cogs oppose the rotation of the manubrium inward, but it can be driven outward without carrying the anvil with it."1 It is of the kind of joint known as ginglymus. The mechanism of this joint is best understood when it is known that the malleus, as a whole, is a lever, the fulcrum of which passes just below the short process. This, of course, leaves the head and neck, i. e. the articulating surfaces for the malleo-incudal joint and all the free tympanic parts of the malleus, above the line of support of the lever, the manubrium being below. The latter is the long arm of the lever, and consequently all its movements are repeated in an opposite direction on the head of the malleus. Each inward movement of the manubrium, therefore, causes a slight outward motion in the head of the malleus and a firm locking of the malleo-incudal joint, by which the incus is carried about an axis drawn transversely through the head of the hammer toward the end of the horizontal or short process of the incus. The incus being also suspended as a lever, about the line just named, when all above that line moves outward, all below the line moves inward, i. e., as the upper part of the incus is moved outward the long process swings inward and carries the stapes ahead of it, thus forcing the foot plate of the latter into the oval window. The Stapes or Stirrup.—The smallest bone in the body and the innermost of the three auditory ossicles is the stapes or stirrup. Its name is derived from the striking resemblance it bears to a stirrup. It is divided into a head or capitulum, a neck, two branches or legs (crura), and a foot-plate or basis. The head, which is really a cup-shaped button, is placed at ' Helmholtz's Mechanism of the Ossicles of the Ear, etc., English translation by Buck and Smith, 1873, p. 33. 76' MIDDLE EAR. the junction of the two crura. It is designed for the reception of the processus lenticularis of the incus, with which it forms a ball-and-socket joint. There is a meniscus in this joint according to Riidinger.1 On the posterior surface of the head of the stapes the stapedius muscle is inserted. Ficr. 19. Right Stapes. (Magnified 4 diam.: Henle.)— A. From within. B. From in front. O. From beneath, b. Foot-plate or base. d. Capitulum. e. Anterior, a, posterior shaft or crus of stapes. The two crura or branches are furrowed on their inner surface, which makes them lighter, yet does not deprive them of strength. They arise from the basis forming a graceful arch and unite above in the head, as already stated. The foot-plate of the stapes is oval or slightly kidney-shape, thicker at the periphery than in the centre, is slightly convex towards the vestibule, and concave on its tympanic surface; it fits into the oval window, where it is held by a fibrous packing. This permits of a slight inward and outward movement on the part ofthe base of the stirrup. When the stapes is in position, the long axis of its base is horizontal and coincides with that of the oval window. In this position its convex edge looks upward, and its concave edge, which gives it its slight kidney- shape, looks downward. The ligamentum obturatorium stapedis is a thin membrane stretching across the space between the base and the crura; it is attached to the crista of the former and the furrow on the inner edges of the latter.2 Dimensions ofthe Stapes.—The stapes measures nearly 4 mm. from its head to the under surface of the foot-plate. The latter is 2J mm. long in its horizontal diameter, 1 mm. in its vertical 1 Virchow's Archiv, Bd. xx. 1860. Monatsschr. f. Ohrenh. Jan. 1873 2 Riidinger, Atlas of Osseous Anatomy of Human Ear, edited by Blake Boston, 1874, p. 9. TYMPANIC CAVITY. t i diameter (the bone of course must be imagined in normal posi- tion), and about | of a millimetre thick, at its edges. It is slightly concave towards its centre. Joint between Base of Stirrup and Oval Window.—According to Helmholtz,1 the base of the stapes is surrounded at its edge by a lip of fibro-elastic cartilage 0.7 mm. thick. The union between the base of the stirrup and the wall of the labyrinth appears to be formed by means of the periosteum of the vesti- bule, extended over the base of the stapes (Henle), but the fibrous lip on the edge of the base of the stirrup is not attached to the fenestra ovalis. The mucous membrane of the tympanic cavity extends over the outer or tympanic surface of the base of the stapes. In 1869 Dr. A. H. Buck examined very closely the fixation of the base of the stirrup in the oval window, and made the following conclusions:—2 1. The base of the stapes is fastened to the edge of the round window by a ligament or elastic fibres. 2. The fibres of the ligament gradually converge towards the edge of the base of the stapes. 3. The ligament arises from the periosteum in the neighborhood of the oval window and passes over to the base of the stirrup, where it again assumes the function of peri- osteum. 4. The breadth of the ligament is the same all around the periphery ofthe base of the stapes. Dr. Gustav Brunner,3 of Zurich, regards the malleo-incudal and incudo-stapedial joints as a variety of symphysis or synchon- drosis. He is disposed to regard the connections between the ossicula auditus not as true or ordinary joints. As described by him, they are all of peculiar construction, since between the cartilaginous surfaces of the bones there is a fibrous or fibro- cartilaginous intermediate substance. Dr. Riidinger4 reasserts the true joint-like structure of the articulations of the ossicula. He also maintains his viewT that in both the malleo-incudal and incudo-stapedial joint there is a ' Op. cit., pp. 34-35. 2 Archiv f. Oph. and Otol. von Knapp u. Moos., 1 Band. Carlsruhe, 1870. 3 Ueber die Verbindung der Gehorknochelchen, namentlich, des Hammer- Ambossgelenks, Vorlauflge Mittlieilung. M. f. O. No. 1, 1872. * Ueber die Gelenke der Gthoiknochelchen, M. f. O. No. 3, 1872. 78 MIDDLE EAR. fibrocartilaginous disk connected with the capsular ligament, but not with the hyaline covering of the articular surfaces of the bones. Dimensions ofthe Ossicula Auditus.— Urbantschitsch,1 by com- paring the auditory ossicles of 50 different tympana, found that the malleus varied in length from 7.0-9.2 mm.; the average length is 8.5 mm. The short process varies from 1.2-2.6 mm., with an average length of 1.6 mm. The long process (the Folian process) was found in one case, an individual 30 years old, to be 2.5 mm., and in another, a man 20 years old, 5.8 mm. long. The manubrium has an average length of 5.0 mm. from the short process to the point. In the incus, the distance of the upper end of the articular surface from the free end of the horizontal ramus is, on the average, 5.3 mm. The under end of the surface of the joint is 4.6 mm. distant from the incudo-stapedial joint. The incus is the most porous of the ossicles. The average length of the stapes is 3.7 mm.; its average breadth between the rami, 2.3 mm. Its head is either entirely straight (29 times), or else inclined towards the anterior (18 times) or posterior (3 times) limb ; in one case the head pointed upward, i. e. towards the upper edge of the foot-plate of the stapes. The entire paper of Dr. Urbantschitsch will amply repay a careful reading. According to the investigations of Dr. C. J. Blake,2 the weight of the ossicula auditus varies greatlj' with the age and indivi- dual. It is also worthy of note that the proportionate weight of the ossicula, one to another, is not constant. Dr. Blake states that in the new-born child, the proportionate weight of the malleus to the incus is generally as 20 to 17, and in a malleus weighing 20 milligrammes, the weight would be distributed as follows: u the capitulum mallei, including that portion of the neck just above the processus brevis, 16 milligrammes; the pro- cessus longus, including the processus brevis, 4 milliorammes." "In an incus weighing 17 milligrammes, the corpus incudis, including the processus brevis and the base of the processus ' Archiv fur Ohrenheilkunde, Band. xi. p. 1-11. * Distribution of Weight in the Ossicula Auditus. Transactions Amer. Otol. 8oc, vol. i. p. 543. TYMPANIC CAVITY. 79 longus as far downward as the lower lip of the inferior articu- lating surface, 14 milligrammes ; and the processus longus, with the os ienticulare attached, 3 milligrammes, the corresponding stapes weighing very nearly 4 milligrammes. In the adult, the weights of the malleus and incus are, as a rule, more nearly equal; in some cases, however, the proportionate weight of the malleus to the incus is as 7 to 8." The distribution of weight above and below the axial line— the line about which the malleus tends to swing (see p. 72)—is as follows, according to the investigations of Dr. Blake: In a malleus which weighed 21 milligrammes, and the incus 25 milli- grammes, the combined weight of the portions of these two bones, above the axial line, the line of section in the experi- ments, was 30 mg.; that belowT the line, 16 mg., or in the pro- portion of 15 to 8. This preponderance of weight in the parts of the malleus and incus above the axial line, tends to act as a mechanical counterbalance, and renders the two bones better able to vibrate upon the axial line. It also serves to increase the delicacy of a mechanism which responds to sound-waves in excursions so infinitesimal that the highest powers of the micro- scope cannot render them visible, as shown by Helmholtz. The Tympanum.—The tympanic cavity is about half an inch in height and width and a line or two deep, measuring from within outward. It is lined with mucous membrane, which is reflected over all the tympanic contents, and is a continuation of that of the throat, nose, and Eustachian tube. The drum cavity lies entirely within the temporal bone, and is bounded by a roof and floor, and the four walls. The roof, or tegmen tympani, is the boundary between the base of the brain and the tympanum. This osseous partition is very thin, and in some cases congenital fissures in it persist; in such instances the only boundary at the dehiscences, between the tympanum and the cerebral cavity, is formed by the mucous membrane of the former and the membranes of the brain. It is evident that in such cases, pathological processes in the drum- cavity are especially liable to pass upward to the brain. The Malleo-incudal Joint and surrounding parts viewed from aoove,—If the tegmen tympani be removed, let us say, from the 80 MIDDLE EAR. right tympanic cavity, the malleo-incudal joint and the mcudo- tympanic joint will be laid bare, and just in front of the head of the malleus, but below it, will be seen the tendon of the tensor tympani muscle coming upward and inward from the left, to be inserted into the tubercle on the neck of the hammer. Above this tendon, winding from within outward and to the right, around the neck of the malleus, is seen the chorda tympani, a branch of the facial nerve, on its way. to the Grlaserian fissure. Of course this pic- ture is to be reversed for the left ear. The suspensory ligament of the mal- leus is attached to the roof of the tympanic cavity. Right Tympanic Cavity viewed prom above ; Malleo-incudal and Incudo-tympanic Joints. (Magni- fied 2 diam.: Henle.)—o. Head of mal- leus, e. Short process of incus. /. Tendon of tensor tympani muscle. d. Capsule of incudo-tympanic joint. n. Ligamentum mallei anterius. b. chorda tympani. The F[oor ^ thg Tympanum.—The floor of the tympanum is not much more than a groove between the outer and inner wall. It is below the lower periphery of Inner Side of the Outer Wall of the Right Tympanic Cavity ; Hammer and Anvil in situ ; Canalis Musculo-tubarius laid open. (Magnified 2 diam.: Henl6.)—b b. Tensor tym- pani. d. Head of the malleus, h. Tip of the manubrium mallei, e. Short,/, long process g Pro- cessus lenticularls of the incus, c. Chorda tympani. a. Septum tuba:. J. Eustachian tube i Membrana tympani. the drum-head, the opening of the Eustachian tube, and the opening in the mastoid cells. It is entirely within the boundary TYMPANIC CAVITY. 81 of the petrous portion of the temporal bone and above the jugu- lar fossa. The outer Wall of the Tympanum.—The outer wall of the tym- panic cavity is composed mainly of the membrana tympani. The bony framework of the annulus tympanicus around the membrana tympani, constitutes the limit of the outer wall of the tympanum. In connection with the outer wall, i. e., in it or on it, we find the manubrium mallei, the chorda tympani, and the duplicative of mucous membrane about it, which also forms the so-called pockets of the membrana tympani. The pockets or pouches of the membrana tympani are the dupli- catures of mucous membrane around the chorda tympani hi the horizontal portion of its passage through the tympanic cavity. They were first described by von Troeltsch, in 1856,1 and are situated on the inner side of the upper part of the drum-head. The posterior pouch lies between the malleus and the posterior periphery of the membrana tympani, and is the larger of the two. It contains in its structure fibres of the fibrous layer of the drum-head. The shape of the posterior pouch is triangular or tent-like, the apex of which is directed inward, and its base outward. It is about 3 mm. high, and 4 mm. broad. This pouch is best seen when the inner side of the drum-head is viewed, but it can also be seen from the outer side, when the drum-head is thin and properly illuminated. The anterior pouch lies in front of the malleus, and is smaller than the posterior pouch. It is composed of mucous membrane only. It is not so well marked as the posterior pouch, but con- tains " all the parts which proceed from or enter the Glaserian fissure."2 It is much lower and shorter than the posterior pouch. There is a third pocket or pouch of the membrana tympani described by Prussak3 and G-ustav Brunner.4 This cavity is bounded behind by the neck of the malleus, below by the upper 1 Wiirzburg Transactions. 2 See Roosa's translation of v. Troeltsch on the Ear, X. Y., 18G9, pp. 32-33. 3 Archiv fur Ohrenheilkunde, vol. iii. « The Connections between the Ossicles of Hearing. Archives of Oph. and Otol., vol. iii. pp. 14.-)-172,.1874. 6 82 MIDDLE EAR. surface of the short process of the hammer, in front by the membrana flaccida, and above by a ligamentous band, the liga- mentum mallei externum, which is inserted between the margo tympanica and the spina mallei. This cavity is separated from Fie. 22. Section through the long Axis of the Malleus at right angles to the Membrana Tympani, from an Adult. (Brunner.)—fc. Bony ridge at the upper segment of the drum- head. (The segment of Rivinus, according to Helmholtz.) g. Head of malleus, p. Neck of malleus, o. Handle of malleus. Z. Short process. ./. Membrana flaccida. h. Lig. mallei externum. m. Chorda tympani. n. Tendon of tensor tympani. i. A cavity according to Prussak. a. Carti- lage. 6, b. Fibres of the membrana tympani. c. Dermoid layer of membrana tympani. e. Haver- sian canals. /. Medullary space. the anterior tympanic pouch by the upper blind end of the latter; posteriorly, it communicates with the tympanic cavity by a good-sized opening, above the position of the posterior tympanic pouch. This pouch, being thus placed in communica- tion with the tympanum, may become filled with mucus or pus, and it may, in consequence, be ruptured. Many cases of earache,, which present no features of disten- sion of the drum-head proper, nor, in fact, of the region of the TYMPANIC CAVITY. 83 membrana flaccida, may be relieved instantly by puncturing the latter at the third pouch. The point of the puncturing in such cases is just above and in front of the short process. As a general rule, when there is great earache, attended only by redness of the flaccid part of the drum-head, and neither congestion nor bulging of the drum-head proper, a cut into the congested flaccid part will relieve, in most cases, the suffering. Mucus or pus will usually escape ; sometimes only blood. Inner Wall of Tympanum.—On the inner wall of the tympanic cavity there is found a convexity, the promontory caused by the projection outward at that point of the lower turn of the cochlea. This eminence is usually seen through the membrana tympani, as a pale yellowish spot. At this point the inner and outer walls of the tympanum are closest to each other. Above the promontory, in a depression named the fossula fenestra? ovalis, of Riidinger, is the oval window, fenestra ovalis, which receives the foot-plate of the stapes. Behind the promontory is the Fig. 23. Inner Wall of Tympanic Cavity. (Gray.) niche in which is found the round window, fenestra rotunda. The lono- diameter of the oval window is 3 mm., and its short diameter 1.7 mm. The diameter of the round window is 2 mm. A rido-e starts above the oval window and curves backward and downward behind the promontory and round window. This rido-e is the posterior limit of the inner wall of the tym- 84 MIDDLE EAR. pan urn, and marks the position ofthe canal for the facial nerve, which escapes from the tympanum at the stylo-mastoid foramen. The course of the facial nerve will be considered further on. Eminentia Stapedii.—Behind, and a little below the line of the oval window, is a bony eminence, the eminentia stapedii. This little conical eminence is hollow and contains the stapedius muscle, to which it gives origin. The tendon of this muscle, after passing through a small opening in the apex of the emi- nence, runs a little upward and forward, forming an obtuse angle with the long axis of the muscle, and is then inserted into the edge of the articular surface of the head of the stapes.1 The stapedius muscle is supplied with a branch from the facial nerve. Function of the Stapedius Muscle.—According to Henle",2 it is probable that the stapedius muscle serves to hold the stapes in a firm position rather than to move it, and that it acts only when there is danger that an undue force communicated to the malleus will be conveyed to the stapes by means of the inter- vening incus. Its action then is to prevent the stapes from being forced into the oval window. Fixator Baseos Stapedis.—Riidinger has described an organic muscular structure on the tympanic surface of the stapes, which he calls the fixator baseos stapedis. It arises from a small bony ridge (diameter 0.80 mm.) situate one millimetre from the upper and posterior circumference of the oval window, and is inserted into the angle formed by the leg of the stapes and its somewhat projecting foot-plate. It is supposed to be an antagonist of the voluntary muscle, the stapedius, and prevents the latter from forcing the stapes too far into the vestibule.3 Topographical Relation of the Stapedius Muscle to the Facial Nerve.—Prof. A. Politzer4 has added greatly to the knowledge respecting the relation of these parts to each other. In the 1 Henle. 2 Eingeweidelehre, p. 749. 3 Das hautige Labyrinth, by Riidinger, Strieker's Handbuch, pp. 912-913, 1872. 1 Prof. Politzer, Zur Anatomie des Gehororgans, I. Ueber das Verhiiltniss des Muse. Stapedius zurn nervus facialis, II. Ueber den Processus Styloideus, Archiv f. Ohrenh., cap. ix p. 158. TYMPANIC CAVITY. . 85 foetus only the upper part of the stapedial cavity is separated from the facial canal by bone, the lower part having free com- munication with the canal. At this point, the soft tissues sur- rounding the muscle and the nerve are in contact. In the adult, however, the communication between the bony cavity contain- ing the muscle and the facial canal is less free, being effected by means of one or more small openings or by one long slit-like aperture 3-5 mm. long, and \ mm. wide. Transverse sections of this muscle show that it is a triangular prism ; longitudinal sections show that its general form is pear-shaped. In addition to the anatomy, Prof. Politzer has added to the knowledge of the physiology of the stapedius muscle. He shows that this muscle acts as a laxator of the membrana tym- pani, and, as far as its effects upon the labyrinth are concerned, it diminishes the pressure in that cavity by drawing the stapes out of the oval window.1 The oval window is separated from the round window by the tract of bone corresponding to the posterior surface of the promontory. They are about two milli- metres apart. The plane of the former looks outward, and is nearly vertical in its position; that of the latter looks backward and downward. The oval window is the entrance to the vesti- bule and mediately to the cochlea. The round window is an exit from the cochlea into the tympanic cavity. This window, however, in its normal state, is hermetically closed by a mem- brane, the membrana tympani secundaria, or membrana fenestras rotunda?. Well forward, on the inner wall, towards the tympanic open- ing of the Eustachian tube, are the processus cochlear iformis, the spoon-shaped tympanic end of the septum tuba?, which separates the Eustachian tube from the bony furrow containing the tensor tympani muscle, and the tendon of the latter as it passes to the malleus. The processus cochleariformis is the fulcrum over which the tendon of the tensor tympani plays. Tensor Tympani Muscle.—This muscle originates from the anterior mouth of the canalis musculo-tubarius of the pyramidal portion of the temporal bone, the upper wall of the cartilage of the Eustachian tube, and from that small portion of the sphe- noid bone which joins the temporal bone, the processus angu- 1 Loc. cit., p. 162. 86 MIDDLE EAR. laris. The muscle then passes over the septum tubce and enters the canalis tensoris tympani.1 Its tendon passes over the pro- cessus cochleariformis, and turning outward, crosses the tym- panic cavity at right angles to the belly of the muscle, to be inserted into the malleus. The tensor tympani is connected with the dilatator tuba? or tensor palati, by both tendinous and muscular fibres, as shown by Kessel, Riidinger, Mayer, Rebsa- men and others. The motor nerve of the tensor tympani is derived through the otic ganglion2 from the motor root of the trigeminus.3 The tensor tympani muscle has been described as a penniform muscle,4 in allusion to its appearance, which is due to the fact that the muscular fibres arise from the periosteum of the upper wall of the bony canal in which the muscle lies, and pass into the tendon which lies on the under edge of the muscle; the latter is turned towards the floor of the canal. As the fibres of the muscle are short, a large portion of the tendon is within the canal. Within the canal the muscle is covered by a peri- osteal sheath, which is continued over the free portion of the tendon, crossing the tympanic cavity, and is there covered with mucous membrane. This sheath of the free tympanic part of the ligament, Toynbee called the tensor ligament of the membrana tympani. Helmholtz has found that in some cases the ligament is movable within this sheath, as described by Toynbee; on the other hand, Henle has never found them entirely separate, nor differing from similar fibrous structures of other tendons. In any event, the play of the tendon within the sheath cannot be very great, on account of the slight motions of the malleus, as shown by Helmholtz. The transverse section of a perfect tensor tympani muscle measures 2£ mm., the length of its tendon from the processus cochleariformis to the insertion into the malleus is 2| mm., and the length of the muscle from its extreme origin on the Eusta- chian tube to the turn of the processus cochleariformis is 2.2 centimetres, somewhat more than an inch, as shown by Weber- 1 This canal is not always perfectly closed, and hence it has been called the semi canalis tensoris tympani. 2 Henle, Eingeweidelehre, p. 747. 3 Ludwig and Politzer, Meissner's Jahresbericht, I860, p 583. • Helmholtz. TYMPANIC CAVITY. 87 Licl. The tendon of the tensor tympani is inserted on the anterior surface of the inner edge of the manubrium, rather than on its posterior surface; hence, traction inward of the muscle will bring about a rotation of the malleus about its long vertical axis, and thus twist the posterior surface of the handle of the malleus outward, and with it the posterior segment of the membrana tympani. It therefore often seems, in certain pathological retractions of the malleus, that the anterior seg- ment of the membrana tympani is sunken, and that the anterior outline of the manubrium is especially prominent. Anterior and Posterior Walls of Tympanic Cavity.—The most important point in the anterior wall is the tympanic opening of the Eustachian tube, situated considerably above the floor of the tympanum, an arrangement which often produces a reten- tion of small amounts of fluid in the cavity. It remains to consider, now, the posterior wall of the tympanic cavity, in which is situated the important opening communi- cating with the mastoid antrum, and by that means with the mastoid cells. The mastoid antrum is a cavity of irregular shape, the roof of which is a continuation backward of the tegmen tympani. It is formed by a hollowTing out of the basis of the pyramidal part of the temporal bone, which is joined to the mastoid portion and the upper part of the latter. This cavity may extend forward into the root of the zygomatic arch and downward into the mastoid cells. It communicates with the tympanum by means of a wide opening, the under edge of which is about on a level with the oval window. The floor of the tym- panic cavity rises backward to meet this opening, in the same way as it rises anteriorly to the opening for the Eustachian tube. Course of the Facial Nerve.— Although the canalis facialis has been already mentioned in connection wTith the inner wall of the tympanum, further attention should be given at this point to the course of the facial nerve, and the important relations it sustains to the structures in the posterior portion of the tym- panum and to the mastoid cells. The facial canal rises at the fundus of the internal auditory meatus, and after leaving it passes somewhat in front of and 88 MIDDLE EAR. further outward than it, between the cochlea and the semi- circular canals, above the roof of the vestibule. Upon reaching the plane of the inner wall of the tympanic cavity, it turns1 suddenly backward at right angles to its former course, and running above the position of the oval window, curves gradu- ally backward and downward, to escape from the tympanic cavity at the stylo-mastoid foramen in the postero-exterior sur- face of the petrous bone. In the anterior wall of the facial canal, i. e. in that surface turned towards the tympanic cavity, very near the stylo-mastoid opening, is a small foramen leading to the canalis chord®,, which, leaving the facial canal at an acute angle, runs upward and fonvard through the substance of the petrous bone to the tympanum, in the lower external corner of which it opens. (Fig. 23.) Development of the Bony Canals in and about the Tympanic Cavity.—1. Carotid canal. The carotid canal is the simplest in structure and formation of the canals in or about the tympa- num.2 It appears about the third or fourth month of foetal life, as a simple furrow on the inner side of the blunt point of the petrous part of the temporal bone. By the end of the fourth month a bony ridge rises out of the furrow on the tympanic side and pushes its way between the cerebral carotid and'the tympanum, thus forming a bony partition between them. An- other osseous ridge grows from below upward and joins this first ridge, forming with it, by the ninth foetal month, the complete carotid canal. 2. Fallopian canal. This canal, too, appears at first as a simple broad groove in the tympanum. About the third month of foetal life this canal begins to form by the gradual growth of thin bony lamellse. The eminentia stapedii forms as a branch- like projection from the facial canal. The formation of the Fallopian canal is not complete until after birth. Dr. Riidinger also describes a constant opening in that part ofthe facial canal over the oval window. This would seem to correspond to that one described by Dr. Zuckerkandl as the point of entrance of the stapedial artery into the tympanic cavity. The history of ' Genu canalis facialis, at which point the canal for the great superficial petrosal nerve joins the facial canal. (Henle.) 2 Prof. Riidinger, Monatsschr. ,f. Ghrenh., No. 5, 1873. TYMPANIC CAVITY. 89 the development of the canaliculus chordae, the canaliculus tympanicus and mastoideus Arnoldi,and ofthe bony portion of the Eustachian tube and semicanal of the tensor tympani is, in many respects, according to Riidinger, similar to the above. Lymphatic Cavity in the Facial Canal.—On the inner side of the facial canal, Dr. Riidinger1 has described an empty space lying between the nerve trunk and the periosteum. This cavity or cleft, as it would appear in a transverse microscopical section, presents a sharp definition, and appears as a constant occurrence in every individual case examined. The supposition is that this space marks an extension of the araclmoideal sac of the brain running along the facial nerve, and is similar to that which is known to accompany both the optic and the acoustic nerve; it may therefore be regarded as a lymph cavity. Chorda Tympani Nerve.—The chorda, tympani, as already indicated, is a branch of the facial nerve. After its entrance Fig. 24. Nerves in and about the Tympanum. (Heath.)—1. Sensory portion of fifth nerve with Gaserian ganglion. 2. Tensor tympani muscle. 3. Motor portion of fifth nerve passing beneath the ganglion. 4. Malleus. 5. Small superficial petrosal nerves of Arnold. 6. Incus. 7. Otic gHnglion. 8. Facial nerve. 9. Chorda tympani. 10. Membrana tympani. 11. Tensorpalati muscle. 12. Middle meningeal artery. 13,13. Lingual nerve. U. Auriculotemporal nerve. 1.3. Inferior dental nerve. 16. Pterygoideus externus. 17. Pterygoideus interuus. IS. Internal maxillary artery. 20, 20. Mylohyoid nerve. into the tympanic cavity it becomes invested with mucous membrane, and, ascending into the cavity, follows quite closely i Ueber den canalis facialis in seiner Beziehung, zum aiebenten Gehirnner- ven beim Erwachsenen, M. f. O., 1873, No. 6. 90 MIDDLE EAR. the posterior periphery of the membrana tympani until it reaches the height of the tendon of the tensor tympani, when it winds forward, above this tendon, between the malleus and incus, and finally escapes from the tympanic cavity at the Gla- serian fissure, through the canal of Huguier. It then descends between the two pterygoid muscles, to unite with the gustatory nerve, and is finally distributed with it to the submaxillary gland; it then joins the submaxillary ganglion and terminates in the lingualis muscle, as shown by Gray. This nerve has very little sensibility according to Vnlpian,1 whose experiments have shown that the chorda tympani contains both centrifugal and centripetal fibres, the latter serving as a means of excito-motory irritation, destined to act on the sublingual gland. According to Vulpian, and Prevost of Geneva, part of the chorda tympani accompanies the lingual nerve in its peripheric distribution, furnishing: branches to all the terminal filaments of the latter. This nerve has no connection whatever with the auditory nerve, and therefore no phenomena of the former can be construed into symptoms of diagnostic value respecting the nerve of hearing. Nerves supplying the Mucous Membrane of the Tympanic Cavity. —The nerves supplying the mucous membrane of the tympanic cavity as well as that of the Eustachian tube and mastoid cells, are derived from the tympanic plexus, an anastomosis between the otic ganglion, petrosal ganglion of the glosso-pharyngeal nerve, and the carotid plexus, by means of the superior cervical ganglion of the sympathetic nerve.2 The otic ganglion is situated on the inner side of the sensory division of the inferior maxillary nerve, and sends several small branches to it. It is important to bear these relations in mind when considering certain neuralgias in and about the ear, which might otherwise prove very puzzling. In an infirmary practice, numerous cases of earache are con- stantly seen, which are solely and clearly due to imperfect teeth. By means of the otic ganglion, the soft palate, the drum-head, and tensor tympani muscle, the lining membrane of the cavity 1 Gazette Medicale de Paris, Feb. 15, 1873. 8 Bischoff, Microscopische Analyse der Kopfnerven, Munchen, 1865. TYMPANIC CAVITY. 91 of the tympanum, and the integument of the external ear are put in sympathetic relation with each other and with the nervous system. Perhaps certain epileptiform phenomena which have been observed in connection with well-marked disease of the middle ear, as well as similar phenomena which could be seen to be connected with an obscure disease of the organ of hearing, may be explained by reflex communication through the tympanic plexus, especially through the petrous ganglion of the glosso- pharyngeal, to the brain and spinal cord. The tympanic nerve or Jacobson's nerve is a branch from the petrosal ganglion1 of the glossopharyngeal nerve; "it enters a small bony canal on the base of the petrous portion of the tem- poral bone, ascends to the tympanum, enters this cavity by an aperture in its floor close to the inner wall, and divides into three branches, which are contained in grooves upon the surface of the promontory."2 This is the largest nerve branch given to the tympanic cavity, and therefore it has received its special name and consideration from most anatomists. Since, however, the tympanic nerve contains so large a number of large ganglion cells, either solitary or grouped, and thus makes numerous con- nections with other important ganglia and nerves, the name tympanic plexus is now given to what formerly was named, in its tympanic portion at least, the tympanic nerve. Bloodvessels of the Tympanic Cavity.—The chief artery of the tympanic cavity runs along the floor of the tympanum and over the promontory. The capillaries of these vessels empty at last into the veins of the periosteum.3 According to Gray, the arteries supplying the tympanic cavity are as follows : The tympanic branch of the inferior max- illary which is given to the membrana tympani, the stylo-mastoid, branch of the posterior auricular, distributed to the back part of the tympanic cavity and mastoid cells, a number of smaller branches from the petrosal branch of the middle meningeal, and branches from the ascending pharyngeal and internal carotid. The veins of the tympanic cavity terminate in the middle menin- geal and pharyngeal veins, which form a plexus near the glenoid 1 An der sch. 1 Gray. ■ Kessel. 92 MIDDLE EAR. articulation, and then empty into the internal jugular vein. It is very important to bear in mind these distributions of blood- vessels, when the ear is to be leeched. Dr. Zuckerkandl1 has described as constant, an artery which he has termed the arteria stapedia. This artery is a branch of the stylo-mastoid artery, which enters the tympanum through an ever-present triangular opening in that part of the facial canal passing just above the fenestra ovalis. This small vessel descends through the membrana obturatoria of the stapes, either to anastomose with a branch of the artery following Jacobson's nerve, or to break up into secondary anastomoses before it reaches this point. P>efore the artery passes the stapes it gives off a branch to the anterior crus of the stapes and to the ante- rior part of the membrana stapedia which it divides in two, a second branch to the hinder crus and to the posterior part of the stapedial membrane, and a third arteriole usually from one of the lateral branches passes inward to the foot-plate of the stapes. PHYSIOLOGY. The function of the tensor tympani muscle is somewhat like that of the palmaris,2 i. e. it is better adapted for tension than for motion. It also appears that, by exerting a slight tension on the membrana tympani, this muscle can bring about a muffling or damping effect without any visible movements in the ossicles. In 1860, Politzer3 showed that the tensor tympani was sup- plied by a branch of the motor division of the fifth nerve. Later, Voltolini4 performed a series of experiments which led him to the following conclusions: — " 1. Irritation (by electricity) of the trigeminus produces dis- tinct and powerful contractions of the tensor tympani, which can be kept up for some time on the dead animal; these con- tractions can almost always be produced even by weak streams of electricity. " 2. The same result can be obtained by irritation of the facia- ' Ueber die Arteria Stapedia des Menschen, Monatsschr., f. O. No. 1, 1873. 2 Henle, op. cit. p. 748. 3 Meissner's Jahresbericht, p. 583. 4 Virchow's Archiv, Band Go, p. 467. TYMPANIC CAVITY. 93 lis, but usually only by strong electric currents, and the irrita- bility is generally soon lost. " 3. During this contraction of the tensor, the drum-head is drawn strongly inward by means of the manubrium, but, of course, these excursions of the drum-head vary in different ani- mals ; in guinea-pigs they are so small as to be undistinguishable unless an indicator is attached to the membrane. " 4. During such a contraction ofthe tensor and the consequent tension ofthe membrana tympani, a simultaneous ascent of the lymph in an opened semicircular canal becomes visible in the dead animal, and when the tension is removed the fluid sinks back. "5. In no instance, neither by excitation of the trigeminus, nor of the facial nerve, nor even by mechanical movement of the stirrup, was a simultaneous movement in the membrana tympani secundaria visible, not even by microscopic observation of a reflection, or an indicator attached to the membrane. " 6. During irritation of the trigeminus, and the consequent contraction of the tensor tympani, there ensues a contraction of the palatal muscles and an opening of the Eustachian tube, for the anterior membranous wall is drawn aAvay from the posterior cartilaginous tubal ridge." The fact that the tensor tympani can be put into motion by excitation of two cerebral nerves, as above stated, may, accord- ing to Voltolini, be used as an explanation of the power the muscle has of both voluntary and involuntary movement. In one of his experiments, Voltolini observed that excitation of the facial nerve produced contractions in the tensor tympani and stapedius muscle. Such a process, says the observer, is of highest importance in the act of hearing, if, indeed, such a pro- cess occur in the living ear, which is not to be doubted ; in such an event the stapedius muscle acts as a check on the movement of the hammer by the tensor tympani.1 The reflex movements of the tensor may be accounted for by the branch of the trige- minus which passes through the otic ganglion. Then arises, as Voltolini suggests, the important question whether the fibre from the facial nerve, supplying the tensor, also passes through the otic ganglion, or goes directly from the facial to the muscle; in the latter case the muscle would evi- 1 Loc. cit., p. 479. 91 MIDDLE EAR. dently possess power of voluntary motion. Although no one has demonstrated that a branch of the facial nerve does pass directly to the tensor tympani, the muscle certainly possesses power of voluntary contraction, as held by Johannes Miiller, Voltolini, and others. Physiological Nature of certain Tympanic Bands, heretofore con- sidered Pathological—Dr. Victor Urbantschitsch1 has pointed out the physiological nature of certain membranous and cord-like adhesions in the cavity of the tympanum, which have heretofore been considered pathological. As he states, Prof. Politzer was the first to express the opinion that such might be the case, and the former has verified this opinion by a series of careful and copious investigations on the cadaver of embryos, new-born children, and adults. Dr. Urbantschitsch has frequently found, in the new-born child, membranous and cord-like connections between the inner side of the vertical shaft of the incus and the inner wall of the tympanum. This has been considered pathological by Toynbee and other authors; but Urbantschitsch has shown that these formations are remnants of an embryonic fold, running from the vertical ramus of the incus to the inner wall of the tympa- num, entirely inclosing the stapes. This was seen eight times in embryos, fifty times in the new-born child, and sixteen times in fifty examinations ofthe tympanic cavity in the adult. There is also an embryonal stapedial fold which sometimes leaves as residue small membranes or cords passing from the head and shafts of the stapes. But this observer does not assert that all of the connecting bands or membranes which he has described are always of a physiological nature ; he believes that their occurrence, without any morbid changes in the tympanic cavity, would not justify the conclusion that a pathological pro- cess preceded their formation. Similar connections between the posterior, anterior, and exterior surface of the vertical ramus of the incus with the structures of the tympanum are shown to be normal. The first point agrees with the investigations of Lincke; the second point agrees with the statement of v. Troeltsch. 1 Beitrag zur Entwickelungsgeschichte der Paukenhohle. Report of Royal Academy of Sciences, Vienna, Jan. 1873. TYMPANIC CAVITY. 95 The horizontal ramus of the incus may be joined to the external wall of the tympanum, and with the mastoid cells, by similar membranous connection. The union with the outer wall has already been shown by Zaufal to be a normal one. This was found by Urbantschitsch in eighty per cent, of all the adults examined. The membrane so frequently found between the tendon of the tensor tympani and the antero-superior wall of the tympa- num, as described by Prussnk, Gruber, and Zaufal, has been observed in adults by Urbantschitsch, sometimes as a perfect membrane, and sometimes perforated in the middle or repre- sented only by a few adhesive bands. Hyrtl's discovery that osteophytes are regularly found in the tympanum of many of the mammals, is carried still further by Urbantschitsch, who shows that there is in the tympanum of man, a series of membranous bands containing structures similar to osteophytes which are of a physiological nature. They were found in one-third of all the adult tympana examined. Hyrtl says that these osteophytes are formed in the tympana of animals during the early years of life; Urbantschitsch has found them in the tympanum of the new-born child sixteen times in fifty examinations. These are usually found on the eminentia pyramidalis. They may also be found on the hinder and outer wall of the tympa- num, and on the border ofthe round window. They are usually in connection with a membranous or cord- like structure. Meckel has described a bony ridge between the eminentia pryamidalis and the oval window. In one case, among fifty examined, Urbantschitsch found a bony growth between the eminentia pryamidalis and the inner wall of the tympanum. The posterior wall of the tympanum often contains a bony formation resembling a lamella. " This forms, either alone or in combination with membranes, a partition which divides the posterior portion of the tympanic cavity into a superior, larger space, and an inferior, smaller one." Function of the Round Window and. its 31embrane.—In 1871 I made some investigations into the condition of the membrana secundaria, or the membrane of the round window, during the 96 MIDDLE EAR. movements of the ossicles of hearing; and the excursions per- formed by it were measured under the microscope. During these investigations I also noticed the effect of varying laby- rinthine pressure upon the small bones of hearing and the membrane of the round window. All the observations were made upon temporal bones from human subjects, as soon as possible after death. Of the ten specimens thus used, eight were from males and two from females; the ages varying from six years to forty-five years. During the intervals between the experiments, the temporal bones were kept in a ten per cent, solution of alcohol. To pre- pare the bones for examination under the microscope, the Eus- tachian tube was removed up to its bony portion, but the membrana tympani, with the annulus tympanicus, the chain of ossicles, and the labyrinth, were left entirely intact. In order to obtain the best view of the fenestra rotunda, the floor of the tympanum was removed as high as the round window, till it and the promontorium cochleae were fully ex- posed. The chief difficulty experienced in thus exposing the round window is the liability to encroach upon the posterior semicircular canal. To avoid this, a view of the window wras first gained, by cautiously chiselling away the posterior portion of the floor of the tympanum. Then the entire preparation was turned for- ward about an axis running through the porus acusticus in- terims and the external auditory meatus, and the bone was chiselled away in all directions, excepting outward and upward, till a perfect view of the round window was obtained. The preparation was then fastened firmly in a vise, and laid so as to be conveniently approached by a microscope, and to receive, by means of a condenser, light from a kerosene lamp. The prepa- ration now lay so as to expose the chain of ossicles from under- neath, and the membrana tympani secundaria, at an angle of about 45°. These were sprinkled lightly with powdered starch,1 so as to insure bright vibrating points. Sources of Sound.—As sources of sound, four organ-pipes were used, of respectively 50, 140, 630, 1160 vibrations per second. The first was a reed-pipe, the three remaining ones were stopped 1 Lissajou's Method. TYMPANIC CAVITY. 97 pipes. These were connected with the ear, in each case, by means of a gutta-percha tube one metre long, and one-half cm. wide, fastened to the side of the reed-pipe; but in the case of the other three, at the closed end. The free end of the connecting gutta-percha tube was supplied with a tapering glass tube, pointed with sealing-wax, moulded to the external auditory meatus, thus procuring an air-tight communication between the organ-pipe and the membrana tym- pani. All unwished-for vibrations were avoided by placing the pipes upon separate tables, and in some instances they were held in the hand during the sounding of a note. This necessitated all vibrations which reached the ear to pass through the con- necting gutta-percha tube. The position of the glass tube in the external auditory meatus has great influence on the experiments. When the tube is directed downward and forward, the experiments are almost invariably successful, but in any other position they may be partially or entirely unsatisfactory. For, in the former position, the sound-waves strike more di. rectly against the membrana tympani and the hammer, whereas in any other position they are forced against the sides of the auditory canal, and are deflected and destroyed before they reach their destination. This seems to indicate that sound, entering the external auditory meatus, produces no easily dis- tinguishable effect upon the ossicles of hearing and the laby- rinth, by simple conduction through the bony walls of the audi- tory canal. It must, indeed, be forced against the membrana tympani, and through it act upon the ossicula auditus. These, in turn, act like a lever, communicating their movements to the fluid of the labyrinth and the membrane of the round window. Upon producing a note upon a given organ-pipe connected with the ear, as already described, the chain of bones was seen to vibrate in excursions, bearing a fixed relation to each other.1 At the same time, their motion was communicated through the labyrinth to the membrane of the round window, upon which ' The movements of these bones, in connection with sound-waves, have also been observed, and their excursions measured by Politzer and Buck. 7 98 MIDDLE EAR. the excursions of the shining particles maintained an almost constant relation of equality with those ofthe stapes. The excursions, both upon the chain of ossicles and upon the membrane of the round window, varied in their length with the pitch of the note produced by the organ-pipe; the longer excursion corresponding to the deeper note. By the use of a syren, which was fitted to a pipe opened at its side to accommodate the gutta-percha connecting tube, excur- sions synchronous with the revolutions of the disk were pro- duced upon the chain of ossicles and the membrane of the round window. These could be counted during the early revolutions of the disk ; but as they increased and the note ascended, the vibrating points became lines diminishing in length with the increasing rapidity ofthe revolution. During these observations one preparation was found which did not respond to the notes of the organ-pipes as the previous ones had done. The ossicula auditus manifested some very slight vibratory motions, but the membrane of the round window showed none. In order to explain this apparently abnormal result, and to find out whether an increased or diminished labyrinthine pres- sure could have produced it, the following experiments were instituted :— Upon a perfect petrous bone, which failed to respond to the sounds produced by the already-mentioned pipes, the superior semicircular canal was opened at its summit, and to this open- ing one end of a small glass tube, 1 centimetre long by 5 mm. wide, was hermetically sealed. The bone thus modified was placed in water and brought under the air-pump, in order to remove any air which might have entered the labyrinth. After these arrangements the glass tube, sealed to the superior semi- circular canal, was connected by a gutta-percha tube, of similar diameter, to a reservoir of water, consisting of a funnel placed in a retort-holder, and which could be elevated or depressed at will. The pressure exercised by the water upon the labyrinth could be easily seen with the unaided eye, as the varying height of the funnel caused the column of water to press with a greater or less force upon the membrane of the round window. TYMPANIC CAVITY. 99 \Vith these modifications the preparation, which formerly failed to respond to the notes of the organ-pipes, was placed in connection with the sources of sound, and the chain of bones, as well as the membrane of the round window, was observed during the passage of a note to the ear. The desired excursions now became apparent upon the hither- to abnormal specimen, and resembled those upon other prepara- tions so long as the pressure was maintained at a certain grade; but when increased or diminished beyond a given point, the excursions ceased upon the ossicles and the membrane of the round window. This was observed to be the case sooner during the occurrence of high than of low and powerful notes. The human ear, in the living state, sometimes fails to perceive high notes, while lower ones are distinctly heard. Perhaps such phenomena may be explained by an application of the results obtained in these investigations, in which artifi- cial labyrinthine pressure interfered with the action of the chain of ossicles and the membrane of the round window, sooner in connection with high notes than with lower ones. Pathological processes, with results of a purulent,1 serous, or hemorrhagic2 nature, have been'observed, and their injurious effects upon the sense of hearing noted. In such cases it may be supposed that the increased amount of pathological fluids in the labyrinth interfere with the action ofthe chain of bones and the membrane ofthe round window, just as the artificial pressure did in my experiments. In addition to these destructive changes, which follow patho- logical processes in the ear, the perilymph of the labyrinth may be subject to great fluctuations in its amount, since the arach- noid sac and the labyrinth are so intimately connected, as ex- periments of Weber-Liel3 and Hasse show. The latter says:4 tw All vertebrates possess a duct which originates in the vesti- bule ; and in all animals, with the exception of the Plagiostomes, 1 Moos, Deafness in Meningitis Cerebro-spinalis. Archives of Ophthalmol. and Otol., vol. i., No. 2, 1870. 2 Moos's Four Cases of Gunshot Wounds of the Ear, Archives of Oph. and Otol., vol. ii. p. 343. 3 M. f. O. August, 1870. * Anatomische Studien, No. xix. p. 768. 100 MIDDLE EAR. in which it passes directly to the surface of the skull, this duct enters the cavity of the cranium and there terminates either in a closed sac at the confines of an epicerebral lymph-cavity, or opens into the same. This is the ductus endolymphaticus or the aquasductus vestibuli with the saccus endolymphaticus, the former of which, in most vertebrates, arises from the sacculus, that is, from the inferior portion of the vestibule. " Every increased or diminished pressure of the fluid of the liquor cerebrospinalis in the subarachnoid cavity will make itself felt per continuitatem through the saccus and the ductus endolymphaticus, in the interior of the auditory apparatus, in the endolymphatic cavity and upon the terminal apparatus of the auditory nerve found therein. We may thus explain most easily the impairment of hearing for high tones in cases of in- creased pressure." In concluding this account of my experiments, I would call attention to a fact of interest respecting the direction of a line described by a vibrating starch-point upon the membrane of the round window. It was observed that such a line invariably remained parallel to the plane of the membrana tympani. An explanation may be found in ultimately discovering an unequal tension of the membrana tympani secundaria, depen- dent upon the manner of its insertion into its frame. The following deductions may be drawn from the foregoing experiments:— 1. The excursions of the chain of ossicles of hearing bear a fixed relation to each other. 2. The excursions of the ossicles of hearing are communicated through the labyrinthine fluid to the membrane of the round window. 3. The excursion of the membrane of the round window generally equals that of the stapes ; but it may equal that of the membrana tympani, at the point of the manubrium mallei. 4. The pressure within the labyrinth, increased beyond cer- tain limits, causes cessation of the action of the membrane of the round window and the chain of ossicles of hearing:. This occurs sooner in connection with high notes than with the lower notes of the scale. 5. If the labyrinthine pressure is greatly diminished or totally TYMPANIC CAVITY. 101 removed, the chain of ossicles may continue to vibrate, but they exert no influence upon the membrane of the round window. 6. The vibrations of the membrane of the round window vary from toVo- mm- t0 iffo mm-1 A difference of opinion has existed respecting the part the membrane of the round window plays in the conduction of sound. Without doubt the excursions of the ossicles of hearing are conveyed through the water of the labyrinth to the membrane ofthe round window, as shown by the experiments of the author, and later by the corroborative experiments of Weber-Liel. Some authorities have thought that perhaps the membrana tympani secundaria participates directly on the sound waves transmitted to it by the membrana tympani through the air of the tympanum. Johannes Miiller inclined to this opinion, but the experiments of Schmiedekam and Hensen seemed to show- that he was incorrect in his viewrs. Recently Weber-Liel2 has performed a series of experiments which are not only very in- teresting, but tend to decide this question affirmatively. These experiments were performed on nine fresh preparations of the ear; seven were from man, one from a calf, and one from a horse. The ears were prepared for examination in a way similar to that described on page 96. The sources of sound were the human voice and three organ- pipes ; the fundamental notes of the latter were such as gave 180, 210, and 540 vibrations per second. The sounds from these pipes and the voice were conveyed to the prepared ears, in a manner similar to that described on p. 97. The preparations were sprinkled with starch, illuminated, and held firmly, in the manner described at the same place. The first results of Weber-Liel's observation were in entire harmony with those obtained by the author. But Weber-Liel then carried his experiments further, and obtained the following results :— 1 All the measurements I obtained may be found recorded in the Archives of Oph. and Otol., 1872. 2 Centralblatt f. Med. Wiss., Jan. 8,187G. 102 MIDDLE EAR. 1. If the incudo-stapedial joint is divided, and the incus pushed somewhat aside, and then the tympanic cavity hermeti- cally closed by a firmly inserted pane of glass (a microscopic cover) on the artificially opened side, while the Eustachian tube is kept slightly open, then microscopic examination of the mem- brane of the round window through the glass cover reveals, almost invariably, that also under these circumstances during the sounding of the pipes and during the singing of deeper notes, the particles of starch or the reflecting points on the membrane performed excursions, which were but slightly less (1| : 2) than those occurring before the division of the incudo-stapedial joint; these excursions, however, were observable only on certain parts of the membrana tympani secundaria. They did not occur when the cavity ofthe tympanum was reopened. On the head and rami of the stapes faint simultaneous vibra- tions were observed in two cases. 2. Upon slightly rarefying or condensing per tubam the air in the tympanic cavity of the preparations arranged as above, no change was produced in the w7idth and direction of the excur- sions ; when the air became more condensed, the high notes first ceased to produce vibrations ; with increasing condensation, the deeper notes ceased to have effect. 3. In order to exclude the possibility of the communication of sound waves from the oval window (foot-plate of stirrup) through the labyrinth to the membrana tympani secundaria, the labyrinth was opened and the vestibule exposed from behind. After the fluid of the labyrinth had escaped, sound-waves con- ducted by the membrana tympani to the labyrinth, produced no visible effect on the membrane of the round window. This negative result is attributable to the loss of pressure consequent upon the escape of the labyrinth-fluid; for, when the cochlea was sawed transversely through, a narrow glass tube placed in the transversely sawed scala tympani, and the latter, with the glass tube, filled with various heights of water, by means of which once more a certain amount of pressure was brought upon the labyrinth side of the membrane, then, when the tympanic cavity was again closed, immediately the excursions became once more visible upon sounding the organ-pipes or singing. 4. With some of the preparations, a glass tube was cemented to the temporal bone, and through this tube, by means of a rub- TYMPANIC CAVITY. 103 ber pipe, the labyrinth being undisturbed, sound vibrations were conveyed to the bones of the head. No excursions were per- ceptible, neither with the tympanum opened nor closed. These experiments seem to prove that the membrane of the round window may be set in vibration by sound-waves from the membrana tympani conveyed through the air of the tym- panic cavity. The Power of 31uscular Accommodttion.—According to Prof. Lucre's experiments,1 the ear has, in the tensor tympani and stapedius muscles, an apparatus for accommodating itself to various sounds. The first muscle aids in the accommodation for low musical tones, the latter accomplishes the same for high, unmusical sounds. Abnormal contraction of the tensor tympani, within sufficient antagonism of the stapedius, produces a modification of percep- tion, termed by Dr. Lucse " low hearing;" an analogous condi- tion ofthe stapedius muscle in its relation to the tensor tympani produces " high hearing." Action ofthe Tensor Tympani and Stapedius 3Iuscles.—Confirma- tory observations of Drs. Mach and Kessel2 show that the traction on the stapedius muscle drives the head of the malleus inward, and the lower part of the membrana tympani outward. The substance of these observations is in harmony with the cele- brated theories of Weber. Bibliography ofthe Mechanism ofthe Memhrnnn Tympani, ofthe Auditory Ossicles, and ofthe Membrana Tympani Secundaria. 1851. Weber, Edward. Ueber den Mechanismus des menschlichen Gehoror- gans. Bericht iiber die Verhandlungen der Konigl. Sachs. Gesellschaft der Wissenschaften zu Leipzig. 1856. Meyer, G. Hermann. Lehrbuch der Physiolog. Anat. des Menschen, p. 276. 1861. Fick, Adolph. Lehrbuch der Anatomie und Physiologie der Sinnesor- gane, p. 138. 1 Die Accommodation und Accommodationsstorungen des Ohres. Dr. A. Luca?, Berlin Klin. Wochenschrift, 1874, No. 14. Abstract by Dr. Jacoby, Archiv f. O. Band ix. p. 184-185. * Beitriio-e zur Topographie und Mcchanik des Mittelohrs. Wiener Sitz- ungsb., 23 April, 1874. 104 MIDDLE EAR. 1861. Magnus, A. Beitrage zur Anatomie des mittleren Ohres. Virchow's Archiv. Band. xx. 1864. Politzer, A. Archiv f. Ohrenheilkunke. 1865. Wundt. Lehrbuch der Physiologie des Menschen, p. 571. 1866. Funke, O. Lehrbuch der Physiologie, Bd. ii. 1868. Henke, A. Der Mechanismus der Gehorknochelchen. Zeitschrift fur rationelle Medizin. 1868. Hensen, V. Versuche iiber den Mechanismus, und die Schwingungen der Gehorknochelchen. Arbeiten aus dem Kieler Physiologischen In- stitut, pp. 68-86. 1869. Helmholtz, H. Die Mechanik der Gehorknochelchen und des Trommel- fells.1 1870. Buck, Albert H. An investigation concerning the mechanism of the ossicula auditus. Archives of Oph. and Otology, vol. i. 1871. Burnett, C. H. An investigation concerning the mechanism of the ossicles of hearing and the membrane ofthe round window. 1874. McKendrick, John G. Physiological Laboratory, University of Edin- burgh. Edinburgh Med. Journal, January. 1876. Weber-Liel. Centralblatt fur Med. Wissensch, Jan. 8. CHAPTER II. EUSTACHIAN TUBE AND MASTOID PORTION. ANATOMY. The Eustachian tube, though discovered by Vesalius, gets its name from Bartolommeus Eustachius,2 who gave a more com- plete description of it than any of his contemporaries or prede- cessors. Though it is generally conceded that Vesalius was the discoverer of the tube, some authorities think that even Alc- meon3 and Aristotle4 knew of its existence. The Eustachian tube is the only means of aerial communica- tion between the pharynx and middle ear. It opens into the pharynx a little above the floor of the nose, and passes back- ward, upward, and outward to the cavity of the tympanum, forming an angle of 40° with the horizon, and 135° with the axis of the external auditory canal. The pharyngeal mouth of the tube is wide, but the tube narrows rapidly to the isthmus, 1 Pfliiger's Archiv fur Physiologie, I. Jahrgang. ; Bonn, 1869. 2 1500-1574. 3 570 B. O. * 384-322 B. C. EUSTACHIAN TUBE AND MASTOID PORTION. 105 from which point it widens again to the tympanic cavity. It therefore resembles, somewhat, two short and wide-based cones, placed point to point, their junction marking the position of the isthmus. The pharyngeal mouth of the tube is oval in shape, being 9 mm. high and 5 mm. wide. At the isthmus, the junction of the osseous with the cartilaginous part of the tube, the diameter is 1.5 to 2 mm., and the greatest diameters of the osseous canal vary from 4 to 4.5 mm. The entire length of the Eustachian tube is 35 mm., a little more than 1 inch; the bony portion being 11 mm., and the cartilaginous part 24 mm. long. Bony Portion of the Eustachian Tube.—As already indicated, the Eustachian tube is composed of a bony and a cartilaginous portion. The former lies entirely within the petrous bone ;l the latter portion is joined to the former and is about two-thirds of the entire tube. The calibre of the bony portion is triangular, the angles, however, are rounded by the mucous lining of the tube. Its average diameter is about 2 mm. The outer wall of the three composing this triangular bony tube, belongs to the pars tympanica, the tympanic bone, the inner wall separates the tube from the carotid canal, and the upper wall is formed inter- nally by the septum tub?e, and the floor of the canal for the tensor tympani, and outwardly it unites with the outer wall of the bony tube in the petro-tympanic or Glaserian fissure. The posterior wall of the bony portion of the canal is somewhat longer than the anterior wall. Usually the bony Eustachian tube is twice as wide as the semi-canal of the tensor tympani, but in some instances these relations are reversed, as shown by Riidinger. Cartilaginous Portion of the Eustachian Tube.—In order to understand the true form of this part of the Eustachian tube, one must imagine a shell of cartilage, not quite an inch long, bent so that a section of it at right angles to its long diameter resembles a hook or shepherd's crook. The longer portion of this section of cartilage will represent a section of the inner ' In some cases the large wing ofthe sphenoid bone Unites in the formation of the osseous part of the Eustachian tube, or at least it forms with the pars petrosa, the sulcus petro-sphenoidalis for the reception of the cartilage of the tube. (Riidinger, Die Ohrtrompete, p. 2.) 106 MIDDLE EAR. Fig. 25. wall, the shorter portion represents that of the anterior or outer wall, and the curve shows the position of the roof of the Eu- stachian tube. It will be seen, therefore, that this part of the tube is not a complete and round cartilaginous canal, but rather a flattened tube, the posterior wall and roof of which are made entirely of cartilage, while the anterior wall is of cartilage only in its upper part, its lower por- tion being muscular* and com- pleting the tube. The upper part of the inner cartilaginous wall, as well as the roof of the tube, is fastened to the base of the skull by means of the basilar fibro-cartilage. The lower end of the inner wall is movable. That part of the cartilage of the Eustachian tube which curves forward to form the upper part of the outer or anterior wall of the tube, is widest and most movable in its middle portion; it is narrower and more firmly fixed at its two extremities, viz., above, where it is joined to the jagged bony edge of the osseous canal, and below, to the pterygoid process. The calibre of the tube, in the main, is not round but cleft- like, and slightly sigmoid in shape; however, that portion of the calibre lying in the curve formed by the cartilage as it turns forward, i. e. that part lying entirely within cartilagi- nous boundaries, is round and more open than the rest of the lumen of the tube, owing, probably, to the stiffness of the cartilage. This fact would always insure at least a portion of the tube's being more likely to be free from obstructions or from having its two sides stick together. To this more patu- lous part, Riidinger has given the name of safety tube (Sicher- 1 Formerly, this part of the canal was called membranous, but since muscu- lar tissue is so intimately concerned in its formation, Riidinger proposes to call it muscular, as being more truly descriptive. Transverse Section of the Cartila- ginous Part op the Eustachian Tube near the Foramen Ovale. (Henle.)—6. Section of the internal carotid, a. Carti- lage of the tube. h. Third branch of the trigeminus, g. Middle meningeal artery. /, e Transverse section of the external and internal pterygoid muscles, d. M. spheno-staphylinus (tensor palati). c. Transverse section of the M. petrostaphy- linus (levator palati). EUSTACHIAN TUBE AND MASTOID PORTION. 107 heitsrohre), and to the cleft-like calibre of the tube below this rounder lumen, he has given the name of "accessory cleft," (Ililfsspalte), "since, according to Du Bois Raymond, these terms express most clearly their physiological importance."1 The posterior cartilaginous wall of the Eustachian tube projects well into the pharynx, forming there a prominent ridge, the anterior boundary of the fossa of -Rosenmuller. Into the latter, the Eustachian catheter is often placed in mistake for the pha- ryngeal mouth of the Eustachian tube. When the latter is to be catheterized, this prominent ridge, marking the termination of the cartilage of the Eustachian tube, should be sought for and thoroughly located with the beak of the catheter. In order to do this it is well to allow the catheter to pass first into the fossa of Rosenmuller, then to glide gently forward over the aforesaid cartilaginous lip, by which act the beak can hardly escape going into the pharyngeal mouth of the tube. As already stated, the cartilaginous shell of the Eustachian tube is adherent at its curve or roof to the base of the skull, by means of the basilar fibro-cartilage; the edges of the shell, i. e. the edges of the anterior and posterior lips of the cartilage of the tube, are free, and from them important muscular structures arise. The inner dilator of the tube, or the salpingo-p>haryngeus muscle, is one of these, and arises from the edge of the posterior cartilaginous wall of the Eustachian tube, and passes towards the superior constrictor of the pharynx. There is also an inti- mate topographical2 relation between this inner wall and the inner surface of the levator palati (petro-staphylinus, Henle), which muscle, in conjunction with the salpingo-pharyngeus, the inner dilator of the tube, brings about movements of the cartilage. " If the levator palati be pulled upon in a fresh pre- paration, the under end of the inner plate of cartilage will be pushed inward and upward, by which means, the pharyngeal mouth of the Eustachian tube will be considerably widened."3 Since, then, the conjoined action of these two muscles, the levator palati and the salpingo-pharyngeus, together with the dilatator tubse or tensor palati, yet to be described,brings about 1 Riidinger, Die Ohrtrompete, p. 7. 2 This muscle sends a few fibres to the posterior cartilaginous wall of the Eustachian tube near the junction of the cartilage with the bony portion of the tube. s Riidinger, Die Ohrtrompete, p. 4. 108 MIDDLE EAR. these changes in the pharyngeal mouth of the Eustachian tube, it can easily be seen how the act of swallowing, which brings them into action, opens the tube and ventilates the middle ear. Fig. 26. Palatal Muscles viewed from behind. (Gray.)—The Eustachian tube is shown here, in its regional relations to the palatal muscles, but not in its true anatomical shape. Tensor Palati Muscle.—The most important of all the muscles of the Eustachian tube is the tensor palati.1 This muscle arises by a flat tendon from the posterior edge of the hard palate, in intimate connection with the tendon of its fellow of the opposite side, and, gradually narrowing into the tendon which passes 1 This muscle has received various names : Tensor veli; Tensor veli palatini • Dilatator tubae (Riidinger) ; Spheno-salpingo Staphylinus, etc. 7935 EUSTACHIAN TUBE AND MASTOID PORTION. 109 around the pterygoid hook, spreads out again from this point into a fan-shaped muscular layer, the free broad edge of which is inserted into almost the entire length of the anterior lip of the cartilage of the Eustachian tube. Respecting the much-disputed origin of the tensor veli, it may be said that, according to the investigations of Dr. Urbant- schitsch,1 there are individual variations in the origin of this muscle from the membranous part of the Eustachian canal. In some cases such an origin is wanting. Hence has arisen the great difference of opinion between many noted investigators of the anatomy and physiology of this tube. A very important variation also occurs in the connection between the tensor tympani and tensor veli, for sometimes such a connection is not to be found, while in other cases it un- doubtedly exists. In one instance it was found that the spindle- shaped tendon of the tensor tympani passed entirely into the middle belly of the tensor veli muscle. These facts are in harmony with the well-known investigations of Weber-Liel. By the contractions of this muscle the anterior wall of the cartilage of the tube is pulled outward and downward, and thereby the calibre of the canal is widened. According to the investigations of Riidinger,2 it is shown that there is a direct connection between the tensor palati (Dilatator Tubas) and the tensor tympani muscle. Xot only do the tendi- nous fibres, but also the muscular fibres, of the one pass over into those of the other, at the upper part of the Eustachian tube. This connection is of the greatest importance when considering the cause and treatment of certain forms of hardness of hearing due most probably to a kind of paresis in the tensor veli. The Inner Pterygoid Muscle.—This muscle is considered by \Veber-Liel as specially belonging to the muscles of the Eusta- chian tube.3 According to his observations some of the upper, shorter, and hinder fibres of this muscle are inserted into the fascia of the floor of the tube throughout its length, and are 1 Zur Anatomic der Tuba Eustachii des Menschen. Victor Urbantschitsh. Med. Jahrbuch, 1 Heft, 1875. 2 Op. cit., p. 6. 3 Proo-ressive Schwerhorigkeit. Berlin, 1870, p. 68-71. 110 MIDDLE EAR. then lost in the fibrous covering of the petrous bone. Its func- tion is that of a tensor of the fascia of the Eustachian tube. The Ligamenta Salpingo-pharyngea.—T>r. Zuckerkandl1 has described a constant and peculiar anatomical connection between the Eustachian tube and the constrictors of the pharynx, under the name of the ligamenta salpingo-pharyngea. His statement is that upon laying bare the posterior wall of the pharynx and dissecting off the mucous membrane, along the periphery of the pharyngeal opening of the Eustachian tube and adjacent parts, there will be found three, four, or five, perhaps more, tendinous, rarely elastic cords, attached to the pharyngeal end of the hooked cartilage of the tube, and to the outer wall ofthe same, which in their fullest development are likened to the tendinous cords ofthe valves of the heart. This anatomical arrangement, it is said, produces a free opening of the Eustachian tube at each contraction of the superior and middle constrictor of the pharynx. The same observer has described a salpingopharyngeal recess below the faucial mouth of the Eustachian tube.2 Mucous Membrane of the Eustachian Tube.—The mucous mem- brane of the Eustachian tube is a continuation of that of the pharynx. It is supplied with ciliated epithelium, the cilia of which move in a direction from the tympanic cavity towards the pharynx, thereby favoring the passage of fluids from the cavity of the drum and tube into the throat. The Eustachian tube is very rich in glands at certain places; although the upper concave portion of the cartilaginous roof of the canal is entirely free from glands, the sides of the tube, in the pharyngeal portion, are richly supplied with " acinous mu- cous glands," emptying into the folds of mucous membrane, as shown by Riidinger. These mucous glands do not differ from those of the oesophagus and pharynx. In the upper portions of the tube, towards the tympanic cavity, all glands become sparse. In addition to the glands just named, Gerlach3 has shown the 1 Zur Anatomie und Physiologie der Tuba Eustachiana. M. f. O., 1873, No. 12. * Monatsschr. f. Ohrenh., No. 2, 1875. 3 Zur Morphologie der Tuba Eustachii. Sitzungsberichte d. Erlanger Physi- calisch-Med. Soc. Abstract by Yon Troeltsch, A. f. O., vol. x. p. 58, 1875. EUSTACHIAN TUBE AND MASTOID PORTION. HI mucous lining of the cartilaginous portion of the tube is richly supplied with follicular glands, which are most numerous at its middle part. Placed still deeper in the submucous connective tissue, are numerous acinous glands. The follicles of the tubal mucous membrane are about half as large as those of the pharynx, but take in the entire depth of the mucous membrane. Tonsilla Pharyngea.—According to the investigations of San- torini1 and Luschka,2 it is shown that the lining structures of the roof, and to a great extent the hinder wall of the nasal part of the pharynx, are composed of a tissue so strikingly like the substance of the tonsils that it has been named the " pharyn- geal tonsil." Luschka states that this spongy tonsillar substance, of a maxi- mum thickness of 7 mm., which he has never failed to find, extends from the posterior boundary of the roof of the nasal cavity to the edge of the foramen magnum of the occipital bone, where it either assumes a more or less uneven surface, or, breaking up into separate sebaceous glands, is gradually lost in the pos- terior wall of the pharynx. The same kind of structure forms the chief constituent of the recessus pharyngeus, and extends in a thinner layer over the ridge of the pharyngeal mouth of the Eustachian tube. Differences in Size and Shape of 3Iouth of Eustachian Tube.— Dr. Urbantschitsch,3 a writer distinguished for conscientious research, has described some great variations in the shape and size of the pharyngeal mouth of the Eustachian tube. These variations occur not only in those of the same age, but also in the same individual. The variation in form of the cartilaginous part of the tube is observed to occur in both the posterior and anterior wall. The former may terminate in a sharp point, or it may be very blunt and rounded at the lower and posterior end ; it may also be corrugated on the surface towards the lumen of the pharynx, or curled decidedly upward and forward 1 Parma, 1775. 2 Der Schlundkopf des Menschen. Tiibingen, 1868, p. 20-27. 3 Anatomische Bemerkungen tiber die Gestalt und Lage des Ostium pharyn- geum tubae beim Menschen. A. f. O., vol. x. pp. 1-7, 1875. 112 MIDDLE EAR. towards the so-called floor of the tube. Another curious devia- tion found in the posterior wall of the tube is a bifurcation, the hinder limb pointing backwards, the anterior curling forwards. The various deviations in shape, position, and direction of the walls of the tube, described by Dr. Urbantschitsch, apply only to the mouth, and not to the cartilage in its upper parts. They may, in many cases, cause a widening or a narrowing of the mouth without, of course, producing changes further up the calibre of the tube. According to the same authority, the direction of the pharyn- geal mouth of the tube is generally oblique from above and in front, backward and dowmvard ; in exceptional cases the axis of the mouth of the tube may run vertically or even horizon- tally. Bloodvessels and Nerves of the Eustachian Tube.—The arteries supplying the Eustachian tube are the pharyngeal from the external carotid, the middle meningeal branch of the internal maxillary, and various small branches of the internal carotid. The nerves are distributed as follows: The tensor palati, or the dilatator tubse muscle, is supplied by a branch from the otic ganglion, and also by a motor branch from the internal pterygoid nerve. The levator palati muscle is supplied by the facial nerve through its connection with the vidian and petro- sal nerves as well as by a branch from the vagus. The inner dilator of the tube, the salpingo-pharyngeus, is supplied by the glosso-pharyngeal nerve. The inner pterygoid muscle is sup- plied by the inferior maxillary nerve. The mucous membrane of the tube is supplied by branches of the glosso-pharyngeal nerve, which also supplies the mucous membrane of the tym- panic cavity. The Mastoid Portion and its Cells.—The mastoid portion is that highly important part of the middle ear situate behind and partly below the cavity of the tympanum. It corresponds to the protuberance behind the auricle. This hollow portion is developed partly from the squamous portion, but chiefly from the petrous part of the temporal bone. As is well known, the temporal bone is formed from three distinct pieces, the squama, the annulus tympanicus, and the petrous pyramid. The squama EUSTACHIAN TUBE AND MASTOID PORTION. 113 is divided into two parts, viz., the vertical and the horizontal portions. The horizontal portion is subdivided into an inner and an outer lamella, the latter of which forms part of the air- cavities of the mastoid portion. This portion of the temporal bone has a distinct existence by the fifth foetal month. The mastoid portion is really a continuation of the petrous part of the temporal bone, backward and downward. In the new-born child it extends half an inch beyond the hindmost boundary of the squama, and forms a three-sided pyramid, the point of which is behind, the base of which is in front towards the tympanum, and the sharp free edge of which is directed down- ward. The outer surface of this pyramid corresponds of course to the outer wall of the mastoid portion, the inner surface divides the mastoid cavity from that of the cranium, and the upper surface is in the same plane with, and is a continuation backward of, the upper surface ofthe petrous portion ofthe bone. All of these features are most clearly seen in the new-born child. The upper surface of the mastoid portion unites with the postero-external edge of the roof of the tympanum. This is marked by a furrow until immediately after birth, when it usually becomes invisible. The outer surface shows a deficiency in the child a fewT months old, at its upper and anterior edge, in the shape of a fissure named the mastoid-squamous. Sometimes at this early age, the fissure is not at all marked, its place being represented by a series of irregular openings varying from two to three mm. in diameter, as though union between the squama and the outer mastoid wall were already far advanced. The inner surface is quite concave, and over it runs a furrow, which at last is fully developed into the sigmoid sinus. The mastoid foramina are found near that point where the upper and under edges of the mastoid portion meet. In some cases the foramina are not complete until the occipital bone joins the mastoid edges. These openings are for the passage of arteries to the dura mater, and for small veins which connect the transverse or lateral sinus with the veins of the scalp. Mastoid Cells.—Within the mastoid portion are found the delicate mastoid cells. These are a series of bony air chambers of variable size, communicating with each other by means of 8 114 MIDDLE EAR. foramina in their thin walls. They communicate with the tympanic cavity by means of the mastoid antrum, and are lined by a continuation of the same mucous membrane lining the Eustachian tube and tympanic cavity. The quantity and de- velopment of these cells vary, not only in different individuals, but in the same individual, on the two sides. It is of the highest importance to understand their general distribution in the adult bone, in order to diagnose and treat inflammatory processes arising there, or which have spread to that part from the tympanic cavity. Fig. 27. Mastoid Portion of the Left Temporal Bone laid open and viewed from behind.— A. Mastoid cells extending from the mastoid process below, upward and inward, over the lateral sinus B. c. The zygoma. In the mastoid portion of the child it is found that the sep- tum dividing the mastoid cavity from the sigmoid sinus is very thick, and hence inflammation is not likely to pass from the former to the latter, as it is in adults, in whom this septum is always thin. Hence, in very young children, meningitis very rarely, if ever, occurs from inflammation of the mastoid cavity, from which inflammation tends to pass outward rather than inward, not only because the dividing septum between it and the sigmoid sinus is thick, but because, as already stated, the outer wall of the mastoid portion is imperfect in early child- hood. This is the reverse of what we find in the adult, so that EUSTACHIAN TUBE AND MASTOID PORTION. 115 in the latter, everything favors a passage of disease inward towards the brain, while in the child, the conditions are in favor of a passage of disease outward. The lower pointed part of the mastoid portion is known as the mastoid process ; to it the stemo-cleido-mastoid muscle is attached. The development of the mastoid process is greater in the strong and muscular, while it is less developed in the weak and in children. The mastoid portion is also subject to differ- ences of development in different races, being small and solid in negroes, while in Mongolians it is found much more highly developed than in Caucasians, as shown by Welker. By the eighth month of foetal life the mastoid cells are very distinctly seen as depressions in the bone of the mastoid portion. These cells are not developed first at that part of the foetal temporal bone which, at a later period, corresponds to the mastoid process, but from the upper and hinder parts of the mastoid antrum, i. e. from above downward, as demonstrated by Schwartze and Eysell.1 In the first year after birth the mastoid cavity loses its pyra- midal shape by assuming a more ovoid form, and the mastoid cells are formed gradually. Those which are included in the upper and outer portion of the mastoid portion where it joins the squama, are the most highly developed at this time, and lined with mucous membrane, while the mastoid process as yet contains no air cells. From this time on, the external differ- ences of this part of the temporal bone are much less than the differences in development of the air-cells within, for the latter are subject to the greatest variations in number and distribu- tion, as can readily be seen in the skulls of adults. The mastoid antrum, which is a connecting air chamber between the tympanic cavity and the air-cells of the mastoid portion, is of a triangular shape. Its position is somewhat above, in front of, and further inward than, the rest of the mastoid cells. Its walls, with the exception of part of its outer wall, are formed by the petrous part of the temporal bone, and communicate by numerous perforations with the mastoid cells, with which it is surrounded on all sides excepting in front and on the inner side. Anteriorly it has a wide opening into the tympanic cavity, and 1 Archiv f. Ohrenh., Band i., 1873. 116 MIDDLE EAR. on its inner side it is bounded by that part of the petrous bone covering in the horizontal semicircular canal. It is stated in a valuable paper by Schwartze and Eysell1 that the general shape of the mastoid cells is that of a hollow pyra- mid, and that their axes run like the radii of a hollow sphere, towards their centre, viz., the mastoid antrum. The air-containing cavities fill the entire mastoid portion of the temporal bone, and in most cases they spread downward and outward to the very point of the mastoid process. Limits of the 31astoid Cells.—The mastoid cells extend as far backward as the Emissarium mastoideum, where they are in close contact with the outer side of the groove for the mastoid sinus, and they are found as far forward as the external auditory canal. Mastoid cells are also found continuous with those which reach as far forward and upward as the petro-squamous suture, above that point where the outer table of the mastoid portion is nearest the inner table, that is, the outer wall of the sigmoid groove. In a temporal bone shown in Fig. 27, in which the section of the mastoid portion has been made in the plane of the pos- terior surface of the petrous portion, and carried through the mastoid where the inner and outer tables nearly meet, character- istic air-cells are seen lying above this point in a tent-like space half an inch high, the apex of which points into the cranial cavity, and the floor of which is in the same plane as the upper surface of the petrous portion. The outer side of this tent-shaped cavity shows on section that it is continuous with and a part of the outer wall of the mastoid portion, which has grown inward, away from the squama. The lowest limit of the mastoid cells is the tip of the mastoid process. Those cells which are developed from the petrous part of the bone are the largest; those which arise from the squama and lie over the external auditory canal are the smallest. PHYSIOLOGY. The Amount of constant Patulence of the Normal Eustachian Tube.—Some investigators and writers, among whom are LucaB and Schwartze, have thought that every act of breathing is con- 1 Archiv f. Ohrenheilk., Band i. pp. 1G8-169, 1873. EUSTACHIAN TUBE AND MASTOID PORTION. 117 veycd to the drum-cavity by a normal tube, and they have de- clared that this can be shown not only by the oscillations ofthe manometric column placed in the external auditory canal, but also by a direct viewing of the motion of the drum-head at each respiration. Politzer, on the contrary, denies this, believing that the tube is opened only at swallowing, and the facts are in his favor. Mach and Kessel think the movements of the drum-head observed by Lucse and Schwartze are due to a to-and-fro motion of the column of mucus, in the capillary safety tube, produced by rarefaction and condensation of the air at the faucial mouth of the Eustachian tube. During regular respiration through the nose the relation of the parts about the faucial mouth of the Eustachian tube does not materially change. The pharyngeal opening of the tube either remains at rest or opens and closes slightly with succeeding in- spiration and expiration, after a few moments coming again to rest. On pronouncing the vowels, particularl}' a, e, and i, the mouth of the Eustachian tube opens downward and forms an oblique triangle on the lateral wall of the pharynx.1 According to a subsequent paper by Zaufal,2 Bidder3 was the first to examine the normal relations of the parts in the naso- pharyngeal space. His investigations were succeeded by those of Schuh4 and Voltolini,5 the latter being the first, however, to view the tubal ridge through the intact nose. Subsequently observations of these parts were made by Michel in 1S73, and by Zaufal in 1875. Dr. Zaufal examined the movements of the tubal opening by means of long funnels armed with mirrors, in- troduced into the nares and passed back into the nasopharynx. It is now generally conceded, through the labors of Riidinger and others, that there is a small part of the normal Eustachian tube, the so-called safety tube, in its upper part, under the carti- laginous hook, always wide enough open to allow a recoil of air to occur from the drum-cavity, if the drum-head is suddenly driven in, as in explosions, and also to permit a slow equaliza- 1 Die normalen Bcwegungen derRachenmiindung der Eustachischen Rohrc. Prof. Zaufal, Archiv f. Ohrenli., Band ix. 1875, pp. 133 and 228. 2 A. f. Ohrenh., vol. x. p. 19, 1875. 3 Dorpat, 1838. « Wiener Med. YVochenschr., No. 3, 1838. 5 1801. 118 MIDDLE EAR. tion of pressure in the tympanic cavity, from the pharynx, in- dependently of the act of swallowing. But this *' canal of safety" is not wide enough to allow constant ventilation of the drum-cavity to go on. Therefore, to insure ventilation of the tympanum, the normal tube is opened at every act of swallowing. Prof. Moos,1 after a careful study of the Eustachian tube, con- ducted chiefly by transverse sections of the frozen preparation, concludes that the tube wdien in a state of rest is closed at a point just behind the funnel-shaped end of the faucial opening, and that the closure extends over about two-fifths of the length of the canal. On the lower surface or floor of the tube the closure is effected by the longitudinal folds of mucous membrane which, as seen in cross-section, form a considerable prominence, literally a valve, the size of which is subject to individual variations. On the opposite surface of the canal, under the cartilage hook or roof, there is another prominence of mucous membrane, heretofore overlooked. These two prominences or folds of mucous membrane, judging from analogues in animals, seem to facilitate, by their rapid and easy unrolling, the pates- cence of the tube. The islands of cartilage described by Zuckerkandl,2 and hinted at by Riidinger,3 are regarded as fibro-cartilage, having physio- logically the function of sesamoid bones, in the mechanism of the tube, by their connection with the submucous tissue, the fascia or ligamenta salpingo-pharyngea and the tendon of the tensor veli. In the horse the inner belly of the abductor tubre is inserted into such a cartilaginous disk. That the Eustachian tube is practically closed, except at swallowing, is further proven by observations on themselves by Poorten,4 Riidinger,5 and Yule, in all of whom, when the tube was either voluntarily opened as in Yule, or involuntarily opened as in Riidinger and Poorten, the voice was heard abnormally loudly and painfully. The same is proven by the observations of \V. Flemming, of P ramie.6 1 Beitrage zur normalen und pathologischen Anatomie und zur Pysiologie der Eustachischen Rohre, Wiesbaden, 1874. Blake's Report, 1875. American Otological Society. 2 Centralblatt, 638, 1874. 3 Qp. cit., p. 3. 4 Monatsschr. f. Ohreuheilk., No. 2, 1874. s ibid., No. 9 1872. 5 Monatsschr. f. O., No. G, 1875. EUSTACHIAN TUBE AND MASTOID PORTION. 119 Mr. Yule1 has given an account of the muscular process seen to occur in his own throat during the voluntary act of opening the Eustachian tube, a power which he seems to possess. When he makes the contractions for opening the tube, it is noted: " First, that the velum palati does not change either its position or its shape, in fact, that it remains unmoved ; and further, that it does not become tense, but hangs as soft and flaccid to the touch as at ordinary times of rest. Secondly, that the only parts that do move are the two posterior pillars of the pharynx; and their motion is ample and decided, and altogether unmis- takable. They both move inwards simultaneously towards the middle line, moving from their old position from one-half to three-fourths of an inch. This action is not spasmodic, but perfectly steady, and can be sustained for some considerable time at will, the pillars maintaining their new position all the while." Mr. Yule is quite satisfied and certain that during this period the Eustachian tube is open, and he concludes that from the flaccid condition of the velum, and also from the fact of its position and form remaining unaltered, the tensor and levator palati can have no participation in the opening of the tube, and that the muscles most evidently concerned are the palato-pharyngei. Mr. James Hinton2 taught that, since the salpingo-pharyngeus is united at its lower attachment with the palato-pharyngeus,aud as this muscle during swallowing is drawn inwards, the salpingo- pharyngeus is drawn imvards also, and so draws the projecting cartilaginous lobe of the tube, to which it is attached superiorly, away from the opposite wall. Therefore, the new direction given to the salpingo-pharyngeus by the movement inwards of the pillars of the fauces, is the cause of the opening of the tube. This seems to give but a partial explanation of the mode by which opening of the Eustachian tube is accomplished. In the process, as thus explained, it would seem that the tensor palati and the anterior wall of the tube are supposed to remain fixed, the movement being confined to the muscle attached to and operating upon the posterior wall. In swallowing, however, i On Opening and Closing the Eustachian Tube. C. I. P. Yule. Journal of Anat. and Physiol., viii. 1873. 2 Questions of Aural Surgery, p. 101. London, 1874. 120 MIDDLE EAR. the velum palati is thrown into motion, and the anterior w a of the Eustachian tube is thereby drawn away from the poste- rior wall. At the same time, doubtless, the muscles acting upon the posterior wall of the tube are forced into contraction, and help to draw the two walls apart. Prof. Riidinger1 agrees with Rebsamen that the opening of the Eustachian tube is brought about by the action of several muscles. The former supposed that the three muscles—the di- lator of the tube or tensor veli, the levator veli, and the sal- pingo-pharyngeus—act simultaneously; by the action of the first, the cartilage hook is fixed and drawn outward; by the action of the other two the posterior wall is drawn inward and upward, the result being a patulence of the Eustachian tube. When the muscles relax, the natural elasticity of the cartilage causes it to resume its original position, and the tube becomes narrower. Prof. Moos coincides with the view respecting the action of the tensor veli upon the anterior hook of the tubal cartilage, but rejects the idea that the levator veli assists in widening the tube. By direct inspection of the pharyngeal end of the Eustachian tube, Dr. Michel2 has observed that, at the act of swallowing, the velum palati rises and pushes a fold of mucous membrane into the tubal opening between the tubal ridge and the outer edge of the posterior nostril. At the termination of the act of deglutition the velum falls back to its original position and the mouth of the tube is freed from the above-named fold. These observations of Dr. Michel have been confirmed by subse- quent study of the faucial end of the Eustachian tubes in a young man who had lost by necrosis all the osseous contents of the nasal cavities and the bony roof of the nose.3 In this case the entire nasal cavity and the nasopharyngeal space were exposed to view, and the cavity from one tubal mouth to the other, with 1 Die Ohrtrompete, Munich, 1870, p. 6. 2 Das Verhaltniss der Tubenmiindung zum Gaumensegel am Lebenden be- trachtet durch die Nase. Berlin. Klin. Wochenschr., 1873, 34. 3 Neue Beobachtnngen iiber das Verhalten der Rachenmundung der Tuba und iiber die Thatigkeit der Musculatur des Schlundkopfes. Berlin Klin. Wochenschr., No. 41, 1875. See abstract by Dr. Zaufal, Archiv f. O., B. xi. pp. 00-63. EUSTACHIAN TUBE AND MASTOID PORTION. 121 the insertion of the velum palati, could be seen at a glance. The observations already made by Dr. Michel were thus supple- Fig. 28. View of the entire Right Middle Ear, laid open by ax incision from above downward, through the centre of the cavity. parallel to the long axis. (gruber.) —Above the line A B, the outer half ; below the line, the innerhalf.—T,T', T". Eustachian tube. T'. The isthmus. T". The tympanic opening. K, K'. Section of the cartilage ; between these poiuts the groove of the so-called membranous part ofthe tube is seen, below which the muscles of the tube are seen in section. II. The manubrium of the malleus, with a remnant of the tendon of the tensor tympani. Behind the manubrium may be seen the descending process of the incus ; above, the articulation of the malleus and the incus. Between the manubrium of the malleus and the shaft of the incus may be seen the chorda tympani running from behind and below, up- ward and forward, which also marks the edge of the folds of the membrana tympani. W. Entrance to the mastoid cells. W. Large cavity in mastoid cells. The inner half ; below the line A B.—('('. Part of the petrous portion of the carotid canal (opened). X. M. Eustachian tube. L. Canal of the tensor tympani muscle. F. Rostrum coch- leare with part of the tendon of the tensor tympani. G. Promontory on the inner wall of the tym- panic cavity ; on tke posterior boundary the niche of the round window. E. stapes. D. Traus- verse part of the Fallopian canal. C Eminentia pyramidalis with the tendon of the stapedius muscle still attached to the head ofthe stapes. W. Entrance to the mastoid cells. W. Mastoid cells. mented bv watching the act of swallowing in this young man. It was found that during this act, two long vertical ridges form 122 MIDDLE EAR. on the posterior pharyngeal wall behind the lower end of the tubal prominence. These produce an upward movement and project from 1 to 1\ cm. above the surface of the velum, but leave a space about 1 cm. broad between them. In singing, in- stead of such ridges, moderately thick folds are formed. From the formation of these ridges Dr. Michel is led to suppose that the floor of the tube is pushed upward by the combined action of the levator palati and the pterygo-pharyngeus, the latter by its contraction and consequent thickening pushing upward the former muscle. The tendency in swallowing, therefore, would seem to be to force the floor of the Eustachian tube upward and its twTo walls apart. Conjoint Physiology of the Eustachian Tube, Tympanic Cavity, and the Mastoid Cells.—According to the carefully conducted experiments of Mach and Kessel1 on the functions of the tym- panic cavity and the Eustachian tube, it is shown that sound- waves wTill produce the greatest effect when, in the middle ear, the following three conditions are maintained, viz.:— 1. The Eustachian tube must, as a rule, remain closed. 2. It must, however, be opened occasionally for purposes of ventilation. 3. The tympanum should be in connection with large irregu- lar cavities. These conclusions are based on the following observations and facts :— The length of most of the audible sound-waves is so large that the entire head of the hearer is, as it were, submerged in the wave of sound, and in the case of deeper sounds, all of the superficial parts are subjected to the same variations in pressure. If, then, the membrana tympani were exposed equally on both sides to the waves of sound, it could not be set into perceptible vibrations on account of this simultaneous and equal pressure on both its surfaces. Therefore, these observers conclude that " the waves of sound ' Die Function der Trommelhohle und der Tuba Eustachii. Sitzungsberichte clerk, k. Academic d. Wissench., 1872. See also Archiv f. Ohrenh. N. F., Band ii. p. 11C-121. EUSTACHIAN TUBE AND MASTOID PORTION. 123 will produce the best effects upon the membrana tympani when it is unexposed on one side to the sound-waves, i. e., when the Eustachian tube is closed." On the other hand, it must be remembered that a difference in the atmospheric pressure on both sides of the membrana tympani is a serious interference with the mobility of the mem- brane. Therefore, the Eustachian tube must be opened now and then in order to restore the equilibrium in the pressure ot the air on each side of the membrane, wdiich may have been in- terfered with by various physical causes. The capacity of the tympanum must not sink below a certain limit if variations in pressure of a given amount are to produce vibrations ofthe membrana tympani of a corresponding amount; for if the capacity of the tympanum is small, then very slight excursions of the membrana tympani will produce considerable expansive power of the inclosed air, which will operate against further increase in the vibrations. This is a very important circumstance in the consideration of the excursions produced bj- deep tones. In order that the latter may be received, the tympanum must have a certain depth and a generous capacity. Therefore the tympanum is in connection with the cavities of the mastoid process, and those of other portions of bone. A larger tympanum with perfectly regular outline and form would be impracticable from its great resonance. Therefore, the irregular, spongy, bony cavities, with which the ear is connected, appear to be of the greatest advantage. SECTION III. INTERNAL EAR. CHAPTER I. LABYRINTH AND AUDITORY NERVE. ANATOMY. The internal ear, sometimes called the labyrinth, is composed of a bony portion or case, and a membranous portion contained in the latter. The bony portion of the internal ear consists of the vestibule, the central portion, with which the cochlea is connected ante- riorly, and the semicircular canals pos- teriorly. The Vestibule.—The vestibule is a small cavity situate just beyond the inner wall of the tympanum. This wall is common to both cavities, and in it is the oval window, into which tits the foot-plate of the small stirrup bone. A section of the vestibule parallel to its tympanic wall is round or elliptic, but a section at right angles to this, and running parallel to the floor of the tympanum, is in general of a pear shape, the point of which is directed forwards. This of course indicates that there is a general ten- dency on the part of the four walls of the vestibule to unite anteriorly near the cochlea. The average distance of the outer from the inner wall of the vestibule "is External View of a Cast of the Left Labyrinth. (Henle.) — f. Fenestra cochleae or round win- dow, a. Fenestra vestibuli, or oval window, b. Ampulla of su- perior semicircular canal, e. Am- pulla of posterior semicircular canal, d. Common shaft of union of these two canals, c. Ampulla of the horizontal semicircular canal. g. Tractus spiralis foraminosus. LABYRINTH AND AUDITORY NERVE. 125 from 3 to 4 mm.; its long diameter, running between its ante- rior and posterior limits, is about 5 mm., as given by Henle. On the inner walls are found two depressions separated by a narrow, sharp ridge; the anterior depression is the recessus sphcericus for the reception of the sacculus rotundus, and the posterior depression is the recessus ellipticus in which lies the utriculus. The ridge between these grooves is the crista vestibuli. Fig. 30. Section* of the Pyramidal Part of the Eight Temporal Bo>-e, through the Vesti- bit.im parallel with the Outer Wall of latter; View of I.nxer Wall. (Henle.)—a. Common opening of the superior and posterior semicircular canals, b. Sinus sulciformis. c. Ampullar end of anterior vertical or superior semicircular canal, d. Recessus ellipticus. e. Crista vestibuli. /. Section of the small canal which conveys the branch of the vestibular nerve to the pyramid of the vestibule, g. Section of the facial canal, h. Recessus sphajricus. i. Canal of the tensor tympani. j. Scala vestibuli. k. Lamina spiralis. I. Scila tympani. tn. Inner opening of the aquacductus cochleae, n. Crista semilunaris, o. Recessus cochleae, p. Fossa jugularis. q. Ampullar opening of the posterior vertical, or posterior semicircular canal, r, r. Sections of this canal, s. Posterior opening of the horizontal semicircular canal. The latter finally terminates above the oval window, on the outer wall, in a sharp point named the pyramis vestibuli. Below, the crista vestibuli divides into two branches, the one skirting along the lower edge of the recessus sphairicus, and the other running backwards towards the ampulla of the posterior semi- circular canal. These branches inclose the recessus cochlearis ofReichert. The recessus ellipticus is further bounded below by a shallow furrow, the sinus sulciformis. lite Ampullar 31ouths of the Semicircular Canals.—On the upper wall of the vestibule, just above the recessus ellipticus, is the ampullar opening of the superior semicircular canal; in the anwle between the posterior and inner wall near the inner open- inbroad, smooth spot in the canal and project at right angles into its calibre. Thus from their position they would be especially sensitive to the variations of the currents in the endolymph, and it is known that they are connected with nerves, the termi- nations of which they represent. In order to harmonize both of these facts with Goltz's theory, Breuer assumes that every current of the endolymph is perceived by the nerves of the ampullae, that it produces an idea of the rotation of the head in the plane of the semicircular canal most implicated, in a direction opposite to the current, and that the perceptions of the six ampullae of both labyrinths unite in forming a joint conception. Prof. E. Mach2 has seemed to add corroboration to the theo- ries of Goltz and Breuer by a series of novel experiments upon man, which were published a short time before the results of Breuer's labors. Mach suspended a chair in which a man could sit with ease, in a framework, so that the chair could be revolved about a 1 Wiener Med. Jahrbiicher, 1874, Heft I. 2 Wiener Sitzungsberichte, Nov. 6, 1873. LABYRINTH AND AUDITORY NERVE. 155 horizontal axis and fixed at any inclination. In addition, the entire framework with the chair could be revolved about a vertical axis. In many of the experiments the chair was covered by a paper box, which, following all the motions of the chair, prevented the person sitting in it from observing with his eye the motions of the apparatus in which he was seated. The principal results of the experiments with this apparatus were the following:— A revolution about the peculiar vertical axis of the body is perceived by the person experimented upon only so long as it is accelerated. A continued and constant revolution is not perceived. Retardation of the revolution is perceived as a revolution in the opposite direction. It is apparent that these facts agree wnth the theories of Breuer. The sensation of revolution in the opposite direction is converted into the sensation of motion in the true direction, in two seconds, by a renewed acceleration of the original motion. This sensation, therefore, must continue a few seconds longer than the cessation of the retardation; for otherwise, the new acceleration should produce immediately a sensation of revolu- tion in the original direction. If we accept Breuers hypothesis, we must suppose that by the law of inertia the currents pro- duced in the semicircular canals continue some seconds after the force producing them has ceased. If during the revolution about the vertical axis the head is inclined forward and then suddenly elevated at the moment the revolution ceases, in those cases where the revolution has oc- curred from the left, forward and towards the right, an impres- sion will be gained that a revolution is occurring from the right, upward and towards the left, and the person thus experimented upon will fear that he is about to fall towards the left. This fact is also in harmony with the hypothesis of Breuer, and proves most strikingly that the position of the head is a meas- ure of the sensations of revolution, and that the organ of these sensations must be found in the head. These two fundamental facts have already been observed by Purkinje. Furthermore, Mach has established, by the aid of his apparatus, the fact that we have, either with the body at rest or revolved with a con- stant velocity, a distinct consciousness of the direction of the 156 INTERNAL EAR. resultant accelerating force without the assistance of the eyes. A man sitting in Mach's chair was able to give, by means of an indicator projecting from the case, a tolerably correct statement as to the vertical direction in any of the variously inclined positions of the chair. When the case containing the chair was revolved about a vertical axis situate at some distance from the chair, and when the face of the one experimented wTith was turned towards this axis, the axis then given by him as the vertical one was in reality one inclined diagonally downwards from the axis corre- sponding to the resultant of the centrifugal force produced by the revolution with constant velocity, and the weight of the body revolved. Certain facts of a similar nature, perceived prior to this, induced Breuer to add to his hypothesis already described, the supposition that we should consider the macula acustica with the otoliths as possibly an organ for the perception of the posi- tion of the head at rest, in respect to the direction of the resultant accelerating forces and the rectilinear motions. In this portion of the acoustic apparatus he perceives the fulfil- ment of the necessary conditions and assumes that the otoliths are specifically heavier than the endolymph, and that they con- sequently have a tendency to sink in it in the direction of the resultant accelerating force. According to the direction of this force in the head, the otoliths would drag, in various ways, upon the hairs with which they are connected, and thus produce a varied excitation of the terminal nervous apparatus. In addition to this, the specifically heavier otoliths would have, at the beginning of a rectilinear motion, a tendency to remain behind the endolymph, and at the cessation of the same they would go in advance of it, and therefore they would, by mechanical action upon the cilia, produce a perceptive sensation.1 Berthold's2 experiments were performed with great care to avoid any implication of the central organ. He confirmed the above-mentioned statements of Schklarewsky and Boettcher, respecting the danger of wounding the aquaeductus vestibuli; in order to avoid hemorrhage or any undue lesion he used silk 1 See abstract by Prof. Fick, Archiv f. Ohrenheilkunde, vol. ii. N. F. p. 306. 2 Archiv f. Ohrenheilkunde, Band ix., 1874. LABYRINTH AND AUDITORY NERVE. 157 thread for cutting through the canals. 3Ianege movements, consequent upon section of the semicircular canals, were not observed by Berthold, but vomiting was found to occur in cases where it could not be attributed to injury of the brain. He also observed that injury of the above-named " process of the cerebellum," or aquaeductus vestibuli, alone produced symptoms partly resembling those resulting from injury of the semicircular canals. His final conclusions are in favor of regarding the function of the semicircular canals as assisting in the coordina- tion of motion by means of reflex action. They perform their function in company with two other senses, viz., with that of sight and with that of touch. The experiments of Flourens and Goltz, on pigeons, have been repeated by Curschmann,1 who has observed three very impor- tant cautions in his investigation, viz.: 1. The least possible destruction of tissue about the semicircular canals; 2. The avoidance of excessive hemorrhage, especially from the venous sinus near the canals ; and, 3. The infliction of the least possible injury to the bony canals, since, from their intimate relation to the cavity of the cranium, they cannot be destroyed without a previous opening of this cavity, which is followed by an imme- diate or secondary injury ofthe cerebellum. The conclusions of Curschmann are that: 1. Injuries of the semicircular canals are positively followed by disturbances in the equilibrium of the body ; 2. The phenomena are propor- tional to the lesions; 3. The derangements are constantly observed in connection with muscular movements ; 4. The canal operated on, as well as unilateral or ambilateral destruction of the semicircular canals, determines the character of the resultant phenomena; 5. The phenomena are the more intense and defined, the more energetically the animal moves about; 6. The phe- nomena of deranged coordination in muscular movements are expressed in the head, trunk, and limbs of the animal operated on ; 7. The supposition that the derangements of motion of the trunk are due to a defective carriage of the head is not tenable ; 8. After total removal of all three membranous canals on both sides of the head, the pigeons do not appear entirely bereft of the power to direct their movements; 9. Simple section of a 1 Deutsche Klinik, No. 3, 1874, Archiv f. Ohrenheilkunde, vol. ii. N. F. p. 307, abstract by Prof. Luca?. 158 INTERNAL EAR. single canal, if the structure is not secondarily diseased, is fol- lowed in four or five days by a diminution, if not a total cessa- tion, of the resulting phenomena, even without a restitutio ad integrum on the part of the incised canal; 10. The almost constant increase of, and frequent changes in, the original symptoms, appearing after extensive injury to the canals, are referable to subsequent disease of the remnants of the injured canals, or to secondary alterations of the canals which were left intact; 11. The semicircular canals are not to be considered as an organ of the sense of equilibrium ; 12. The phenomena are the result of a cessation of function, not the result of an irritation, certainly not of a specific irritation of the acoustic nerve; 13. Since the hearing is not materially altered by a removal of the semicircular canals, it cannot be concluded that they are not connected with this sense. Lowenberg's experiments1 have led him to the following conclusions: 1. The derangements in motion, which manifest themselves after the semicircular canals are cut through, depend upon such section only, and not upon the accompanying injury to the brain. 2. Vomiting, which was noted by Czermak in his experiments, depends upon the attendant injury to the cerebellum. 3. The disturbances in motion are due to irritation of the semicircular canals, not to paralysis of them. 4. The irritation produces, reflectively, spasmodic paralyses, without participation of consciousness; fresh irritations of the canals are induced only by calling forth voluntary movements. 5. The conveyance of this reflex excitation to the motor nerves occurs in the thalamus. 6. Section of the auditory nerve does not produce these derangements of motion. Bornhardt,2 the latest experimenter upon the semicircular canals, is forced to conclude that the phenomena of deranged movements succeeding section of the canals are due to unavoid- able injuries of other parts. He rejects the theories of Breuer and Mach, and is of the opinion that " the semicircular canals serve, by transmission of the vibrations resulting from muscular contraction, to intensify the muscular sensation during action of 1 Archives of Ophthalmology and Otology, vol. iii., part ii. pp. 26-44. 2 Med. Centralblatt, May, 1875, and Blake's Report on Progress of Otology, American Otological Society, 1875. RELATIONS OF MIDDLE AND INTERNAL EAR. 159 the muscles of the head. The following experiments Bornhardt considers as confirmatory of this conclusion: The horizontal semicircular canal of a rabbit being exposed without injuring its osseous covering, and the back of a knife being rubbed back- ward and forward upon it, by which means it is merely agitated, the same movements of the head and eyes occur, which are characteristic of division of the membranous canal. The direc- tion of the muscles attached to the head is parallel to the direction of the semicircular canals, which fact seems to favor the above conclusion. Movements similar to those resulting from division ofthe canals have been induced by an experiment which leaves the brain and osseous canals intact. The vertical and hori- zontal canals in pigeons were exposed to a continuous stream of ether by means of an atomizer; they were also touched by a red-hot needle. In both cases the same symptoms appeared as in division of the canals ; the same result was also obtained by touching the canals with a vibrating tuning fork. CHAPTER II. SCHEME OF RELATIONSHIP BETWEEN THE MIDDLE AND INTERNAL EAR. Schematic Description of the 3Iiddle Ear, of the Internal Ear, and ofthe relation they bear to each other.—-In order to understand the general features of the middle ear and of the internal ear and the general relations they sustain to each other, let there be imao-ined, first, a broad and shallow barrel, closed at each end and divided in the middle by a partition. If this barrel be laid upon its side with one end towards the reader, it will give a fair representation of the middle ear, in the near half, and of the internal ear in the far half. The head of the near half of this barrel will represent the membrana tympani or drum-head, while the partition in the centre of the barrel represents the inner bony wall of the tympanic cavity. In this partition let two openings be made, one oval-shaped, situated above and in front of the other which is round. The former represents the foramen ovale or the oval window, and the second, the foramen rotundum or the round window. 160 INTERNAL EAR. From the membranous head of the near half of the barrel to the partition in the centre, is stretched a bony bridge composed of three pieces. This of course is the chain of ossicles, contain- ing the malleus or mallet, the incus or anvil, and the stapes or stirrup, and stretching from the membrana tympani to the inner wall of the tympanic cavity. The handle of the outermost of the three ossicles, the manu- brium of the mallet, is inserted into the fibrous or middle layer of the drum-head ; the innermost, the stirrup, by means of its foot-plate, fits into the oval window in the inner wall of the tympanic cavity, and the middle bonelet, the anvil, is held in position between the other two. They are furthermore held together and fastened to the roof and wall of the tympanic cavity, by means of ligaments. This bridge of ossicles may be said to have two guys which steady it and give it proper ten- sion, one of which is fastened to the mallet and the other to the stirrup. The former will at once be recognized as the tensor tym- pani and the latter as the stape- dius muscle. In the outer half of the imagi- nary barrel are two bung holes, one in front, the other on the back. The front bung-hole repre- sents the tympanic opening of the Eustachian tube, by means of which the middle ear, or drum, is ventilated, and the atmospheric pressure on each side ofthe drum- head equalized. The back bung-hole is the communication be- tween the mastoid cells and the cavity of the tympanum. The mastoid portion may be likened to an ivory box filled with sponge, the latter representing the series of bony cells, which communicate with each other and at last by means of the mas- toid antrum with the cavity of the middle ear. (See p. 115.) Fig. 39. b Auditory Ossicles in connection : viewed from in front. They are sup- posed to be from the right side of a head turned slightly about the vertical axis towards the right. (Magnified 4 diam.: Henle.)—/. Malleus, k. Incus. I. Stapes. i, Head, h, Keck, g, Long process, /, Manubrium of the malleus, a, Body, 6, Short, c, Long process, e, Processus len- ticularis of the incus. d. Small head of stapes. RELATIONS OF MIDDLE AND INTERNAL EAR. 161 In this simple manner, the middle ear, with its ossicles and more important appendages, may be sketched. The functions of this cavity are dependent on aerial life, and equal pressure of air on each side of the drum-head. This air-containing cavity is separated from the internal ear, or labyrinth, a water-containing cavity, by means of a bony par- tition, viz., the inner wall of the middle ear already described, in which is the oval window, into which the foot-plate of the stirrup fits. Hence, these two important cavities have one wall in common through which, by means of the foot-plate of the stirrup, the movements of the chain of little bones are com- municated to the fluid of the internal ear and to the thread-like ends of the nerve of hearing suspended in it. In order to understand the general features of the internal ear, let us still retain the simile of the barrel. In this instance the inner half of the barrel must be regarded as made entirely of bone, as filled with water, and communicating at no point with the atmosphere, but in direct communication with the arachnoid space by means of the aqueducts ofthe vestibule and cochlea. Since the walls ofthe internal ear are made of bone, there can be no giving on their part to the pressure of the fluid of the labyrinth produced by the movements of the stapes. In order that these movements may go on, there is found at the extremity of one of the passages of the internal ear, viz., the cochlea, the round window, over which is stretched a membrane which yields slightly to the pressure brought about in the labyrinth by the movements of the stapes. On the front of this inner cavity representing the internal ear, is a spiral tube, with two and a half turns. Being wound around like a snail-shell, it long ago received the name of cochlea. On the back of this inner cavity are found five openings communicating with three semicircular tubes. We would naturally look for six openings into the ends of three semicircu- lar tubes, but only five are found in this instance, as two ends of two of the semicircular tubes, viz., the superior and poste- rior semicircular canals, join together and have a common opening into the internal ear or labyrinth at that part of it called the vestibule. 11 162 INTERNAL EAR. On the far-head of this inner barrel-half, we find the nerve of hearing pushing its way into the labyrinth, through a sieve-like spot. After forcing its way into the cavity of the internal ear through this sieve-like spot in the inner bony wall of the inter- nal ear, at the fundus of the internal auditory canal, the auditory nerve divides into two main branches, one of which, the cochlear branch, is distributed to the cochlea, and the other, the vesti- bular branch, is given to the sacculi and to the ampullae of the semicircular canals. PART II. DISEASES AND TREATMENT. SECTION I. EXAMINATION OF. PATIENTS. CHAPTER I. INSTRUMENTS AND METHODS OF THEIR EMPLOYMENT. The light employed in examining the ear is usually reflected into the auditory canal by means of mirrors, to be described later. But the ear may be examined by direct rays of light in such a way as to give considerable aid in some instances. If daylight is to be reflected into the ear, the light coming from the north will be found to be the most luminous. If, however, examination by direct rays of sunlight is desired, the ear must be so situated that the sun's rays may fall directly upon it. If artificial light is used, that of an Argand gas-burner will be found the brightest. The flame of a petroleum-burning student- lamp is also very good, but if neither of these can be com- manded, a candle will render good service, especially at the bed- side, for it is much easier to move the light in examining a patient in bed than it is to adjust the head of the sufferer. Examination of the Ear by means of Polarized, Light.—This mode of examining the ear has been attempted by Drs. Hagen and Stimmel,1 and they were able thus to effect the entire dis- appearance of the posterior-superior quadrant of the drum-head, and a consequent revelation of the long process of the incus and portions of the stirrup. Other portions of the membrana tym- pani appeared much thinner, and it was possible to determine the presence of adhesions and pseudo-ligaments in the tympanic cavity. By using this mode of examination, all opacities of the membrana tympani, such as calcareous spots, ecchymoses, and 1 See Report on Progress of Otology, by C. J. Blake, 1873. 166 EXAMINATION OF PATIENTS Piff. 40. Ear Mirkor. INSTRUMENTS AND METHODS OF EMPLOYMENT. 167 the like, appear more distinctly defined, and the bloodvessels of the manubrial plexus were more clearly visible. Transparent spots seemed to disappear entirely. From what has been done already with this mode of illumination of the ear, it would seem that it could be rendered of the greatest aid in diagnosis, if its application be not too complicated. Instruments for Examining the Ear.—The instruments used in examining the ear should be as simple as possible. The first demand is for a concave mirror with a focal distance of from four to six inches, according to the eye of the examiner- That form known as Von Troeltsch's ear mirror is most widely used, and is the best. (Fig. 40.) Otoscopes, or Aural Specula.—The next want will be a nest of specula or ear funnels. There are numerous forms found in the instrument makers' shops, under the names of Kramer, Toynbee Wilde, Gruber, Politzer, and others. While all are good, pre- Fig. 41. Gruber's Aural Specula. ference should be given to Gruber's specula, because a transverse section of their calibre at right angles to the long axis, most closely resembles a similar section of the auditory canal, i. e., it is slightly ovoid in shape. The great object in using a specu- lum or aural funnel, is simply to hold the tragus away from the meatus, and to push away the stiff hairs about the opening of the external auditory canal. In some cases, moderate dilatation of the cartilaginous canal may be effected, but usually, all 168 EXAMINATION OF PATIENTS. endeavors at dilatation of the external auditory meatus are worse than useless—they are painful and injurious. All forms of specula or ear funnels are made of metal and of hard rubber. Both kinds possess peculiar advantages as well as disadvantages. The first are less brittle than rubber, but they are colder in winter-time, and sometimes are objected to by the patient. On the other hand, the hard rubber ear-funnels, while being more agreeable in feeling to the patient, are extremely brittle. In some instances, ear-funnels have been made of glass. This kind would be as little likely as any to be affected by the various caustics sometimes used in the treatment of aural dis- eases. But when such substances are applied carefully to the ear, no speculum will suffer, for the latter need not be touched by the medicinal substance. In any event, the metallic specula will be mOre easily attacked by acids, nitrate of silver, and the like, than the hard rubber variety. In no case will it be neces- sary to oil the funnel before it is inserted into the meatus, for if it require greasing to make its way into the canal, then the instrument is either too large for the ear, or the auditory canal is too swollen to permit an examination by means of the ear- funnel. Fig. 42. If magnification is desired, it can be neatly and cheaply obtained by the employment of Bonnafont's otoscope. The specula are adjustable, thus permitting the ready use of various sizes ; these and the case are made of hard rubber. There is a magnifying eye-piece, and a perforated mirror for reflecting light into the auditory canal. Sigle's Pneumatic Otoscope.—T>r. Sigle* of Stuttgart, some time ago, invented a most valuable instrument, which is known in Germany as Sigle's pneumatic ear-funnel. It consists in a hard rubber, round speculum, like Politzer's, to which is attached an air-tight chamber 3 cm. in diameter. The upper, or outer wall of this chamber is glazed, and forms an angle of 40° with INSTRUMENTS AND METHODS OF EMPLOYMENT. 169 Sigl£'s Pneumatic Otoscope. the plane of the inner wall. On the longer side of the chamber there is an opening with a perforated knob, to which is attached a piece of rubber tubing about a foot in length, ending in a mouth-piece for the surgeon. This chamber is made to screw off and on ear-funnels of different diameters. When all Fig- 43. the parts are fully adjusted, the surgeon has an air-tight speculum with a glass end, through which he can examine the movements the drum-head makes during condensation and rarefaction of the air, brought about by his own mouth through the rubber tubing at the side of the instrument. This is really the only means the surgeon has of fully deter- mining the mobility of the drum-head, though both Valsalva's and Politzer's methods of inflation, if carried out while the surgeon's eye is fixed on the drum-head, will give him some idea of the extent the membrane can Fig. 44. move. But when the Eustachian tube is imper- vious, Sigle's instrument is the only means of determining the mobility of parts or of the whole of the membrana tympani. Kramer's Ear-speculum.—There is sold in the shops an instrument under the name of Kramer's ear-speculum. Its inventor, Dr. Kramer of Berlin, designed it for use only in the direct rays of sun- light. This, of course, renders it an instrument of very limited usefulness respecting the ear. As it is a bivalvular instrument, and designed there- fore for dilatation, it will slip from the meatus as soon as the handles of the instrument are brought together, or else great pain will be caused by its use. It is an admirable aid, however, in anterior rhinoscopy. 170 EXAMINATION OF PATIENTS. Blake's Operating Otoscope.—-Br. Clarence J. Blake's operating otoscope is intended to overcome the disadvantages of the usual monocular examination of the ear. "It consists of a hard rubber speculum (Politzer's) of the largest size, fitted with a metallic rim, to which is attached a revolving prism and an arm, bearing at its outer end a lens of about an inch focus; this arm is movable, but sufficiently firm to remain fixed at any angle at which it is placed. The prism is just within the focal distance of the lens, and its incident face is armed with a small metal shield, having an opening in the centre corresponding in its short diameter to the diameter of the pencil of light falling upon it from the lens. The advantage of the prism over a mirror or other reflecting surface is, that we have almost total reflection, and but little of the light concentrated upon the prism by the lens is lost. " In operating, an assistant is required to draw the auricle upward and backward, and keep the speculum in position, with the funnel of light upon the opening in the shield of the prism. It is not claimed for the instrument that it at all supersedes the head mirror of Von Troeltsch, but it is certainly of great advan- tage in the more complicated operations, when a steady and uniform illumination is indispensable. The instrument, as a whole, weighs only about one hundred and twenty grains, and can be made much lighter; so that when once firmly inserted in the meatus, it remains in position, and there is no necessity for holding it nor fear of its slipping out of place during the operation."1 Dr. E. De Rossi,2 Professor in the University of Rome, claims to have invented a binocular otoscope. It is simple and inex- pensive, differing very slightly from the original form of Ilelm- holtz's ophthalmoscope. It is so arranged on a forehead-band as to allow the use of both hands, but the distance of the eye from the membrana tympani, thirty centimetres, necessary to obtain a binocular view, renders the instrument of no very great practical utility. Voltolini3 has devised a pneumatic aural speculum, which is 1 Roosa's Treatise, p. 87, 1873. 2 Ein einfaches binoculares Otoscop. 7, 1872. 3 M. f. O., No. 2, 1873. Monatsschr. f. Ohrenheilkunde, No. INSTRUMENTS AND METHODS OF EMPLOYMENT. 171 a compound of Sigld's pneumatic speculum and Brunton's speculum. With this he proposes to investigate more tho- roughly and most boldly the middle ear, after cutting away the posterior segment of the membrana tympani and turning it forward over the hammer. He thus obtains a more perfect view of the fenestra of the labyrinth and of the stapes. He also proposes to operate with this speculum in situ, by introducing a knife through a slit in the funnel portion of the speculum. He reports one case of tenotomj7 of the tensor tympani performed successfully by its aid. If the instrument is all the inventor claims it to be, it may be considered a valuable addition to the diagnostic as w^ell as surgical means of otology. The middle-ear mirror of Blake1 is the modification of the laryngoscope and rhinoscope, ap- plied to the exploration of the tympanum with reflected light. The mirrors are of three sizes, as represented in the wood-cut, and are of polished metal. The mir- rors are made so as to be flexible at the junction with the shaft, and are thus adjustable at any angle best suited for examining the various walls and the roof of the tympanic cavity. By placing the shaft in a tenotome handle of Weber-Liel, the mirror can be rotated as desired, by moving the thumb-piece on'the ivory handle. Under thorough illumination of the auditory canal, these mir- rors can be carried into the tym- panic cavity if the membrana tympani be destroyed, and by careful manipulation the condi- tion of the cavity may be studied. blakb's middle-ear mirror. They are specially adapted to the search for, and examination of small polypoid growths on the roof of the cavity. 1 Transact. Amer. Otol. Soc, 1872. 172 EXAMINATION OF PATIENTS. Position of Patient's Body and Head.—As by far the most usual way of examining the ear is by reflected light, I shall suppose, in what follows, that reference is made entirely to that mode. The patient should sit with the ear turned from the source of light. He may lean back or sit high and straight in the chair, but the axis of his body should not be inclined either to the right or left. His head should be inclined somewhat towards the shoulder opposite to the ear to be examined. It is important for the comfort of the examiner that the body ofthe patient should not be inclined away from him, for if it be, then a great strain must come on the back of the surgeon in his endeavor to reach after the ear. Position of Surgeon.—The surgeon standing alongside of the patient, in front of the ear to be looked into, should grasp the auricle at its upper and posterior margin, gently between the index and middle finger of his left hand, and pull the auricle a little upward and backward. This is always to be done by the left hand, no matter wrhich ear is examined. This leaves the right hand free to hold the mirror. The patient should be placed, and the surgeon should stand so that the light may fall on the mirror slightly from the surgeon's right side, or directly from in front—never from the left in the above position of patient and examiner. These rules of position of light, patient, and physician are especially important when artificial light is used. Insertion of Ear-speculum.—With the auricle grasped as directed above, between index and middle finger of the left hand, the speculum or ear-funnel may be gently inserted in a direction slightly downward, inward, and fonvard, or in general terms towards the patient's nose, by the other hand, and then grasped by the thumb and index of the left hand. Or it may be inserted by the thumb and index of the left hand at the same moment the index and middle fingers grasp the superior posterior margin of the auricle. In the latter instance a very gentle and slight rotation will be all that is sufficient to place the ear-funnel pro- perly. The speculum being now in the meatus, light is to be reflected into it from the mirror. The first point to be decided upon in making an examination of the ear is whether the auditory canal is entirely free from INSTRUMENTS AND METHODS OF EMPLOYMENT. 173 obstruction or not. If it is, then the eye of the observer should, after ascertaining the state ofthe wall ofthe canal, seek the mem- brana tympani. The chief obstacle in such a search is usually the misdirection of the axis of the funnel. This, instead of being made to correspond with the axis of the auditory canal, is directed most usually by the unskilled so as to fall on the sides of the canal or only partially on the drum-head. Hence it is not at all uncommon to hear a diagnosis made for the membrana tympani, which is based entirely on a view of the condition of the skin lining the auditory canal. What should be seen at the fundus of the canal is described on p. 47, yet it will be a long time before the eye can accommo- date itself to the conditions of illumination in the external ear, so as to fully interpret what it sees. The experienced eye is able to resolve into depressions, elevations, curves, etc., that which is projected entirely in the same plane by the beginner. Removal of Obstacles to a View of the Membrana Tympani.—It requires but a small object, a few stiff hairs, or a flake of cerumen, or of epithelium, to obstruct the view of the drum-head. All such are most easily removed by a few syringefuls of warm Fig. 40. Delicate Forceps for Removing Foreign Bodies from the Ear. water; this, however, will render the drum-head a little mace- rated, and hence deprive it of whatever lustre it may have had. This must be borne in mind in looking at the drum-head after warm water has been syringed upon it. Therefore, when it is especially desirable that the amount of natural lustre in a given 174 EXAMINATION OF PATIENTS. Fig. 47. case should be estimated, an obstructive substance might better be gently and most carefully lifted or wiped out of the canal. The former is most readily accomplished by the delicate forceps shown in Fig. 46, while the canal is thoroughly illuminated by the forehead mirror. If the obstruction to vision can be wiped or swabbed out, the cotton holder, with its little wad of cotton at the roughened end, will enable one to do this. The Cotton Holder.—This is a most useful instru- ment, both for cleansing the ear and conveying medications to diseased surfaces in the organ. The shaft is made flexible for an inch or two, as indi- cated in the wood-cut, and roughened at the tip. At the latter point, a small tuft of cotton may be coiled, and then used, as already indicated, for cleansing, and for treating the ear. When the cotton is to be removed, it should be twisted off in a direction opposite to that in which it was wound about the end, and not submitted to a flame, as has been done, greatly to the detriment of the instru- ment. During all these procedures for removing small obstructions to a good view of the drum-head, the canal is supposed to be most carefully lighted by light reflected from the forehead mirror, and the operations performed by a skilled hand. If the methods suggested should be inadequate to remove obstacles in the auditory canal, recourse may be had to syringing. The syringe should be carefully chosen; one that holds two fluidounces will be large enough, though both larger and smaller ones may be used. The syringe should work per- fectly, being neither too loose nor too tight in the piston. The model ear-syringe is one made by Leiter of Vienna, and shown in the wood-cut. (Fig. 48.) It holds two fluidounces, is made of fine brass throughout, excepting at its nozzle, where it is of hard rubber. A nozzle of such material is at once less cold to the ear, and less easily corroded by the various fluids syringed into aud out of the ear ; its shape, furthermore, renders it less likely Cotton Holder. INSTRUMENTS AND METHODS OF EMPLOYMENT. 175 to wound the meatus should the instru- Pig- 48. ment slip or be pressed too firmly against the skin of the canal. To prevent slipping of the instrument, the twTo rings at the top of the barrel will be found of highest use- fulness. But brass syringes of this kind are expensive in this country, and being rarely called for by physicians, nor ordered for their patients, are rarely found ready made in the shops. There is, however, an excellent syringe for aural purposes always at hand in the hard rubber, male syringe No. 2. This is not only very good, but reasonable in price, so that all patients, even the majority of those seen in the infirmary, can buy it. At this point it ma}7 be said unhesitatingly, that all forms of syringes sold in the drug stores and else- where, under the high-sounding name of " ear-syringes," are uniformly dear and as uniformly worthless. There is one specially bad form of syringe sold under the name of ear-syringe. It is made of hard rubber; the chief, if not the only danger in this instrument, lies in its slender point about a half-inch in length, in which the otherwise harmless conical nozzle is made to terminate. This point, the patient is told by the ignorant vendor, to insert into his auditory canal. This done, the slightest turn, either of the head or of the handle, will drive the point against the sensitive canal and wound it. Such a syringe, with its elongated tip, could, in the shallow meatus of a child, reach, and thus injure the membrana tympani. Ear Syringe and Olive- shaped Nose-Piece, for syringing nares. Basin and Towel.—In syringing the ear a towel should be laid over the shoulder, and brought up as high as, and turned in over, the collar of the patient. The basin or cup for holding the water and catching the return current from the ear may be of various kinds and patterns. An ordinary kind is made of tin, the floor of which is kidney- 176 EXAMINATION OF PATIENTS. shaped. (Fig. 49.) Such a basin fits very closely under the ear against the neck. But tin soon rusts and becomes useless. If the basin be made of a more durable metal it becomes more costly, but no more easily kept clean. A finger bowl of glass or Fig. 49. Tin Basin used in Syringing the Ear. china is very good, because clean, cheap, and always at hand. A very simple, cheap, durable, and clean bowl may always be had by converting what is known in the china stores as a bird's bath tub, into a cup for holding water during syringing the ear. This little utensil has an oval bottom, the long diameter of which is 12 cm.; the short diameter 8 cm. The sides are 5 cm. high, and form an angle of about 95° with the base of the bowl. Syringing the Ear.—In syringing the ear, cold water must never be used. Let the water used for syringing be pleasantly warm; some patients prefer it much warmer than others. Pro- vided with a syringe as described, as well as with a receptacle for holding and catching the water, let the surgeon grasp the auricle between the thumb and forefinger of the left hand and pull it gently upward and backward. With the auricle thus held let the syringe be emptied slowly but firmly into the audi- tory meatus. Point the syringe downward and forward toward the patient's nose. The current from the syringe should be thrown along the upper wall of the auditory canal, thus per- mitting the return current to take place along the floor of the canal. In some cases considerable force may be used in throwing the INSTRUMENTS AND METHODS OF EMPLOYMENT. 177 current of water into the canal, as, for example, when it is desired to remove a foreign body from the fundus of the canal or when the canal is blocked up with a large and adherent wax- plug. I have found it decidedly advantageous to give to the syringe a gentle spiral motion as the current of water is going into the meatus. This impulse conveyed to the water will thoroughly wash off all adherent matters from the wall of the auditory canal. Examination of the Nares and Fauces, Throat, and Eustachian Tube.—The inspection of the nares, fauces, and throat, and the examination of the state of the Eustachian tube by means of the Eustachian catheter, form perhaps the most important part of a complete aural examination. This is specially true of the Fig. 50. more chronic forms of ear-dis- ease, for to the parts named the chief treatment must be directed. The inspection of the nares may be made either from behind or in front; if in the former way, i. e. by poste- rior rhinoscopy, the ordinary laryngeal mirror may be used, and the light either of the brightest day or of a large argand burner may be thrown on the laryngeal mirror by means of reflection from a large forehead mirror. This is at once convenient, inexpensive, and amply sufficient. If a more elaborate mode is desired, recourse may be bad to the very elegant Tobold apparatus. The former method, however, by means of the large forehead mirror and the argand burner, is vastly preferable for the ordi- nary examination of patients. It is the means used in the large clinics of Vienna, and the student, as well as the practitioner, with the forehead mirror once placed upon his head, may pass from one patient to another without the trouble and inconve- nience which would attend transporting a cumbersome appa- 12 Tobold's Apparatus. 178 EXAMINATION OF PATIENTS. Fig. 51. ratus. All that is needed is an argand burner or a bright flame of any kind, unless bright day-light is chosen. I would say, however, that in using the laryngoscopy mirrors, a bright arti- ficial light in a darkened room is by far the best. Bright day- light is too diffuse, illuminating other parts, and not therefore bringing into bold relief the parts specially under examination. Direct sun-rays, on the other hand, are too powerful when col- lected and thrown by the mirror into the ear or throat. It is a very easy matter to burn the parts thus illuminated by concen- trated sun-rays. Forehead Mirror and small Laryngeal Mirrors.—The forehead mirror which is to be used in the above-named examination is 10J cm. in diameter, and has a focal dis- tance of about 30 cm. There is a small transparent spot at the centre, the glass being left unsilvered at that point. The metallic back which holds the mirror is bored at the centre so as to correspond with the central bare spot in the mirror. It is entirely unnecessary for purposes of inspection that the glass should be per- forated at this point. Such a perforation adds nothing to the optical value of the mirror, but, as it endangers the glass, adds greatly to the cost. All the Vienna re- flectors are now made unperforated, but unsilvered at the centre. The reflector should be provided at a point on the cir- cumference with a small ball which fits into an adjustable socket on the plate of the forehead band. The eye of the examiner may look through the opening in the mirror, in which case it is of course directly in the focal line, or the mirror may be so placed as to permit the surgeon to look either under or to one side of it and yet gain good illumination. The surgeon should provide himself with four sizes of laryn- geal mirrors, two of each size entering into his set. One set should be marked and kept for examining specific or sus- pectedly specific cases, thus removing all danger of contagion from his more fortunate patients. No. 1 should be 1.50 cm. in Forehead Mirror. INSTRUMENTS AND METHODS OF EMPLOYMENT. 179 diameter; Nos. 2, 3, and 4, respectively 1.75, 2, and 2.50 cm. in diameter. These should be fixed at an angle of 40°, to a slender but perfectly stiff shaft 12 cm. long, which is made to slide into a handle 10 cm. long, made of wood, bone, hard rubber, etc., bored its entire length. Into this hollowed handle the shaft of the mirror may be slipped and clamped at any point by a small lateral screw. Thus provided with the three factors of examination, a bright flame, a forehead reflector, and a laryngeal mirror, let the surgeon place the patient on a chair close in front of the light, so that the latter shall come over the left shoulder of the patient. In this position the light will come towards the surgeon from his right, and somewhat from above if the lamp used is of ordinary height. If the larynx is to be looked at, the patient's head may be thrown very slightly backward, his mouth being open. The tongue may be depressed either by the surgeon or by the patient. In many cases all that is necessary in order to get the tongue out of the way is to have its tip seized between the index finger and the thumb of the patient's right hand and drawn outward. To render it less likely to slip from his grasp, the tip should be held between a fold of the edge of a towel or napkin. The laryngeal mirror should then be held for a moment with its glass surface, not its metallic back, over the flame in order to prevent the condensation of the breath on its surface. By hold- ing the glass surface over the flame, not only is the mirror heated more quickly, but its silvered surface is thus kept from melting, for less heat is acquired in this way than if the mirror were heated by subjecting its back to the flame. This rule holds good for all cases in which the laryngeal mirror is to be used, whether for laryngoscopy or rhinoscopy. In viewing the larynx the mirror should be introduced with the shaft on either side of the patient's mouth, rather than in the median line. Then, while the patient phonates the vowel sound aa, a view may be gained of the image of the laryngeal opening, in the small mirror held over the glottis. For all fur- ther explanation of laryngoscopy the reader is referred to works on that subject. Rhinoscopy and Rhinoscopic Examination of the Mouth of the Eustachian Tube.—Rhinoscopy, though by no means indispensable to the aurist, becomes of tar more value than laryngoscopy, on 180 EXAMINATION OF PATIENTS. account of the view he may gain of the faucial end of the Eustachian tube by the rhinoscopic method. The instruments employed are similar to those described above, but the method of introducing the mirror is somewhat different. The patient's head should not be thrown backward; it must be upright or in some cases perhaps a little thrown forward. In rhinoscopy the tongue may be depressed by the examiner, but never by the patient. Here the mirror must usually play the part of the tongue depressor, though the latter may often be used with advan- tage. With the patient's mouth wide open and his tongue lying perfectly naturally within the limits of the teeth, let him try to breathe through the nose. Then, with the shaft of the mirror lying in the median line of the tongue, pass the former slowly toward the velum and behind it, pressing the tongue down as firmly as the patient will permit. Usually all endeavors at get- ting a view of the posterior nares and vicinity fail most signally at first. This of course is due to the involuntary rising of the tongue and the consequent instability of the mirror, to which must be added the blurring of the mirror by the touching of its surface by the uvula. After a few visits or even after repeated trials in some cases at the first visit, the tongue is more easily depressed, the patient gets more used to feeling the mirror in his fauces, and then a view may be gained of the posterior nares and the faucial ex- tremity of the Eustachian tube. There are, however, individuals in whom the velum is placed so near the posterior wall of the pharynx as to preclude any rhinoscopic examination. The surgeon soon learns to recognize these, and is wise in making no attempts at examining them with the rhinoscope. Eustachian Catheters.—The ocular examination of the Eusta- chian tube ceases with the rhinoscopic view of the faucial ex- tremity ; beyond that point the examination becomes entirely aural, by means of the Eustachian catheter and the auscultation tube. The Eustachian catheter consists of a tube of metal or hard rubber, curved at the beak as seen in Fig. 52. The conical handle must be made so as to permit the end of the air-bag to fit accurately into it, and the ring upon the handle should be firmly attached to each instrument in the same plane with the INSTRUMENTS AND METHODS OF EMPLOYMENT. 181 Fig. 52. ABC Eustachian Cathetbrs of Hard Rubber.—Three sizes, A, B, and 0. D. Hard rubber tip of the air-bag, made to fit accurately into the large end of all catheters on the principle of the ground joint. 182 EXAMINATION OF PATIENTS. circle of which the curved beak is an arc. By observing the position of the ring-indicator, one can always know the precise position of the beak of the catheter. Another important though perhaps fortuitous use of this ring is to hold a ticket with the name of the patient using the catheter. Every aurist should have a large number of all sizes of these catheters, so that each patient may have one to himself, and thus escape the danger of contagion. Instead of the ticket each patient may have a long and slender paper box in which the catheter may be kept; but the impor- tance of isolation of patients in this particular cannot be too strongly urged. Not only has secondary syphilis been communicated by using the same catheter for all patients,1 but catarrh, not dependent upon such a specific poison, may also be thus communicated. Since it will be necessary to have catheters of different sizes, the diameter should vary from 1 to 3 mm., the size with a diameter _. „ of 2 mm. being; the one most used, as it is best adapt- Fig. 53. . ft. . . ed to introduction into nostrils of average width. The hard rubber catheter has the advantage of lightness and cheapness, and of not being easily corroded. Its cheapness renders it easier for the aurist to supply himself with a number of such instruments of all diameters. On the other hand, a virgin silver catheter is very flexible, and any need to change the curve of the beak is thus easily met in one instrument. But to have dozens of such instruments becomes expensive for the bonnafont's surgeon, though of course incumbent upon him if each patient is to have his own instrument. The catheter may be held in position in the nostril by means of Bonnafont's nose clamp. The Auscultation Tube.—This instrument is the highly impor- tant adjuvant of the Eustachian catheter; in fact, in so far as the latter is of aid in an objective examination, it owes that power to the auscultation tube. The therapeutic effects of the use 1 A celebrated occurrence in Paris, by which a number of people, including some of highest position, were inoculated. INSTRUMENTS AND METHODS OF EMPLOYMENT. 183 of the Eustachian catheter are, of course, entirely independent of the auscultation tube. The latter consists of a yard of rubber tubing, 8 mm. in its outside diameter. Black rubber tubing is preferable, being more lasting and less sulphurous in odor than the ordinary domestic white rubber tubing. Upon one end of this tube there should be a white bone end-piece made to fit the surgeon's own ear; at the other end there should be a black end-piece, for the patient's meatus. In using the auscultation tube, one end should rest snugly in the meatus of the ear cathe- terized, while the other end must rest equally well, though not too tightly, in the examiner's ear. Fig. 54. Auscultation Tube.—Black end for patieut's, white for surgeon's, ear. Let it be supposed, for example, that the patient's left ear is to be catheterized, and that the auscultation tube is also to be used. Let the examiner place his end of the auscultation tube in his left ear, bring the tube loosely around behind his neck and over his right shoulder, placing the other end of the tube in the patient's left ear. If the tube be thus supported it is less in the way of the surgeon, and less likely to fall either out of his or the patient's ear. The usual method given in most works on aural surgery, is to allow one end to rest, for instance, in the patient's left ear, while the other end is resting in the surgeon's right ear. In such a case, not only will the tube hang down between the patient and surgeon and be in the way, but the mere weight of the auscultation tube when thus suspended is sufficient to drag it out of place. The Air-bag or Hand-balloon.—The general appearance of the hand-balloon is given further on, in the figure of Politzer's appa- ratus. The use of this bag is to force air through the catheter into 184 EXAMINATION OF PATIENTS. the Eustachian tube and tympanic cavity. It is of the greatest importance that the end-piece at the point of the balloon-like bag should fit accurately into the catheter, and, like it, be of hard rubber, Fig. 52, D. This hand air-bag is of the greatest importance and usefulness, for with it not only air, but medi- cated solutions may be forced through the catheter and into the Eustachian tube. It is very uncommon that more impelling force is needed in catheterization of the Eustachian tube than can be exerted by means of the hand as it squeezes the air from this bag. During the expulsion of the air from the bag great care should be taken not to force the axis of the bag out of line with that of the catheter, for, if this should occur, either by an upward or downward movement of the hand and wrist, the catheter if of hard rubber will be very apt to break, if of silver, to bend. In compressing the air-bag, no motion should occur, except in the fingers of the right hand or the hand employed in compressing the bag. A little practice will enable the operator to make only such a motion with the fingers, though at first there is an almost involuntary tendency to flex the hand laterally on the w7rist towards the ulna, at the same moment the fingers are made to squeeze the bag. If the bottom of the bag is made to rest on the palm of the hand while the fingers surround the sides, this tendency to lateral motion will be removed. Catheterization of the Eustachian Tube.—Provided with the three instruments described in the preceding pages, viz., a catheter, an auscultation tube, and a hand air-bag, the surgeon may endeavor to catheterize the Eustachian tube, i. e. he may endeavor to place the beak of the Eustachian catheter in the faucial end of the Eustachian tube, so as to enable him to force air into the latter, and if that be patulous, the air may pass into the tympanic cavity. In catheterizing the Eustachian tube, the patient may sit or stand at the surgeon's option ; as a rule, it will be more desirable for the patient to sit, since it is more comfortable for him, and will hence enable him to hold still much better. Let the patient, then, sit down with the hips well back in the chair, and his spinal column and head erect, The latter may be braced against the wall or the back of the chair, should the latter come above the INSTRUMENTS AND METHODS OF EMPLOYMENT. 185 patient's head. Then, with the auscultation tube adjusted as described, the surgeon should place the fore and middle fingers of his left hand on the patient's forehead a little above the root of the nose, and with his thumb he should lift up the tip of the patient's nose and hold it up until the catheter is well inserted. Fig. 55. Insertion of the Eustachian Catheter. With the tip of the patient's nose held up as just described, let the surgeon grasp the catheter as he would a penholder, between the thumb and forefinger of the right hand, holding his hand down about as low as the patient's chin, towards wiiich the palm of the catheter-hand should be turned. Now insert the beak of the catheter into the nostril corresponding to the ear to be catbeterized, and with a compound upward and forward motion carry the instrument along the floor of the nose until the beak reaches the nasopharynx and at last touches the posterior pharyngeal wall. The ring should point directly downward upon the arrival of the beak of the catheter in the nasopharynx. 186 EXAMINATION OF PATIENTS. With the catheter's beak in the position above named, viz., at the posterior pharyngeal wall, the beak may be turned outward toward the ear to be catheterized. By tfns motion the beak will slip into the fossa of Rosenmuller. The mistake Fig. 56. Inner View of the Right Half of the Head ; Antero-posterior Section. (Gruber.)— o. Superior turbinated bone. m. Middle turbinated bone. u. Inferior turbinated bone. R. Rosenmiiller's fossa, bounded in front by the cartilaginous lip of the tube ; in front of the latter the pharyngeal opening of the Eustachian tube, in which the catheter k is placed. is usually made at this point, in supposing the catheter's beak rests in the mouth of the Eustachian tube, and unsuccessful attempts at inflation may be made. But in order to place the beak in the mouth of the tube, the following manipulation becomes necessary. After the beak of the catheter has been turned into the fossa of Rosenmiiller, draw the catheter forward, letting the beak slip over the posterior lip of the Eustachian tube, and as soon as this is done turn the catheter so that the ring-indicator will point towards the ear catheterized, at an INSTRUMENTS AND METHODS' OF EMPLOYMENT. 187 angle of 45° ; at the moment this movement is made with the catheter, its beak slips into the faucial extremity of the Eusta- chian tube. Of course, this is easily said, less easily done; but with a little practice the touch is soon educated, and the Eustachian catheter can be inserted into the mouth of the tube with great ease. Fixation of the Eustachian Catheter.—After the catheter has been thus put in place, let the thumb and forefinger of the left hand grasp the instrument close to the nose, while the remaining three fingers are braced above the root of the patient's nose, at the point formerly occupied by the middle and index fingers, during the elevation of the tip of the nose by the left thumb, and the insertion of the catheter by the right hand. Fig. 57. Fixation of the Eustachian Catheter in position, preparatory to inflation. With the catheter thus fixed in position, and the auscultation tube passing from the patient's ear to the ear of the examiner, the latter may grasp the hand air-bag and make inflations into the tube and tympanum. If the Eustachian tube is pervious, 188 EXAMINATION OF PATIENTS. air will be heard to enter it with more or less force. As a rule, two or three inflations with the contents of the air-bag will be sufficient, both in force and in number, to properly and safely ventilate the middle ear. When considerable stimulation is demanded by the atonic condition of the muscles and mucous membrane, numerous inflations, even as many as a dozen, may be made with entire safety. In using the Eustachian catheter, the only danger is from emphysema; but this can never occur unless the mucous membrane has been abraded by the unskilful introduction of the catheter. Even should such abrasion occur, emphysema might not be produced unless very powerful infla- tions were to follow. The twTo fatal cases which occurred, during inflation, in the practice of a well-known London quack, were caused, probably, by the use of a powerful air-pump; but air-pumps are no longer used, or at least very rarely, by respon- sible men. There is certainly no record of a case of death from emphysema resulting from gentle inflation made by the hand air-bag. Where death has occurred from emphysema of the pharynx and the parts about the larynx, the fatal result has most pro- bably been brought about just as it is in oedema of the glottis. The treatment, therefore, should have been the same and just as prompt in the former as in the latter malady, i. e. a free scarifica- tion of the puffed-up parts in order to permit the air to escape from the cellular tissue beneath the mucous membrane. As the Eustachian catheter is in constant use all over the w7orld, and as the only cases of death which were ever suspected of being caused by its use occurred at the hands of a quack, the latter, and not the instrument, should be held accountable for the un- fortunate result. Voltolini1 has demonstrated how- ephysema may be produced by the improper use of the catheter, and how death may occur when the introduction of air producing the emphysema is very powerful. After the introduction of a probe or bougie into the Eustachian tube, the mucous membrane is probably somewhat lacerated, and therefore no air should be forced in immediately after probing. Hence, the air-pump and all means of inflation more powerful than the hand air-bag should be discarded. 1 Ueber das Emphysem bei der Luftdouche in das Mittelohr, M. f. O., vii. No. 1. INSTRUMENTS AND METHODS OF EMPLOYMENT. 189 Death in cases of emphysema produced in the above way might be due to pneumothorax. Voltolini proved this to be the cause of death in a dog, into the naso-pharyngeal region of which he first introduced a catheter, then a wire, by which he wounded the mucous membrane of the parts near the opening of the Eustachian tube. By a powerful introduction of air he produced sudden death, and a post-mortem examination of the animal showed that air had entered the pleural sac and pro- duced collapse of the lungs. There was no emphysema of the vocal cords nor of the larynx. Other Methods of Catheterization.—Prof. Gruber recommends a somewhat different method from the foregoing. Thus, after the catheter has been introduced through the nose and has reached the hinder wall of the pharynx, let the instrument be drawn straight outward until its curved beak lies against the soft palate. Then push the catheter a short distance (from half an inch to an inch) inward, and turn the beak outward towards the ear. It will be found that as a rule the beak will slip into the mouth of the Eustachian tube. A somewhat less complicated method is that known as Low7enberg's. In this method the catheter is introduced in the usual way through the nose until it reaches the posterior wall of the pharynx. Then let it be turned in- ward and drawn forward until the curve of its beak touches the septum narium. If now with a downward turn the point of the catheter be made to describe a semicircle, the beak will usually slip into the mouth of the Eustachian tube. All of the above efforts at insertion of the point of the catheter into the mouth of the Eustachian tube, as well as inflation, may be greatly helped by an act of swallowing on the part of the patient at the precise moment the instrument is to be inserted into the mouth of the tube, or just as the air-bag is emptied through the catheter. Dr. H. D. ISToyes,1 in order to obtain a catheter to be intro- duced into the Eustachian tube from the opposite nostril, gives the beak of an ordinary catheter, of rather more than the average length, a double curve. The elongated beak generally used in such cases, at three-eighths of an inch from the point, is bent " in a plane transverse to the plane of the primary curve." ' Transactions ofthe American Otol. Soc, vol. i. p. Ill, 1870. 190 EXAMINATION OF PATIENTS. Fig. 58. Politzer's Air-bag and Method of Inflation ofthe Eustachian Tube and Tympanic Cavity.—Prof. Adam Politzer has given to the profession a most valuable means of inflating the naso-pharynx, Eustachian tubes, and tympana. The instrument bears his name, being known as Politzer's air-bag, and the method of its employ- ment is known as Politzer's method of inflation. The instru- ment consists chiefly of an ordinary air-bag such as is used for forcing air through the Eustachian catheter. Instead of the conical tip of the ordinary hand air-bag, the instrument devised by Politzer is supplied with a somewhat bulbous tip, to which is attached a piece of black rubber tube 8 cm. long, which forms the pliable connection between the air-bag and the nose-piece. The latter piece is made of hard rub- ber, and varies from 3 to 4 mm. in diameter. It is curved slightly at the beak and resembles at this point a coarse Eustachian catheter. In fact one may extemporize a Politzer's apparatus by attaching an ordinary hard rubber catheter to the hand air-bag. But in this case the disadvantage is in the stiffness of the catheter and its great liability to snap in half. Politzer's method of inflation depends upon the physiological fact that, at the moment of swallowing, the velum palati rises and thereby draws the anterior wall of the Eustachian tube from the posterior. At this moment the faucial extremity of the tube is so patulous that air forced through the nares, not being able to pass downward into the fauces and mouth, because the velum palati prevents it, will by following the course of least resistance pass into the tube and usually into the tympanum. In order to accomplish this result at the desired moment, the patient is instructed to take a sip of water and retain it in his mouth until told to swallow. After Politzer's .Airha(> for In FLATINO THBMIO OLE EAR.—(One third natural size.) INSTRUMENTS AND METHODS OF EMPLOYMENT. 191 the water has been thus taken, let the surgeon place the curved nose-piece into either nostril aud compress the nostril in front of the nose-piece. The usual error is made of trying to com- press the ala of the nostril down upon the nose-piece. This is not only very painful to the patient, but defeating to the surgeon. The index finger should compress the other nostril so that no air from the bag shall escape outward through the nose. The point of the nose-piece should be directed outward against the ala, rather than inward against the bony septum. If the latter is done, and it usually is the mistake of beginners, the septum will be painfully pressed if not wounded, and bleeding from the nose may be the very undesirable result. In using this method of inflation one ear of the patient may be connected by the auscultation tube to the ear of the surgeon; but this is by no means necessary, since, as a rule, when the method is properly carried out, a peculiar gulping sound is pro- duced which the surgeon soon learns to recognize. By the very nature of the physiological process called to aid in Politzer's method of inflation, both ears are likely to be in- flated at the same time. The fact that one ear cannot be isolated during this mode of inflation should be borne in mind, if for any reason such isolation on the part of either ear should be demanded. In such a case the tube demanding inflation must be catheterized. The force of the Politzer inflation, however, can in any case be augmented on either side by pressing the finger firmly into the canal of the ear opposite to the one it is specially desired to ventilate. By some, it is supposed that this latter modification is aided by holding the head over towards the shoulder opposite to the ear which is to receive the greater amount of inflation. As in such a position the ear on the up- turned side is highest, it is to be supposed that the air may take its course more readily toward that ear than the one turned downward and firmly stopped by the finger. Respecting the method of inflation during phonation, instead of during swallowing, as lately suggested by Profs. Lucse and Gruber, I would say that in some cases I have succeeded in in- flating the ears by following their suggestions, but I am equally sure that it is neither as powerful nor as certain as Politzer's method. In very young or unreasonable children who cannot or 192 EXAMINATION OF PATIENTS. will not swallow, but do cry, Politzer's method is invaluable, for, as he taught long ago, the more the child cries the more firmly does it lift up the velum palati and favor the surgeon's attempts at inflation of the tympana. CHAPTER II. SOUND, HEARING, AND TESTS OF THE LATTER. Sound is motion imparted to the auditory nerve by undula- tions in the air. A shock from a vibrating body, conveyed to the air immediately surrounding it, is propagated by a wave of undulation, not of progression, to other particles of air. This wave of sound at last reaches the membrana tympani, and transmits itself, by the aid of the latter and the ossicles of hear- ing, to the fluid of the labyrinth and to the nerve of hearing. Hearing is the perception of such sonorous undulations of the air. It implies a free access of air to the drum-head, a perfect oscillation to and fro of the chain of ossicles, unimpeded movement of the stapes in and out of the oval window, and a normal percipient organ in the labyrinth. If any of these requirements is wanting, the hearing will be defective, the degree varying from "hardness of hearing" to total deafness. The vibrations in the air may be periodic or irregular, i. e. they may be of equal length and duration, or they may be unequal and crowded upon each other in the greatest confusion. The former would produce musical sounds or tones, and the latter, noises. Intensity, Pitch, and Quality.—Frequent allusion is made in acoustics to the intensity, pitch, and quality of sounds. The first depends on the breadth or amplitude of the vibration. When a wire is first set in vibration, the extent of the excur- sion it makes, backward and forward between its fixed ends, is visibly much wider than it is as it gradually ceases to vibrate. During these wide excursions the sound is strongest, but it grows weaker as the vibrations become narrower. It must, SOUND, HEARING, AND TESTS OF THE LATTER. 193 however, be kept in mind that only the width, not the number of vibrations, has diminished, and therefore the pitch of the note remains the same, though weaker. Pitch depends simply upon the number of vibrations ema- nating from a sounding body in a second, thus a high pitch means numerous vibrations in a second, low pitch implies but few. Quality or Clang-tint—-The quality of a sound, also called its clang-tint or timbre, depends upon the peculiar kind of vibra- tions and the manner of their occurrence. The difference be- tween one musical quality and another depends entirely on the presence and the strength of the partial or over-tones. Partial or Over-tones.—If a wire be stretched between two points, it can be made to vibrate as a whole, or it can be made to divide itself into a number of equal parts. The note emitted by the wire when vibrating as a whole is called its fundamental note. The notes represented by the vibrating subdivisions of the wire are termed its partial, secondary, or over-tones. All vibrating bodies or instruments, therefore, give out, besides their fundamental notes, their over-tones, or harmonics, as they are also termed, and it is the general admixture of these, with their varying number and strength, which goes to form the quality peculiar to a given sound. This is called timbre by the French, and Klangfarbe (clang-tint) by the Germans. System of indicating 31usical Notes by Letters.—In otology, frequent reference is made to musical notes. This is gene- rally done by citing the letter used by the Germans to desig- nate a particular note. This is a system whereby the position of a note in the scale, and hence the number of its vibrations in a second, are very easily shown. It is accomplished by using different letters for the notes in an octave, and different kinds of type, or adding co-efficient numerals to the same type, to indicate the octave to which the notes belong. As it is of the greatest importance that the reader should know at a glance the relative position in the musical scale of the notes thus cited, in the examination of the ear and in recording the hearing, the 13 194 EXAMINATION OF PATIENTS. Cr-H, C-H c. 33 66 D. 37.125 74.25 E. 41.25 82.5 F. 44 88 G. 49.5 99 A. 55 110 H. 61.875 123.75 c'-h1 c^-h" ciii_j1iii civ-hiv 264 528 1056 2112 297 594 1188 2376 330 660 1320 2640 352 704 1408 2816 396 792 1584 3168 440 880 1760 3520 495 990 1980 3960 following table, as found in Prof. Helmholtz's celebrated work,1 is here given. c-h 132 148.5 165 176 198 220 247.5 The letters at the top of the column indicate the note and the octave in which it lies ; the numerals, the number of its vibrations per second. According to Prof. Helmholtz, the deepest note used in orches- tral music is one of 41f vibrations in a second. In pianos and organs the lowest note is generally one of 33 vibrations per second, but some grand pianos are constructed to give out a note as low as 27 J vibrations. The musical character of such low notes is very imperfect, especially those lower than E, with 41.25 v. s. They become musically useful only when sounded with their octave higher. Some pianos are made to give out notes as high as a'v-cv, i. e. from 3520-4224 vibrations in a second. The highest note used in orchestras is the dv of 4752 vibrations, produced by the piccolo, a kind of flute. Beyond these limits the notes become shrill, disagreeable, and to some ears, absolutely painful. By the same authority it is held that, only those notes lying between 40 and 4000 vibrations in a second, or within seven octaves, are of real musical value. Yet those lying between 20 and 38,000 vibrations a second, or within eleven octaves, may be perceived as musical notes. In this respect, the ear is far superior to the eye, for the latter rarely perceives vibrations of light extending much over an octave. The so-called "Deaf Points" ofthe Ear.—Dr. V. Urbantschitsch2 has pointed out a phenomenon heretofore undescribed, connected with the organ of hearing. He has shown there are some points near the ear, at which a vibrating tuning-fork cannot be heard, and he calls these "deaf points." By following his directions any one can verify his experiments. Thus if a tuning-fork held 1 "Die Lehre von den Tonempfindungen," Braunschweig, 1870. 2 Centralblatt f. d. Med. Wissensch., No. 8, 1872, M. f. O. No. 2, 1872. SOUND, HEARING, AND TESTS OF THE LATTER. 195 perpendicularly in front of the ear be started from the lower edge of the zygoma and moved backward towards the occiput so that the upper end of the fork passes the lower end of the tragus, two points will be reached where, though the vibrations of the fork are felt by the fingers, the ear will for a moment perceive no sound, until this deaf point is passed. The fork is then heard for a short interval until it reaches the second deaf point, after which the vibrations are heard once more as the fork is gently passed on its way backward towards the occiput. The same points are perceived if the vibrating fork is passed in the opposite direction, i. e. from behind forwards in the line above described. The position ofthe first point is at the lower end of the tragus; the second, is at a point where the helix intersects the line of motion given above. If a tuning-fork held horizontally be passed vertically upwards before the ear, the same kind of deaf point is found in the region of the crista helicis. This phe- nomenon remains the same whether the tuning-fork is passed in the same line, at a greater or less distance from the ear. A further investigation led to the discovery of so-called "deaf fields" in the form of two small triangles, the first of which lies in front and above, the other behind and above. The apex of the anterior triangle lies at the lower end of the tragus, already spoken of, from which point the sides diverge gradually towards the frontal and parietal bones. The general tendency of these lines is upward ; at the frontal protuberance they are 2-3 cm. apart. The apex of the second triangle is at the lobule of the auricle or near the lower part of the helix. The sides diverge in the direction of the lateral surface of the parietal and occipital bones. At a point corresponding to the uppermost part of the helix they are about 2-3 cm. apart. Dr. Emil Berthold,1 of Konigsberg explains these phenomena as entirely unconnected with the physiology of the ear, but entirely due to the interference of the vibrations of the fork. Thus if a vibrating tuning-fork is moved slowly past the mouth of a bottle, the fundamental note of which corresponds to that of the fork, the air in the bottle will be set into consonance with the note of the fork excepting at the moment when the sound 1 Monatsschrift f. Ohrenheilkunde, No. 5, 1872, 196 EXAMINATION OF PATIENTS. waves entering the mouth of the bottle are quenched by inter- ference. This will happen, says Dr. Berthold, when the first tine of the fork has just past the inner edge of the bottle, and again when the second tine has almost reached the inner edge of the bottle, i. e. at two points which correspond to the tragus and the helix. Sound and Color.—Dr. J. A. Nussbaumer,1 of Vienna, has communicated some very interesting facts relating to subjective perception of color produced in himself and in his brother by objective perception of sound; but the same sound produces different impression of color in each. The note " small e" on the piano produces in the former the subjective perception of the color'of dark yellow; in the latter the impression of dark blue. There are some colors which no note even calls up; blue, yellow, brown, and violet are most frequently produced. There is no red nor green, nor perfectly black and white in any notes. Dr. Nussbaumer, however, perceived green once, upon hearing suddenly a peculiar noise. Colors are also perceived by him in dreams if noises are dreamt of. The author endeavored to represent the subjective tint of the fundamental note as a mixture of single tints corresponding to the separate partial tones, and he was in a measure successful. TESTS FOR HEARING. Aericd and Bone Conduction of Sound.—Sound is conveyed to the nerve of hearing in two ways: by the air and by the bones of the head. The first, aerial conduction, is the chief means of normal hearing. The second may be very great in the normal organ in the young. In old age, however, it is blunted. The sound-conducting apparatus of the ear is adapted to aerial conduction of sound. Bone conduction of sound comes into consideration chiefly as a test, respecting the condition of the nerve and the remain- ing power of the sound-conducting apparatus in disease of the ear. 1 Ueber subjective Farbenempfindungen die durch objective Gehorempfin- dung erzeugt werden, Wiener Med. Wochenschr., Nos. 1, 2, 3, 1873. SOUND, HEARING, AND TESTS OF THE LATTER. 197 If the nerve or the conducting apparatus of the ear, i. e. the external auditory canal and middle ear, are affected, bone con- duction of sound is soon impeded and manifests itself in such a way as to be of use in diagnosis. Normal Hearing.—No precise standard of normal hearing has ever been defined. The normal ear hears all sounds that fall on it; but it cannot be said, d priori, where good hearing ceases and defective hearing begins, for in many senses these are rela- tive terms. The sense of hearing must be regarded as composite, /. e. it consists in the ability to hear a number of different sounds both periodic and irregular in their vibrations. Such sounds can be heard singly or together. Hence, the sense of hearing may be said to lie in a collection of nervous elements, which can be aroused separately or together. The latter is shown by the well- known fact that more than one sound can be heard at the same time. The Watch.—Some form of watch-work or ticking apparatus is an old and ready means of testing the hearing. In this way the pocket watch, mantel clock, metronome, or an especially contrived ticking machine has been called into requisition. But the watch being a low form of musical instrument accord- ing to Oscar Wolf,1 which at best gives forth only two poor notes, not easily determinable in pitch, it can never have a wide application as a test. When using a watch as a means of deter- mining the hearing, the test is being accomplished with only one or at most two notes. Now if the nerve fibres in the per- ceptive auditory apparatus, which were destined to perceive the notes given out by the test, happen to be the affected ones in a given case, then the watch will not be heard or but imper- fectly, whereas a watch, the notes of which are of a different pitch, might be heard. Hence it is that the watch as a fest so often fails. Its inferiority as a test depends therefore on the fact that in using it the power ofthe ear to perceive only two notes ofthe entire musical scale, is placed on trial. But as far it goes, the watch may be of value as a test, especially if its notes be made 1 Archives of Oph. and Otol., vol. iv. 198 EXAMINATION OF PATIENTS. to come out with intensity and if also the form known as a stop- watch be used. The simplest and most convenient form of watch-test is the ordinary pocket timepiece. When using it as a means of testing the hearing, the watch should be brought from a point where it is not heard, gradually towards the ear, until the ticking is per- ceived by the patient, or until positive inability to hear it, even on contact with the head, is discovered. The distance at which the watch used is heard by the normal ear should be known by the examiner. This distance may represent the denominator of a fractional form of expressing the hearing power: the numerator, the distance heard in a given case. This is a suggestion of Dr. J. S. Prout, of Brooklyn, and a most valuable one it is. Thus a watch is heard by the normal ear 60 inches, and by a diseased ear in a given case 20 inches. The record in such a case would be expressed by the fractional formula — in. 60 Dr. Roosa employs this formula with modifications, as, when the watch is heard only on contact, then ----- would express 60 in. p o this condition. „* ■ and „„ . wound express respectively that a given watch is heard only on pressure or not at all. It is not intended that these fractional expressions should be reduced, for in that case it would be less awkward to say instead 20 of nK, J.* The idea is to let the fraction stand as above, so that the denominator shall show at a glance the exact distance the watch is heard by the normal ear. A somewhat less simple method is given by Dr. Knapp ;' thus, If a watch normally heard 10 feet be heard only 3 inches, 3 1 then the hearing may be recorded as -fo7n-== Jo 0I> tne nor- mal standard. Fractions of an inch are placed, in this method, 1 : 2 either in the numerator, as H izJq, or the unit is to be left 1 Archives of Oph. and Otol., vol. iii. Part I. p. 220. SOUND, HEARING, AND TESTS OF THE LATTER. 199 in the numerator and all other numbers in the denominators, as o 12 10' wn'cn shows the watch is heard at half an inch. In order to avoid a mathematical operation I have found it use- ful to express the formula perhaps a little more arbitrarily, thus i in. nn ;., which shows that the watch of 60 in. is heard onlv h in. ou in. u £ Thus the original idea is fully maintained, and the record can be kept by the least mathematical. The Stop-watch.—Of all forms of watch-work for testing the hearing the most useful is the stop-watch. Besides its power as a test, there is also in it the means of finding out wmether the patient really hears the sound of the wratch, or whether he thinks he does because he knows a watch is being held before his ear. This means is often the first to declare that the patient's state- ments respecting his subjective impressions of sound are un- reliable. If the ticking of the watch can be alternately stopped and set going at the will of the surgeon, errors of observation on the part of the patient may be detected. The same end has been gained by alternately holding and removing a diaphragm of paper between the ear and the watch. Children, as a rule, give erroneous statements as to their ability to hear a watch. The reliability of their statements can soon be decided if a stop-watch be used, for they are obliged then to show wrhether they are aware of the stopping and the going on of the apparatus. A stop-watch for this purpose may be constructed to tick with great intensity. The form I have used for some years can be heard sixty feet by the normal ear, in the open air. In some cases even while the ticking continues the patient will state that he no longer hears the sound of the watch. This may be a perfectly true statement, and is explained by the fatigue ofthe diseased ear. As will be shown later, some ears affected by chronic aural catarrh manifest this tendency to grow fatigued and to cease to hear a sound, while listening attentively to it. As a test for bone conduction the watch is limited both by the age of a patient and by the weakness of its impact. The 200 EXAMINATION OF PATIENTS. latter may be covercome by having the ticking apparatus so constructed as to give its sounds with great intensity. Tuning-forks.—The tuning-fork, like the watch, may be used in two ways as a test. 1. By the air, aerial conduction: this is a test applied to the sound-conducting apparatus chiefly, and only secondarily to the auditory nerve. The use of the tuning-fork as a test is, however, more frequent in another way, viz.:— 2. By the bones of the head, bone conduction, a test applied primarily to the auditory nerve, and secondarily to the sound conducting apparatus. For, the fork thus used shows whether Fig. 59. Fig. 60. Blake's Tcninq-Fork. Clinical Tuning-Fork. the sound can be conducted away from the ear in a given case, or whether, being impeded in their escape from the sound con. ducting parts, the sound-waves are thrown back on the percep- tive part of the organ of hearing. SOUND, HEARING, AND TESTS OF THE LATTER. 201 There are several forms of tuning-fork used in making tests of the hearing. The best results are obtained with a large in- strument giving a powerful fundamental note. A very beauti- ful instrument is the tuning-fork devised by Dr. C. J. Blake, in which the force setting the fork in vibration is obtained by means of a steel hammer padded with rubber. The handle of the hammer is adjustable at any point in its length, by which means the blow can be weakened or strengthened as desired. The clamp with which all tuning-forks should be provided when used in testing bone conduction, are for damping the over- tones of the instrument. An instrument which has given satisfaction and which can be supplied at moderate cost, is the clinical tuning-fork. The instrument is set in vibration by gently tapping it against any firm object, at one of the short stems on the clamp. (See Fig. 60.) While the force thus applied is not always the same, prac- tice will enable the surgeon to apply nearly the same amount of force in a given case. The instrument possesses the advantage of great convenience and simplicity ; it is 26 cm. long, and gives out a full deep note free from discordant over-tones when the clamps are properly adjusted at the points. By altering the clamps the fundamental note is changed. Prof. Politzer1 has devised an acoumeter, consisting of a hard rubber tube 4 centimetres in length, in which is a steel cylinder 28 mm. long and 4 mm. in diameter. Above the latter is a small hammer, which is made to strike the steel rod by touching a spring. There is attached to one side of this instru- ment a small pedestal, which supports the acoumeter against the head, when it is desired to test the perceptive power of the auditory nerve through the bones of the cranium. All these instruments are said to be made alike, and are attuned to the note cu. Prof. Politzer claims for this instrument the advantage of supplying a standard unit of measurement of hearing. It may be stated as an axiom, that the normal ear hears the tuning-fork better through the air than through the bones of the head. ' K. K. Gesellschaft der Aerzte, Wien, March 2, 1877. 202 EXAMINATION OF PATIENTS. According to Politzer,1 E. II. Weber first settled the point that a vibrating tuning-fork, the shaft of which was in contact with the bones of the head, was heard better in that ear, the external auditory canal of which was stopped by the finger. This phenomenon was long unexplained, until Mach, on purely theoretical grounds, advanced the view that the reason of this lay in the hindrance offered by the finger in the auditory canal, to the escape of the sound-waves from the ear. Politzer, having in mind this phenomenon, thereupon made a series of experi- ments upon the human ear, and came to these conclusions:— The above-named augmented perception of sound upon closing the external auditory canal, is due to (a) the reflection of sound- waves from the bones of the head, through the air of the external auditory canal, to the membrana tympani and auditory ossicles, and (6) to the hindrance which the sound-weaves, passing from the bones of the head to the labyrinth and tympanic cavity, meet in escaping from the ear. In the latter conclusion, Mach and Politzer are in entire agreement. If a tuning-fork, vibrating on the vertex, be heard better on the deafer side, because of the hindrance offered to the escape of sound-waves, even while the auditory canal is not stopped by the finger, closure of the meatus by the latter should increase the sound of the fork's vibrations in the diseased ear. Dr. Roosa is of the opinion, that, if closing the auditory canal by the finger does not increase the hearing on the deaf side, it is a sign that the nerve is affected. The late Mr. Hinton, of London, was inclined very strongly to the view, that when, for other reasons, he could diagnose a nerve affection on the deaf side, an increase of hearing for the tuning-fork, by stopping the deaf ear, was confirmatory of the presence of disease of the auditory nerve. Prof. Politzer has shown that a nerve affection may exist on the deaf side to such a degree, that the delicate noise of a ticking watch is not heard better on the deaf side by bone-conduction so long as the auditory canal is left open; but that, by increasing the quantity of sound made to impinge on the nerve through the bones of the head, either by stopping up the auditory canal 1 Wiener Med. Wochenschr., 1868. SOUND, HEARING, AND TESTS OF THE LATTER. 203 and thus reflecting sound from a given source, as when using a watch, or by increasing the original amount of sound employed in the test, as when a large tuning-fork is used, then the diseased nerve, which was too weak to reply to a small amount of sound, is stimulated into action by the greater amount of sound-waves thrown on it. By remembering this latter fact, the views of Roosa and Hinton are less contradictory than would appear at first sight, for the correctness of each theory is dependent on the amount of nerve-disease. It will then be found that the former is correct if the nerve is paralyzed, and that the latter is right if the nerve still retains some of its function. Tuning-fork not Infallible in Bone Conduction.—Although the tuning-fork is an important means of diagnosis of disease of the internal ear, it cannot always be relied upon. Johannes Miiller showed that in testing by bone conduction, conveyance of sound through the auditory ossicles and the air must not be lost sight of.1 As a rule, the ear which hears better the tuning-fork vibrat- ing on the vertex, may be considered the worse ear. But if one auditory nerve is paralyzed, of course the tuning-fork on the vertex, if heard at all, must be heard in the better ear. If there remains in both ears some hearing for sounds, conveyed by the air, then that one which chiefly perceives the tuning- fork vibrating on the vertex may be considered the less able to perceive by aerial conduction. Age does not seem to have as much to do with the interfer- ence in bone conduction as has been stated by some observers— provided that the fork used is powerful. If the auditory nerve perceives at all, individuals over eighty years of age usually hear the fork vibrating on the vertex. But doubtless it re- quires powerful vibrations to make themselves felt through the head-bones of the aged. Where bone conduction in the aged seems to be impaired, it is due probably, as Moos has suggested, to a diminishing sensibility of the auditory nerve. Then too the musical education or sense of the patient, as well as the perceptive powTers, must be taken into consideration. If not, hearing will often be confounded with feeling. 1 Moss : Klinik der Ohrenheilkunde, p. 41. 204 EXAMINATION OF PATIENTS. It has been found that deaf mutes might, to some, appear to hear the tuning-fork vibrating on the vertex, were it not known that what they perceive in such conditions, are vibra- tions at the diaphragm. In the case of a brakeman, struck over the head as the train of cars on which he was standing passed under a bridge, the ears, though entirely and suddenly made deaf to all external sounds by aerial conduction, appeared to hear the tuning-fork vibrating on the vertex. But in this instance it seems rational to conclude that the fork's vibrations were felt rather than heard. Three-limbed Auscultation Tube.—In addition to the patient's statements, there has been advised the use of a three-limbed auscultation tube,1 two arms of which should be placed in the auditory canals of the patient, and the third in the ear of the observer. If now, a vibrating tuning-fork be placed on the vertex of the patient, the auscultator can perceive the sound of the fork streaming from the ears of the patient. By alternately pressing the two arms of the tube, connected with the patient's ears, the auscultator can further learn from which ear the greater amount of sound comes. Of course it is evident that more sound-waves must come from the less obstructed ear. The latter will, as a rule, be the better hearing ear, unless its fellow is deaf, not by obstruction in the sound conducting parts, but by paralysis of the nerve. The Interference-Otoscope.—A somewhat similar instrument, though one used in a different way, has been devised by Prof. Lucas,2 of Berlin, and named by him the interference otoscope. This instrument consists partly of a double stethoscope of Scott Allison, the limbs of which, intended to fit snugly into the au- ditory canals of the patient, are about eleven inches long. At the junction of these symmetrical arms is placed a T-shaped glass tube from the portion of which representing the standard of the letter, passes a rubber tube to a collector of sound, half paraboloid in shape. Here the vibrating tuning-fork is stationed. 1 Moos: Klinik der Ohrenheilk., p. 42, 1866. 2 Archiv fur Ohrenheilk., Bd. iii. 1867. SOUND, HEARING, AND TESTS OF THE LATTER. 205 To the other end of the cross-piece of the glass tube, is fixed the rubber tube 2 ft. long, for the auscultator. Dr. Lucse's experiments in this direction were based on the fact that sound waves, falling on a stretched membrane, are only partly taken up and transmitted by it. The supposition then naturally follows that sound-waves entering the external auditory canal, are only partly transformed into the peculiar pendulum-like, to-and-fro movements of the sound conducting membrana tympani and auditory ossicles. According to the greater or less extent to wiiich the membrana tympani takes up the sound waves falling on it, this so-called reflection of the waves of sound will vary in amount. The investigations made tend to elucidate experimentally this reflection of sound, and the probable influence on it of the changes of tension in the sound-conducting apparatus; also, from a study of these phe- nomena of reflection of sound-waves, an endeavor is made to obtain an objective expression of the sound-waves taken up by the ear. The physical experiments show that: 1. A stretched and inclined membrane of India-rubber, placed in an artificial ear made to represent as closely as possible the natural organ, will reflect a certain quantity of the sound-waves entering the external auditory canal. 2. Closure of the Eustachian tube increases slightly this reflection. 3. Increased tension of the membrane shows that the reflection is directly proportional to the tension. 4. This outward reflection of sound-waves is greatest whenever the tension occurs simultaneously with con- siderable changes in density in the air contained in the tympanic cavity. In order to make practical application of these laws, Dr. Lucae devised his interference-otoscope, by which the relative amounts of reflection from both ears could be determined in a given case. The results obtained by the use of the interference-otoscope (in connection with normal ears), are thus summed up by Prof. Lucae :— 1. The normal organ of hearing reflects a certain amount of the sound-waves entering the external auditory canal. 2. The reflection increases in all changes of the sound-conduct- ing apparatus,-especially in the middle ear, which directly or indirectly lead to an increased tension of the membrana tympani. 206 EXAMINATION OF PATIENTS. 3. The examination of those with normal hearing, by means of the interference-otoscope, shows that the different sensibility of both ears for the same tone is caused by the different amounts of reflection brought about by different tensions in the two sound-conducting apparatus. Respecting the diseased ear, the conclusions are:— 1. The interference otoscope shows in the majority of cases of disease, in analogy with the observations made on those with normal hearing, a greater reflection of sound from the worse ear. 2. This is found in a number of cases in which the ear-mirror and the Eustachian catheter reveal disease in the external or middle ear. 3. In the numerous cases of ambilateral chronic catarrh of the middle ear, without perforation of the membrana tympani, the examination usually reveals a greater, though sometimes a less, reflection from the worse ear; in the latter instance, a simultaneous disease of the labyrinth may be supposed and the prognosis becomes much less favorable, 4. The greatest worth of this method of auscultatory exami- nation lies in the not uncommon cases, in which all other diagnostic means fail to show morbid changes in the external and middle ear; here, too, as a rule, a stronger reflection is observed on the worse side, which points to a deep-seated disease of the sound-conducting apparatus. Only in some few cases does the examination reveal a less reflection from the worse ear, in which cases a primary disease in the labyrinth may be assumed with great certainty. Tuning-fork Vibrating on a Parietal Protuberance in a Normal Case.—If a vibrating tuning-fork be placed on either parietal protuberance of a person with normal ears, it will be heard in the opposite ear. This is most easily perceived when a large and powerful tuning-fork of deep note is used. This phenome- non, if it may be so termed, will often lead to confusion in diagnosis, inasmuch as the examiner would expect the fork to be heard best in the ear nearest to which the fork is placed. As it is heard best in the more distant organ, a conclusion might be made that the latter is diseased in its conducting parts. SOUND, HEARING, AND TESTS OF THE LATTER. 207 Care must therefore be taken to have the vibrating instrument in the central line of the head, either on the vertex or glabella, or held in or on the teeth. An explanation of the above is, perhaps, most satisfactorily given in Dr. Lucre's1 demonstration, that vibrations which fall perpendicularly on the membrana tympani produce the strongest vibrations, and hence a tuning- fork placed on the parietal protuberance, or on the side of the head, will be heard chiefly in the opposite ear. This is very distinctly perceived if both meatus are stopped, but it is equally perceptible, as any one can find out by trying upon himself, with the meatus open. The tuning-fork finds its greatest usefulness in testing bone- conduction. While it has never fully realized in this way all that was hoped for it as an aid in diagnosis, it is still the best means, and a very good one, too, of determining how much sound is perceived by the auditory nerve, through the bones of the head. Its musical nature, as well as its powerful vibrations, render it far superior to the watch as a test for the conducting power of the bones of the head, unless the ticking of the watch be made to occur with great force. But should the ticking of the watch equal in intensity the vibrations of the tuning-fork, the former could never approach the latter in musicalness. The tuning-fork is a means of comparison between bone conduction and aerial conduction of sound, in the same person. For, if the vibrating tuning-fork be held on the vertex until its note is no longer perceived by the examined, and then held before his ear, if he now perceive that the tuning-fork is still vibrating, it is fair to conclude that the sound-conducting apparatus is normal. But, if the fork, when no longer heard through the air alongside of the ear, be heard without being re-struck as soon as it touches the vertex, the conclusion is inevitable that there is some impediment in the sound-conduct- ing part of the ear. This is all the more convincing if it be borne in mind that there is being used the same note, and one, too, growing a little weaker all the time. For, if vibrations of a tuning-fork cease to be heard in front of an ear, by aerial conduction, but are able to communicate themselves while 1 Berliner Klin. Wochenschr., No. 10, 1871. 208 EXAMINATION OF PATIENTS. growing constantly weaker, through the bones of the head, the inference of great derangement in the middle or external ear— the aerial sound-conducting parts—cannot be avoided. Speech.—By hearing speech the intellectual development of the human being is accomplished. There is no sound so fami- liar and none for which all so fondly long at times, as that of our native tongue. One with good hearing can never realize the feelings of a deaf person so vividly as when traveling in a strange land, surrounded by people speaking with each other happily, gayly, and with varying expressions, but in a language unknown to the lonely traveler. Such a one falls into the posi- tion of an invalid, is treated with a kind of pity, and alas, finds himself growing a little suspicious and morose. The deaf person feels the loss of hearing the voice of others more than the loss of power to hear anything else. To recover the ability to hear the familiar tones of his friends' voices he would gladly give up all other hearing. So great is this struggle to hear, what others say, that the deaf gradually learn to understand the words of others by wratching their lips. The power to hear other sounds well, may begin to fail without the knowledge of the patient, but all his endeavors are concentrated almost un- consciously to catch the varying sounds of speech. I have known young physicians to be almost deaf to the ticking of a watch without knowing their loss, for their ability to hear speech was good. All aurists are aware that patients are constantly surprised to learn the amount of their deafness as soon as the face is averted from the speaker. The failure in hearing in this respect is often first detected by the patient in the summer time, when all are accustomed to sit on porches or in the parlor, in twilight and the dark. As the daylight fades and the faces of those around are no longer plainly visible, the hitherto apparently hearing person becomes aware that he is growing deaf. This is often assigned to the night air, but in reality it is due to the loss of vision in the darkness. The surgeon will often gain great aid by a knowledge of these facts, and also by observing how a partially deaf patient will look at the person addressed. Those of delicate sensibility soonest become aware of their defective ability to hear the voice, for speech is not only a deli- SOUND, HEARING, AND TESTS OF THE LATTER. 209 cate sound, but it is highly valued by the cultured as a means of social intercourse. Those of less sensibility are not aware of their loss of hearing for speech, for they still hear loud sounds, and even music so called, for the latter is comparatively much more powerful than the tones of speech. The value of speech as a qualitative test for hearing has been shown by Donders, Helmholtz, and 0. Wolf. But why it was that a patient could hear some words much better than others, though spoken at the same distance, was not explained and applied until Dr. Wolf, of Frankfurt-on-the-Main, published his investigations respecting the acoustic characters of the various elements of speech.1 The human ear perceives, as music, tones varying from 16 vibrations to 20,000 vibrations in a second. Preyer2 has lately placed these limits from 15 vibrations to 40,960 vibrations in a second. Blake3 has shown that the human ear, in some in- stances, distinctly hears, as musical tones, 35,000 to 40,960 vibra- tions in a second. Speech, according to Wolf, embraces only eight octaves, viz.: R. of 16 vibrations, and S. of 4324 vibrations in a second. It may be said, therefore, to lie entirely within the limits of music. Perception of High Musical Tones.—With the view of ascer- taining the power of the ear to perceive high musical tones, Dr. Blake4 has performed a series of most valuable experiments with Konig's rods. The latter are steel rods devised by Mr. Konig, of Paris, for making accurate acoustic tests with notes of high- est pitch. In order to get a clear tone, it is necessary to suspend the rods by means of loops of silk, or fine wire. To obtain the points at wrhich the threads should be attached to the steel rods, the length of the rod should be divided by 4.3. Thus if the length is 70.5, this divided by 4.3=16.4. The latter would be the distance from each end, at which the loop ofthe suspending thread should pass round the rod. Then Dr. Blake suggests • Sprache und Ohr., 1871. 2 Jena, 1876. 3 Transactions American Otological Soc, 1872-1873. » Summary of results of experiments on the perception of high musical tones. Tr. Amer. Otol. Soc, 1872. 14 210 EXAMINATION OF PATIENTS. that in order to obtain a determined intensity of tone, a small steel pendulum, swinging through an arc of 90°, be suspended to the same beam as the steel rod. If the pendulum is made to swing over the arc on which a graduated scale may be placed, the intensity of the blow can always be known and reproduced exactly, if necessary. With this instrument, Dr. Blake has found that the perceptive powder of hearing high musical tones varies with the age. At about the age of 12 or 13 years, a tone of 40,960 vibrations per second was heard 34 feet; at the ages of 18 to 20 years, the same tone was heard at distances of only 13 to 16 ft., wThile at 34 ft. only the tone of 36,864 vs. was heard. At the ages of from 28 to 30 years, only tones of 32,768 vs. were perceptible, while above the age of 50 years the limit of perception, at the same distance, had still further diminished, and in a greater variety of degree. Dr. Blake's further investigations show- ed that these changes in perceptive power were due to thickening of the membrana tympani, the latter caus- ing diminution of the power to hear the high tones. An apparent excep- tion occurs, where in addition to Konig Rod as modified by Blake. thickening, especially in the young, the membrana tympani is drawn in. The increased tension of the latter condition makes the membrana tympani more sensi- tive to high tones, and thus the thickening of the membrane is somewhat counterbalanced. In two cases of voluntary contrac- tion of the tensor tympani, the perception increased from 3000 vs. to 5000 vs., during the contraction of the muscle, above the limit of perception observed when the muscle was not contracted. Further experiments of Dr. Blake showed that when the membrana tympani is perforated, especially at the posterior and superior periphery, the ear can perceive higher notes than when the membrane is intact. This was found to be the case both when perforations had been made by disease, and after artificial perforations. SOUND, HEARING, AND TESTS OF THE LATTER. 211 In one instance, after Politzer's eyelet had been inserted into a thickened drum-head, a steel rod, with a tone of 80,000 vs., was distinctly heard 3 in. from the ear. In a later paper Dr. Blake1 bases the claims of high musical tones, to value in diagnosis, upon the following facts: " That the limit of perceptive power of the cochlea exceeds the limits of sound-transmitting power of the structures of the middle ear in their normal condition; that the structures of the middle ear in their normal condition, therefore, present a barrier as it were to the passage of sonorous vibrations above a given point; and that the perceptive power of the internal ear remaining the same, morbid changes in the middle ear result in a variation in the limit of their transmission of musical tones." This varia- tion may be either above or below a certain standard point; this point as already stated was found to be about 40,000 vs. When the membrana tympani is perforated the ear may per- ceive musical tones of 100,000 vs.; the difference between this tone and the tone given as the normal standard ma}7 be regarded " as the measure of the degree of resistance, so to speak, which the structures of the normal middle ear present to the passage of the short sound-waves of the higher musical tones." Acoustic Character of Vowels and Consonants.—The distance at which separate vowels can be heard has not yet been established, but they are endowed with the greatest strength of tone, being heard and understood at a distance at which all the consonants are inaudible. The intensities of vowels given here are such as are obtainable wiien wrords containing the given vowels are uttered. The consonants differ very greatly from each other in strength of tone, as will be shown further on. Vowel-sounds are composed of a number of beautifully har- monic over-tones, which accompany the fundamental note and strengthen that of the mouth. A good musician can hear a perfect accord when a vowel sound, specially A, is uttered with clearness, which is said by Wolf and Appunn to be most ob- servable when the sound is made in the open air, where the sound waves escape with greater precision than in a room. Dr. 1 Diagnostic value of high musical tones. Transactions American Otol. Soc, vol. i. p. 438, 1873. 212 EXAMINATION OF PATIENTS. Wolf has shown that the broad sound of A has the most over- tones, five in all, and is heard the furthest, 360 paces. The sound of Oo has the fewest over-tones, three in all, and is heard with the most difficulty of all the vowels. It can be heard distinctly 280 paces. The vowel 0, containing many beautiful harmonic over-tones, is heard nearly as far as the broad A. The German E, about equivalent to the English A, is heard 330 paces, and the English E is heard 300 paces. English I is somewhat more powerful (340 paces) than A, but weaker than the broad A or the O sound. Oi is nearly equal to E. Weakest of all diphthongs is Ou, as in out; it is a little stronger than Oo. Consonants.—Consonants may be classified according to their acoustic and physiological laws, under two heads, viz., those which are self-sounding, and those which are sound-borrowing.1 The former are such as possess a sound entirely independent of association with a vowel sound, and one that can be defined respecting its pitch, intensity, and timbre. The latter are such as must be either preceded or followed by a vowel in order to render them audible, and hence the name of sound-borrowing consonants has been applied to them by Dr. Wolf, of Frankfurt- on-the-Main. H is the weakest of all consonants when pronounced without a vowel. It is lost at the distance of a few paces. Next in strength is B, Ba being heard further than Ha. B alone is heard at a distance of 18 paces. The deeper a note is the less effect it has upon the ear. The high notes are the most valua- ble in this respect, as shown by Moos. R, with only 16 vibra- tions in a second, is not distinguishable further than 41 paces. K and T stand next; they are both heard equally well at 63 paces. T resembles pretty closely a simple note, but it has a pitch which appeals more readily to the ear, and is, therefore, heard much better than B, which is otherwise very similar to it. K is formed with relatively favorable circumstances, by means of a powerful movement of the root of the tongue. The soft F is heard somewhat further than the foregoing letters, i. e. 67 paces. S is perceived at a relatively greater distance than > " Selbsttonende" and " Tonborgende," Wolf; Sprache und Ohr, pp. 14-15. SOUND, HEARING, AND TESTS OF THE LATTER. 213 the foregoing, on account of the pitch of its fundamental note, which by its sharp character attracts the ear. " To its properties as a sibilant consonant it owes its ability to express disapprobration in public assemblies, to cry down oppos- ing sentiments, and to enforce silence. Both its moral and physical character are inharmonic." S can be heard very dis- tinctly 170 paces. Sch German, nearly equal to Sh English, is heard furthest of all consonants, because it possesses full and rich clang-tint, and is composed of three harmonic notes which predominate while the inharmonic over-tones recede; this com- posite consonant can be heard 200 paces. M and N unaccom- panied by vowels are only meaningless blowing of air through the nostrils. Mama and Nana are understood 180 paces, but at a greater distance the sounds of M and N are lost while the vowel A is still heard.1 Helmholtz has also pointed out the very noticeable fact that if in calm weather an observer be placed on some elevation near a town—a tower or a hill-top—it will be found that words are no longer distinguishable, or at best only those composed of M and N with vowels. Vowels can be heard following each other in a curious interchange and with remarkable cadences, because no consonants are heard and the other vocal sounds cannot be joined into words.2 It is thus shown that in the component sounds of speech a wide range of tests of different intensities and pitch is offered to the aurist. Such a numerous set of tests is needed in order to discover which sounds are heard best by an affected ear. One sound is not sufficient, because an ear may be unable to hear certain sounds, but comparatively good for others. Hence if only one or two sounds should be employed, as in the watch, just those sounds might not be heard as well as others. No sound-unit has ever been established, and, if it were, it would be useless, since, from the nature of the ear, such a unit would not be equally applicable in all cases. Therefore speech becomes valuable as a test because of its composite sound-nature, and also because it is ever at the command of the examiner, whose object in applying it as a test is comprehended by the patient without 1 Wolf; op. cit., p. 63. 2 Tonempfindungen, etc., p. 118. 214 EXAMINATION OF PATIENTS. any preliminary instruction. By using speech as a test an average condition of the ear can best be obtained. Whispering and Loud Tones.—Very often whispers and words spoken in low tones are heard much more distinctly by the affected ear than loudly spoken words. This is due to the damping of vowels, as shown by Wolf, whereby the consonants, which have been stated to be less sonorous than vowels, have a chance to be heard. This fact is of great importance, not only in estimating the hearing, but in addressing those hard of hear- ing. Members of a family very often pitch their voices too high, and hence confuse the afflicted one, thus gaining the idea that the individual is deafer than he really is. On the other hand, they are surprised that on some occasions he hears sounds and words spoken to others in comparatively low tones. So marked is this in those hard of hearing, that it has been said a deaf person always hears when it is especially desired that he should not. This is due to the physiological acoustic fact mentioned above, that in low spoken tones the vowels are quelled, and the consonants, being allowed thereby a better utterance, are rela- tively strengthened, and the whole word is heard better than if roared out. This damping of vowels has both its good and bad side. Do not elevate the voice too high when you wish to make a deaf person hear, but do not lower it too much, unless to a whisper, if it is not desired that he should hear. Words may be heard even when the letters composing them, spoken separately, are not heard. This is especially so for the letters B, P, T, K, and R. The reason of this lies in the fact that letters pronounced alone are really words. Thus B is really composed of sounds of b and e, as in be; P, of pea or pee ; K, of kay, while R is equivalent to sounds of the word are. It may be said very truly, that in the latter instance, R, when pronounced alone, is altogether of a phonetic value different from that when standing at the beginning of a word, as in Rab, or at the end of a word, as in Tar. Whispering.—Whispering has an advantage over loud words in testing, since the former cannot be as easily conveyed as the latter through the bones of the head to the auditory nerve. However, it must be borne in mind that in a case reported by SOUND, HEARING, AND TESTS OF THE LATTER. 215 Dr. Dennert,1 in which the cochlea had been lost by.necrosis, the normal ear, though artificially stopped up as thoroughly as possible, could yet hear whispers six feet off. Sometimes, patients hear music better than speech, because the faintest music of an orchestra is more powerful than speech, as stated by Wolf. Variable Hearing.—The hearing varies very greatly in cases ■ of movable fluid in the tympanic cavity and in some forms of aural vertigo. When such peculiarities of hearing are fully established, they may aid greatly in diagnosis. The first kind is made manifest by changes of position of the patient's head; the second form of variability of hearing comes and goes with the paroxysm of vertigo. It is probably due to alterations in the condition of the muscles in the tympanum, whereby altered tension in the sound-conducting apparatus is produced. Hearing Low Tones better than High Ones.—It is sometimes observed by patients that they hear low, bass notes much better than high. ones; as for example, in two instances, patients volunteered the information that they heard thunder much better than the chirping of crickets, and bass notes much better than high ones on the piano or organ. In testing with a watch, it was found that one giving out the deeper note was most easily heard by one of these patients ; the other was not thus tested. Experimentally, I have shown that a deep note has the advantage of high notes in cases of increased labyrinthine pres- sure. In an increase of such pressure, the stapes becomes more fixed, and it is on this small bone that the vibrations begin to grow less as the pressure within the labyrinth is increased. In such a case, it is manifest that, if vibrations from without are normally conveyed to the stapes, there they must meet with hindrance in their endeavor to reach the labyrinth. Only the more powerful sound-waves are able to overcome this obstacle and force the stapes into to-and-fro motions with the rest of the chain of ossicles. I have, therefore, thought it might be asked, could not the inability to hear high notes in some cases, while low ones are heard nearly, if not quite, normally, be construed 1 Archiv f. Ohrenh., vol. x. 216 EXAMINATION OF PATIENTS. into a sign that the stapes is impeded, either by undue pressure in the labyrinth, or by catarrhal fixation in the oval window ? That the cause of such a peculiar alteration in hearing probably does not lie in an undue tension in the membrana tympani, appears from the well-known physical fact that the tense mem- brane is more susceptible to vibrations of high notes than to those of the low. The Position and Extent of Perforation in the Membrana Tym- pani may cause variation in the hearing power for certain sounds, especially consonants, as shown by Wolf.1 Experiments with the consonant B upon defective drum-heads show that the perceptive power for this sound diminishes as the extent of the defect increases. The faintness of the consonant is most observable when it stands at the end of the word. It may also be said that defects of the membrana flaccida are attended with great deafness for all sounds, which is probably due to an impli- cation of the malleo-incudal joint. Testing the Hearing in One-sided Deafness.—In measuring the hearing for sounds conveyed through the air in cases of one- sided deafness, or of hardness of hearing confined chiefly, if not entirely, to one ear, care must be taken not to attribute to the worse ear that w7hich is really heard by the better ear, though stopped and turned from the examiner. In any case where one ear is being tested, accuracy would demand the isolation of the other. Usually, the ear not being tested is stopped and turned from the source of sound, the ear under examination being left open and turned towards the sound-source. This method will usually give at least a proximate result as to the amount of hearing in the worse ear, but in order to exclude the fact that the better ear, though stopped and turned away, hears some of the test, it will be necessary to measure the hearing in the worse ear alternately open and. stopped, in order to see what effect this stoppage will have upon the amount of hearing it is supposed the w^orse ear still retains. In the method of Dennert and Luca3,2the voice is relied upon chiefly for the test. The better ear is stopped, turned towards the source of sound, and tested, the deafer ear being alternately 1 Sprache und Ohr., 2d part. 2 Archiv f. Ohrenheilkunde, 1875. SOUND, HEARING, AND TESTS OF THE LATTER. 217 opened and closed. The difference in the hearing, if there be any elicited by this method, is set down to the worse ear. To diagnose deafness of one side, Dr. H. Knapp1 proposes the passing of a vibrating tuning-fork backward and forward, past the affected ear stopped up. If no difference in the sound of the fork is perceived as it nears the meatus, then it may be concluded that sound has reached the brain by the other ear. A plan similar to the foregoing, and one which I have used for a long time in cases of one-sided deafness, is as follows: Place the patient so that the affected ear is towards the sur- geon. Then with the finger stop the ear not to be tested. This may be done by the patient or by an assistant, preferably by the latter when great certainty is needed. Now, with the affected ear open and turned towards the surgeon, let tests of its hearing power be made. When the limit of hearing on that side is obtained, let the ear be closed as the other ear is, and then, with the affected ear still turned towards the examiner, let tests be made again. If the closure of the deaf ear causes no difference in the hearing distance already obtained, it is fair to conclude that whatever amount of hearing exists is not due to passage of sound through the external auditory canal of the worse ear turned towards the test. In such a case the conclu- sion must therefore be, that sound either goes more easily through the bones of the head on the affected side than through the meatus, to the auditory nerve (Avhich would be absurd), or that sound has reached the brain by the other ear. Also, it may be concluded that the thus aftected ear is totally deaf. If, however, stopping the ear turned towards the examiner (the ear supposed to be the deafer) makes that ear still deafer, let the examiner approach the patient and repeat the tests until they are heard once more. The second hearing of them is evi- dently due to conduction of sound through the cranial bones and the finger in the meatus, and therefore must not be mis- takenly regarded as aerial conduction. The extent of the power of the ear to hear in this latter way will be expressed in the difference between the limit of hearing the first test and the limit of the second. Thus, a patient may hear speech as far as eight feet, with the good ear stopped and turned away, and the • Archives of Oph. and Otol., 1873. 218 EXAMINATION OF PATIENTS. affected ear open. When the latter is stopped, but still turned towards the examiner, speech is no longer heard at eight feet, but it may be perceived by the patient at a distance of three feet, both ears still being kept firmly stopped. In such a case, not the former distance, but the difference between it and the latter distance, viz., five feet, must be regarded as the limit of aerial conduction by the external auditory canal, for that repre- sents the amount of loss of hearing caused by stopping the meatus. Whatever is heard just as well with the deafer ear stopped as when open, the better ear remaining stopped throughout the testing, must still be heard by the better ear through the head; but whatever is heard only with the worse ear open, the good ear being stopped, must be attributed to the worse ear. Another method of getting at the amount of hearing in a very deaf ear, or perhaps a totally deaf one for all that is known before the examination, is to begin the testing with both ears of the patient closed. Then, with the worse ear toward the sound-source, try to find out how much is heard ; after which let the artificial stoppage, usually accomplished either by the finger of the patient or of an assistant, be removed from the worse ear, the better one remaining stopped. The difference in the two results, if there is any, must be the true amount of hearing on the affected side. If there is no difference in the result, it is fair to conclude that sound con- ducted through the auditory canal to the deaf ear is not per- ceived by it. This being the case, if words repeated on the affected side are still heard, it is not due to any remnant of hearing power in the deaf ear, but rather to the passage of sound through the head to the good ear. The question might be asked, why cannot sound be conveyed to the deaf ear through the head, if it is conveyed to the better ear, which is stopped and turned away from the sound-source ? The reply would be, that an ear which, either when stopped or open, perceives no difference in sound conveyed by the meatus, is not sensitive enough to hear sound conveyed to it through the head. The Entotic Application of the Ear- Trumpet.—In order to find out which parts of the chain of ossicles are most affected in cases of sclerosis and stiffening of these portions of the middle SOUND, HEARING, AND TESTS OF THE LATTER. 219 ear, it has been proposed by Dr. Albert Bing,1 of Vienna, to substitute the ordinary means of diagnosis found in the catheter, the auscultation tube, and in the direct inspection of the mem- brana tympani, by what he terms the entotic application of the hearing trumpet. This is done by speaking through a collector of sound, one end of which is made to communicate directly with the tympa- nic cavity, through a catheter fixed in the Eustachian tube. By such an apparatus, sound-waves may be brought directly into the tympanum and made to fall immediately upon the foot-plate of the stapes, from which they are carried over to the fluid of the labyrinth and the auditory nerve. During the examination by this method, the ears of the patient are to be stopped, in order to prevent sound from entering by the external auditory canals, and, in order to prevent lip-reading, the eyes of the patient should be closed; he may then be required to repeat what he hears. According to the greater or less ability of the patient to hear by this method, Dr. Bing concludes that, 1, the stapes is entirely normal, or 2, that it is more easily movable than either of the other ossicles ; 3, that the obstacle to conduction lies only in the stapes or in it and the other ossicles at the same time, or 4, that the stapes has become anchylosed. In one instauce in which the patient heard much better by the entotic method, until a perforation in the drum-head was freed of tough exudation, when he heard better both with and without the trumpet, it was concluded that the chief obstacle to conduction of sound lay in the malleus and incus, while the stapes was easily moved. 1 Die entotische Anwendung des Horrohrs. Monatsschr f. Ohrenheilkunde, Nos. 8, 9, and 10, 1876. SECTION II. AURICLE. CHAPTER I. ORGANIC DEFECTS AND CUTANEOUS DISEASES. ORGANIC DEFECTS. Among organic defects in the auricle may be mentioned, ab- sence, plurality, abnormal position and shape, as well as partial and defective development. A partial or total want of the auricle may be congenital. This may be confined to one side, or it may occur on both sides and in conjunction with other defects of the head produced by alte- ration or imperfect development of the visceral arches. Such defects interfere more or less with the fineness of hearing. Traumatic loss of the auricle frequently occurs from accident, punishment, and disease. The treatment consists in procuring the best kind of artificial external ear; for plastic operations so far have not done much, if anything, towards giving a sightly ear in place of the lost one. Plurality and Abnormal Position of Auricles.—A plurality of auricles has been found in lower animals1 and in man. "Oasse- bohm relates a case of a child with four ears, two naturally placed, and two lower down on the neck: there were in this instance two petrous portions in each temporal bone."2 Birkett3 has reported the case of a young girl who, in addition to irregularities in her ears, had on each side above the middle 1 Especially in the Pig, Wilde, op. cit., 161. 2 Wilde, op. cit., p. 161. 3 Transactions of Path. Soc. London, 1858, vol. ix. p. 448. ORGANIC DEFECTS AND CUTANEOUS DISEASES. 221 of the sterno-cleido-mastoid muscle, a large growth resembling the lobule of an auricle, each supplied with an artery, and con- taining reticular cartilage like that of the pinna. 3Il[formations of the Auricle.^-Malformations of the auricle are generally found connected with defects or absence of the exter- nal auditory canal. The surgeon is usually consulted to know whether the malformation will interfere with the hearing of infants thus deformed, and if so whether an operation will relieve the deafness and deformity. Mr. S. Cooper1 states that he had seen a child without ears, exhibited as a curiosity in London, in whom there were no external auditory canals, but the child " could hear a greal deal although the sense was certainly dull and imperfect." There are many other cases on record of malformed auricles and exter- nal ears, and in some cases there is a very defective development of the middle ear ; yet the auricle many be deformed, while all the rest of the organ of hearing is normal. Mr. Toynbee2 in his excellent work has given an account of a paper by Prof. Allen Thomson,3 treating of malformation of the external ear and the condition of the hearing in such cases. It is there shown that in an incomplete development of the integumental part of the apparatus, viz., the auricle and outer part of the meatus, there is usually absence of the tympanic ring and consequently of the bony part of the meatus, that there is also a defective state of the cavity of the tympanum and chain of small bones, and occasional irregularity or deficiency in the development of the malar, palatal, and maxillary portions of the face and mouth. Gruber4 has stated that in deformities of such a high grade he has never found a normal auditory canal. Usually there is not a trace of one present, or at best it is a narrow and short blind passage connected with the auricle. The latter usually does not occupy a position similar to that of a normal auricle, but is either nearer the cheek or pushed downward towards the 1 Cooper's Surgical Diet., 7th ed., p. 470. 8 Diseases ofthe Ear, London, 1868, p. 14-15. 3 Edinburgh Journal of Medical Science, April, 1847. 1 Lehrbuch der Ohrenheilk., p. 275. 222 AURICLE. throat, and is movable in all directions with the neighboring skin. This is an important fact to bear in mind, if there is any in- clination to make an artificial auditory canal. Of the two cases reported by Dr. C. J. Blake,1 the following is considered by him as of great interest:— It occurred in the right ear of a girl three years old ; the long diameter of the auricle formed an angle of 45° with the vertical plane of the head ; the position of the helix was barely indicated by a slight reduplication of the superior portion of the auricle, and the antihelix represented by a slight elevation above the superior border of the concha; the whole of this portion of the auricle resembled that of the chimpanzee, or of the cases of dementia given by Prof. Laycock. The meatus was represented by a slight depression bounded anteriorly by a well-formed tragus, which latter was supple- mented anteriorly by a small cartilaginous nodule, as in the cases described by Gruber. The most interesting and important part of this history is that relating to the auditory meatus and the hearing on the affected side. Dr. Blake says: " The perception for musical tones on this side of the head seemed to be good, and the in- tegument covering the meatus could easily be depressed with a probe. "Under these circumstances an exploratory operation was advised, but, unfortunately, the patient did not return at the appointed time. The family history of the patient gave no other case of malformation, and the little patient herself was otherwise normally developed." A case of congenital one-sided bony closure of the external auditory canal with rudimentary development of the auricle, was observed by Dr. H. Knapp2 in a healthy child three months old. The auricle consisted of a slightly tortuous ridge, was two lines high and three-quarters of an inch long. "It felt rough to the touch like a healthy auricle, being undoubtedly composed of cartilage and skin. Its shape represented the rudi- ments of the helix and lobule; the other parts of the auricle 1 Statistical Report, 1652 cases of Diseases of the Ear. Mass. Charitable Eye and Ear Infirmary, 1872. 2 Transactions American Otol. Society, vol. i. p. 116. ORGANIC DEFECTS AND CUTANEOUS DISEASES. 223 were not visible. Immediately before the middle of the rudi- mentary auricle, there was a small round depression, indicating the situation of the external meatus." Upon making an incision through this depression the knife struck a bony obstruction indicating occlusion of the auditory canal by hard bone, and demonstrated the uselessness of further operative interference. The child was too young to give any information as to the condition of its labyrinth when tested with the tuning-fork. Congenital Fistula of the Ear.—This is a rare form of malfor- mation or arrested development in the ear. Cases of it have been described by Schwartze, Heusinger, Schede, Schmitz,1 and Pfliiger.2 It consists in a small fistulous opening close in front of the tragus, which may extend in some cases as far as the tympanic cavity. It may be symmetrical, as shown by Pfliiger, or in con- nection with defects in the throat, as shown by Schmitz. In the case given by Dr. Pfliiger a probe could be inserted 1J cm. without difficulty or pain. An interesting fact connected with the history of this case was that pus had been discharged a number of times from these openings, after attacks of earache. The cause of this anomaly is considered by Heusinger, Schmitz, and Pfliiger to be an arrest of development in the first visceral cleft, a view also held by Virchow. CUTANEOUS DISEASES OF THE AURICLE. There are some cutaneous diseases of the auricle and of the parts adjacent to the ear which may fall to the care of an aural surgeon ; such as erythema, erysipelas, intertrigo, frost- bite, and chronic inflammation of the skin of the auricle. Simple Erythema.—This disease is usually caused by local irritation from bites of insects, badly fitting head coverings, especially in infants, the action of the sun on the exposed ear, 1 Ueber fistula auris congenita, etc., Halle, 1873. A. f. O. B. ii. N. F. 1874, p. 301. Abstract by Jacoby. 3 Monatsschr f. Ohrenheilkunde, No. 11, 1874, 224 AURICLE. and the instillation of various nostra into the ear, or by irri- tating discharges from the organ itself. The membrana tympani may not be affected. Treatment.—In mild cases of erythema of the auricle very little treatment is demanded. If the itching and burning are great, it is best to use sheathing dressings, such as cream, ung. aqua? rosse, simple cerate and the various mucilages, an excel- lent one being quince-seed mucilage. Erysipelas.—Erysipelas of the auricle may occur as a pri- mary or idiopathic disease from local cold, or secondarily by extension of the disease to the auricle from parts adjacent to it. In the latter instance the prognosis will depend greatly upon the condition of patient and the previous condition of the ear. While erysipelas of the face and head as a rule will render hearing in any case dull, most probably by an occlusion of the auditory canal, it does not necessarily leave the hearing perma- nently impaired. Even where erysipelas attacks an ear pre- viously diseased, the bad consequences are not permanent. In the case of a young lady, 18 years old, I have seen four or five attacks of erysipelas of the face in the course of a few years. On the right side she has a chronic purulent discharge from the ear, dating from early childhood. During the time she has been under my observation the erysipelas has always made the condition of the diseased ear temporarily worse, but notwith- standing the repeated hindrances to recovery, experienced by the ear, it has gradually assumed a more healthy condition. Treatment.—The treatment of erysipelas of the auricle is similar to that of the disease elsewhere, excepting that care must be exercised not to apply such cold dressings to the ear as wTould be justifiable in the disease on the face. It is prefera- ble to apply light dressings to the erysipelatous ear, such as light gauze or linen sprinkled with flour or rice-pow7der, and to avoid cold moisture. Intertrigo.—This disease may be found in children of all classes, and in the healthy as well as the unhealthy. It is caused by mechanical irritation where the posterior surface of the auricle comes in contact with the mastoid surface. It is ORGANIC DEFECTS AND CUTANEOUS DISEASES. 225 due primarily to a certain amount of maceration of these sur- faces, which favors excoriation and chafing. Hence dryness behind the auricle must be maintained. Cleanliness of course must be observed, but too much washing is as bad as too little. The disease may also be caused by too much warmth about the head, tightly fitting caps, picking at the ear on the part of the children themselves, and by tossing or working the head about on the pillow, which of course causes the auricle to rub against the mastoid surface. The prognosis is favorable. The disease should be arrested as soon as possible in order to prevent it from passing into an eczematous condition. Treatment.—After the disease is fully established all washing of the parts behind the ear should cease, and the moist surfaces be dusted with a powder consisting of one part of oxide of zinc (Hubbuc's preferable) and seven parts of pure starch. This will form a white crust, which should be let alone until it drops off, when the surface underneath will be found to have entirely healed. Frost-bite.—In very cold winters with us, and in cold climates every winter, frost-bitten ears are not uncommon. Xo special treatment is demanded in acute cases. Care must be taken to avoid too sudden a reaction, and this is done Iry the application of ice-water or snow at first, with the gradual application of warmer water. If vesicles and subsequent excoriation occur, we must prevent the access of air as much as possible to the affected parts, bythe application of emol- lient cerates or collodion.1 In order to prevent a return in the following winter, the same authority advises that, during the summer, the auricle be carefully and thoroughly washed with cold water, to which a little alum should be added. In many cases, when nothing better can be procured, the excoria- tions, produced by the frost-bites, on the auricle, may be covered by linen smeared with ordinary glue.2 New formations of cartilage may occur throughout the entire helix and the major portion of the pinna, as a result of frost-bite, and hard and sensitive nodules may be felt in the lobe. In such a case, seen recently by the author, the skin was purplish, covered with a 1 Rau, op. cit., p. 161. 2 Ibid. 15 226 AURICLE. slight amount of branny scales, and the nodules could be dis- tinctly seen as well as felt. The nodules in the auricle in this case did not resemble the gouty deposits described by Garrod.1 They were so close together that the surface of the cartilage of the auricle had lost entirely its smoothness. At the same time, the entire auricle, especially at the more elevated nodules, was quite sensitive to pressure. Tophi, as described by authors treating of gout, do not appear to be very common in this country. Lupus erythematosus, lupus vulgaris, psoriasis, ichthyosis, comedo, acne, keloid, molluscum fibrosum, with the disease elsewhere on the body, and ringworm, may attack the ear ; but beyond the mere mention of their occurrence, it is not neces- sary to enter into a discussion or description of them here. The reader is earnestly requested, however, to bear in mind the possibility of these diseases being found on the auricle and concha, and in the auditory canal, and to become acquainted with their nature and treatment as set forth in works on derma- tology. Pemphigus Gangrenosis of the Auricle.—This disease was first described by Dr. Whitley Stokes, and mentioned by Wilde2 in the medical memoir attached to the census of Ireland in 1841. It is peculiar to Ireland, very apt to attack children on or about the ears, is very fatal, and prevails especially among the lower orders. It is said to have caused 17,799 deaths in ten years in Ireland, the truth of which, Wilde is inclined to believe. It is not known in this country, though the scars left by it have been seen by the author, in an Irish woman. Phagedena, or cancrum amis and gangrene from embolism, may be mentioned as of uncommon occurrence. Gangrene of the ears occurs in some low fevers; it may be symmetrical and associated with gangrene of the nose. It has been observed after intermittent fever by H. Fischer,3 and after typhus by Estlander.4 Gangrene of the auricle is similarly 1 Treatment of Gout, London, 1859. 2 Diseases of the Ear, American ed., 1853, p. 174. 3 Langenbeck's Archiv, vol. xviii. pp. 335-339. 4 Quoted by Fischer. ORGANIC DEFECTS AND CUTANEOUS DISEASES. 227 referred to by Patry,1 and by Barker and Cheyne.2 It is usually a very bad symptom, being the immediate precursor of death in most cases, though recovery has ensued after gangrene of the ears had occurred in typhus fever, as shown by Estlander, and by Barker and Cheyne. It is generally associated with livid and gangrenous spots elsewhere on the body. Eczema.—Eczema, both in the acute and chronic form, may be found in the auricle, and, as a disease modified by its seat in an organ of special sense, becomes of interest to the aurist. The acute form is more common than the chronic, attacks all ages and sexes, but is more frequent in children and in females. It is supposed to be connected with the phases of menstruation, and is considered by some, to be, with other symptoms, indicative of the menopause.3 In children, acute eczema is often produced artificially by uncleanliness, by their own picking at the ear, and by head coverings which fit too closely. In adults, acute eczema of the ear is frequently caused by the introduction into the organ, of improper reme- dies for earache, toothache, etc. Acute Eczema of the auricle or auricles may be idiopathic or an accompaniment of other diseases of the ear, or it may occur in the auricle from the contiguity of the latter to other parts of the head affected by the disease. The idiopathic form may appear on both sides of the auricle, or it ma}^ be circumscribed on the anterior surface. The greatest interest this disease can have for the aurist, is when it attacks the auditory canal and invades the membrana tympani. Treatment.—The treatment of eczema of the auricle will be similar to that of eczema anywhere else on the general surface, with of course the modification rendered necessary by care not to apply any remedy which, by escaping into the auditory canal, would injure the drum-head. The treatment of the acute form of eczema of the auricle should always be very simple, and the dressings, when once applied, should not be changed more than twice daily. 1 Archives Generates, 1863, i. p. 144. 2 Observations on Fevers, etc., p. 232, vol. i. See also Toner Lecture for 1877, by Wm. W. Keen, M.D. 3 Gruber, op. cit., p. 288. 228 AURICLE. Prof. Gruber has found that both glycerine and cod-liver oil, applied on pledgets of charpie, and bound firmly to the eczema- tous auricle, are of great value in children.1 The following powders will be found of the greatest benefit in acute eczema of the auricle:— R.—Flor. zinci, 5ij ; Aluminis, Amyli, aa §j. M. Fiat pulv. Another, equally useful, is as follows:— $.—Zinci ox., 3j-iv ; Amyli, 5vij-iv. M. Fiat pulv. These powders should be dusted carefully and thoroughly over the diseased auricle, and the latter should then remain undisturbed as much as possible, for, the general advice not to wash any part aftected with acute eczema, holds good in the treatment of acute eczema of the auricle. The ointment of the oxide of zinc, benzoated, is also a very efficacious remedy in eczema of the auricle. If the heat and burning become very great in acute eczema of the auricle, cold must be applied, with caution, to the diseased surface. This is best done with cloths steeped in cold water. Hebra2 has lately used in acute eczema, a salve which he calls the Ung. Diachyli, which is made as follows:— $.—01. olivse, opt. fl.fxv ; Lithargyri, §iij 3vj ; Aquae, q. s. Coque. M. Fiat Ung.3 This may be used in acute eczema of the auricle. The salve may be rubbed in with the finger two or three times daily, or it may be smeared on linen and the latter applied as a plaster. Subacute Eczema.—Should the eczema pass, as it is apt to do, into a subacute form, characterized by great swelling, • Lehrbuch d. Ohrenh., 1870, p. 292. 2 See Gruber's Lehrbuch d. Ohrenheilk., p. 294. 3 This ointment is difficult to make, requiring more than ordinary pharma- ceutical skill. That form prepared by McKehvay & Borell, Cramer & Small, and Mr. J. P. Remington, of Philadelphia, is recommended by Dr. Duhring, Diseases of the Skin, p. 188, which see. ORGANIC DEFECTS A:ND CUTANEOUS DISEASES. 229 vesicles, and fissures in the skin, the auricle should be thor- oughly rubbed twice daily, with sapo viridis, the Schmierscife of the Germans. Then the disease should be treated as an acute form. The subacute form of eczema of the auricle may be treated beneficially by the application of acetum cantharidis to the sluggish parts, and then pencilling the latter with, the follow- ing :— R.—01. cadini, flgij ; Alcohol, rl§j. This will often prevent the disease from becoming chronic. Treatment.—In chronic eczema of the auricle, the aim must be to allay irritation, and at the same time to stimulate the parts into a healthy action. Attention must also be paid to the general condition of the patient, and the internal treat- ment by means of alterative tonics, among which arsenic will be found highly efficacious, will play an important part in the management of the chronic forms of this disease. Various kinds of local treatment have been proposed for the chronic form of eczema of the auricle, among which, the best are painting the diseased parts with acetum cantharidis, nitrate of silver (gr. x-fl3j aq.), and the application of emollients, the head being kept dry and cool. It has also been proposed1 to coat the auricle with a solution of gutta-percha in chloroform, or to apply to it various forms of ointments of zinc and ammo- niated mercury (U. S. Pharm.). The ointment made of the latter, I have found most useful, as suggested to me by Dr. L. A. Duhring, of Philadelphia, in the following formula:— R.—Hydrargyri ammoniati, gr. x-xx ; Adipis, gj. M. Fiat unguentum. S. To be rubbed gently but thoroughly in. Dr. Duhring2 places the preparations of tar among the most useful remedies, after the acute stages have passed away. The use of solutions of potassa, followed by stimulating ointments, are also highly recommended. Dr. Duhring's experience has 1 Wilde and Graves. See former, op. cit., p. 173. * Treatise on Diseases ofthe Skin, p. 207-208, 1877. 230 AURICLE. been that eczema of the auricles is usually obstinate in its course. When the eczematous disease has invaded the canal, and stimulation of the parts is needed, an ointment may be used, composed as follows:— ty.—Hydrarg. ammonio-chloridi, 9j ; Unguenti adipis, gj.—M. S. Apply with a camel's hair pencil to auditory canal, once or twice daily. Another stimulating ointment is as follows:— fy.—Hydrarg. chlor. mitis, 3J ; Ung. zinci oxidi, 5j.—M. S. Apply to the external ear thoroughly, twice or thrice daily. Acute Phlegmon.—Wilde1 has mentioned a form of simple phlegmon of the auricle caused by the sting of insects, which, however, does not appear to demand treatment. Rau2 has described an idiopathic form of acute phlegmon of the auricle, which, running a severe course, with systemic derangement, rigors, etc., terminated in suppuration. Chronic Phlegmon.—A chronic phlegmon of the auricle has been described by some writers as terminating in cancer. It is characterized by a circumscribed hardening at some part of the auricle, usually the tragus or lobule, which gradually spreads, producing hypertrophy and degeneration of the entire auricle, with thickening of the skin, lymphatic exudation, and after years of suppuration the auricle is at last destroyed. In some cases death has supervened as the result of exhaustion from this disease.3 The auricle may become very large, as shown by Kriigelstein,4 as quoted by Rau, who believes this disease is an insidious form of cellulitis, with secondary scle- rosis of the skin, occurring in unhealthy subjects. The de- scription suggests epithelioma. 1 Diseases ofthe Ear, Phila., 1853, p. 169. 2 Ohrenheilkunde, Berlin, 1856, p. 163. 3 See Rau, op. cit., p. 164 Wepfe., Grundriss der Chirurgie Operat, Niirn- berg, 1825, p. 118. Conradi, Surg. Experiences, Berlin, 1830. * Ueber den Krebs am Ohr. Allg. Med. Annalen des 19 Jahrhunderts, 1827, p. 145, 152. ORGANIC DEFECTS AND CUTANEOUS DISEASES. 231 Treatment.—The treatment must be alterative, and if conside- rable hardening and hypertrophy of the auricle exist, it may be necessary to amputate, which has been performed successfully by Fischer.1 Circumscribed Inflammation of the Cellular Tissue- Circumscribed inflammation of the cellular tissue of the auricle occurs in the form of boils. In the impoverished system they may become carbuncles and produce permanent deformity of the pinna. A chronic attack of boils in the lobule has been noted by the author in a medical friend. These have occurred for years, but have rather decreased in frequency since an attack of typhoid fever. There has never been any deformity nor loss of substance in the lobule, a rather curious fact when we remember the large amount of suppuration that has occurred from the small affected spot. The matter discharged from these boils, wThich usually dis- charged themselves on the posterior surface of the lobule, had a peculiar odor resembling that of Valerian. Cornu Cutaneum Auriculae.—Horny growths are occa- sionally found upon the human auricle. Dr. A. H. Buck2 observed a case of this nature in January, 1871 ; it was a blunted horn-like protuberance, three-fourths of an inch long, and nearly as broad at its base; it sprang from the upper and posterior part of the left helix. It was whitish in color at its base, but gradually grew quite browmish at its summit, which was more or less jagged in appearance. It was distinctly striated, the markings running in a slightly divergent direction from the summit to the base. At the ex- tremity and in the middle portion it was hard like horn, but near the base it could be easily compressed, though yet com- paratively hard. The line of demarcation between the growth and the normal skin was very abrupt. It was not a source of pain to the patient, nor was there any tenderness on pressure. The growth was cut off, by two incisions along either side of 1 Rau, op. cit., p. 167. 2 Transactions of Amer. Otolog. Soc, 1871, pp. 18-19. 232 AURICLE. the base, the fresh edges approximated, and the wound dressed with lint. Union took place by granulation, and at the end of the third week scarcely a trace of the operation was visible. I saw, some time since, in the Philadelphia Infirmary for Diseases of the Ear, a case of horny growth on the upper and outer portion of the helix of the left ear, in a large, strong man, forty-five years old, wiiose occupation obliged him to expose himself to all kinds of weather on the river. The growth was smaller than that described by Dr. Buck, and was not discolored on its outer edge. It caused no annoyance, but the patient had commenced to pick it and it was growing larger, Avhen the man disappeared from observation. The middle ear on the same side was affected by a chronic purulent discharge, of slight amount. Secondary Syphilitic Eruptions. — In a monograph on syphilitic diseases of the ear, Prof. Gruber says he has never met with a primary sore in any part of the ear. He has, however, frequently seen secondary eruptions on the various parts of the ear, and has observed that particular portions of the external ear favor certain forms of eruption, as, for example, the point of insertion of the auricle and the lobule is most liable to a papular eruption, while the other parts of the auricle most frequently show an exanthematous eruption. Squa- mous eruptions, too, are found on the auricle, rather than in the meatus. These diseases of the auricle do not, however, interfere with the hearing to any marked extent, and belong rather to the province of dermatology. Syphilitic ulcers and warts on the auricle I believe are rare. They are certainly not often recognized and described. Tubercular Syphiloderm.—An infiltration of the syphilitic materies may be diffused throughout the skin of the auricle, or it may occur in the form of tubercles, varying in size from that of a split pea to that of a cherry. The latter may coalesce and thus form a general infiltration. The posterior part of the auricle is more likely to be attacked first than any other point, the spot most liable being the point of junction between the auricle and the head. This disease manifests itself any time after the first year of the inoculation has passed. It is most ORGANIC DEFECTS AND CUTANEOUS DISEASES. 233 apt to occur in from twTo to ten years after the primary sore. I have recently observed a ease of this disease of the auricle under the care of Dr. L. A. Duhring. In this instance, there first appeared a circumscribed, infiltrated lump on the posterior surface of the auricle, which gradually increased, until it has diffused itself throughout the tissues of the pinna. It was slightly elevated above the general surface of the auricle, of a deep reddish color, painless, and there was no itching in the growth; the latter was inclined to run a slow course. In the space of a month or six weeks, the infiltration had diffused itself throughout the greater part of the auricle, and somewhat over the mastoid portion. The thickening and deformity of the auricle had become considerable, the groove behind the auricle was obliterated, and the appendages assumed a firm, thick feeling. This condition lasts for some weeks, then soften- ing and ulceration ensue, the latter beginning in some natural groove or depression. The ulcer varies in size, shape, and depth, its base is reddish and covered with a yellowish or grayish puriform matter. The rate of ulceration varies according to the general condition of the patient; the auricle may be de- stroyed in the course of a few months. There is still no pain, the discharge is more or less offensive, usually the latter to a marked degree. Differential Diagnosis.—This disease of the auricle is to be diagnosed by its history and by other manifestations of syphilis in the skin elsewhere, as alopecia, tubercles in the skin, scars, and a general syphilitic cachexia. It might be confused with epithelial cancer, from which, however, it may be known by its history, course, and objective symptoms. In the cancerous dis- ease there is ulceration at the outset, wiiereas, in syphilis, there is first the well-marked deposit and subsequent ulceration. In cancer, there are well-marked everted edges to the ulcer; in syphilis, there are none. The secretion will offer another point of differential diagnosis, since in cancer it is thin, watery, bloody, and scanty, whereas, in syphilis it is thick, yellowish, and copious. In cancer, furthermore, there is pain, while there is none in the syphilitic ulceration. The odor in syphilis is more offensive than in the cancerous disease. In the latter affection, the ulceration spreads peripherally from a single point; in syphilitic ulceration the breaking down is apt to 234 AURICLE. occur at more than one point, It may always be known from eczema by the presence of deeper ulceration. Syphilitic ulcera- tion mis;ht be confounded with lupus vulgaris, from which, however, it is to be distinguished by the history, lupus being more chronic, and the ulceration occurring at various points over the surface, but unattended by discharge. In lupus, a patch of varying size, from that of a pea to that of a small coin, first appears, being covered with small papules and tubercles from the size of a pin-head to that of a split-pea. These, in time, break down, and slowly ulcerate, are accompanied by a slight crusting and scaling of the epidermis, and characterized by marked cicatricial tissue. The treatment, of course, is indicated by the syphilitic nature of the disease. Idiopathic Herpes Zoster Auricularis.—At the end of inflammatory processes in the deeper structures of the ear, groups of herpetic vesicles and pustules appear upon the auricle or very close to it. These may be regarded, in a general way, as favorable symptoms, since they usually appear at the termi- nation of disease in the deeper parts of the ear. In the same way, herpetic patches appear on the auricle in cases of widely diffused facial herpes. But an altogether different state of things is found in cases of idiopathic aural herpes, which is developed only on the structures of the ear.1 According to Prof. Gruber, this disease belongs to the greatest of rarities, for in 20,000 cases of diseases of the ear, he has observed only 5. This disease attacks not only the parts of the organ of hear- ing supplied with true skin, but recently, Prof. Gruber has observed, two cases in his clinic, in which, most probably, the herpetic disease extended to the drum-head and the cavity of the middle ear. Herpes zoster auricularis, like herpes zoster in other parts of the body, manifests itself as an acute skin disease, accompanied by fever, and is characterized by the formation of vesicles and bullae, which appear in groups and are attended with severe pain. 1 Die Blaschenflechte am Ohre., Monatsschr. f., 0., Mai, 1875, by Prof. Gruber. ORGANIC DEFECTS AND CUTANEOUS DISEASES. 235 The pain in these cases of aural herpes exists usually many days, sometimes as long as two weeks, before the eruption occurs. In a case which came under my observation, recently, the patient stated that he was liable to severe earache and pains about the ear, which always terminated in a week or ten days by u an eruption of blisters," which I fully verified during one of his attacks. In this case, the eruption was confined to the meatus and tragus. The pain is not always limited to the spot where at last the vesicles appear, but spreads out in different directions from the eruptive spot. Nerves Implicated.—According to the investigations of Gruber, the nerves affected are the auricularis magnus, from the anterior branch of the third cervical; the auriculotemporal, from the third branch of the trigeminus. He further states, that severe pain is usually complained of along the side of the neck and auricle, and the eruption appears much more frequently on the anterior surface of the auricle than on the posterior surface or in the auditory canal. Even in these favorite spots the vesicles and bullae are more numerous in the tract supplied by filaments of the auricular branch of the pneumogastric nerve, and thus can be explained the fact that the eruption is more copious on the superior and anterior surface of the auricle than in any other part of it, and also wrhy the posterior surface of the auricle remains almost entirely free. Perhaps the disease stands in close relation to fibres of the sympathetic connected with the nerves already mentioned as implicated in this affection, as was suggested by Gruber. The cause of this disease of the external ear is most probably clue to that which produces the disease in other parts of the body, viz., impoverished blood and consequent depraved inner- vation. Symptoms.—Fever precedes the eruption, and in the graver cases may continue after the eruption has made its appearance, for the latter may come on in crops, with intervals between them. In one case given by Gruber, the fever continued thus twenty days in spite of all that was done. The crops of vesicles may succeed each other at the same points on the auricle, and the latter set will prove the most painful, since they produce deeper ulcers. 236 AURICLE. The skin of the helix and of the fossa naviculars is most likely to be attacked with the severest eruption. While herpes ofthe auricle does not present any features of difference from that of the disease elsewhere on the surface of the body, it has decidedly peculiar features when found in the auditory canal. When herpes appears in the auditory canal, the hearing is diminished and subjective noises are heard. The hearing returns slowly after all the herpetic symptoms have disappeared. The membrana tympani is affected in some cases, according to Prof. Gruber, and then the deafness is great, and there is great sense of constriction in the head. After the vesicles rupture, the disease amounts to superficial otitis externa diffusa. Prof. Gruber has scarcely a doubt that herpes occurs in the mucous membrane of the middle ear, basing his supposition upon the views of Bertholle1 on herpes of the soft palate. The prognosis of herpes zoster auricularis is favorable. While the ulcers left by it on the auricle may last for many weeks, the usual duration of the disease in its ordinary phases is from twTo to three weeks. Previous to the publication of Prof. Gruber's paper on herpes auricularis, Dr. J. Orne Green, in a paper on ': Neuralgia in and about the Ear,"2 alludes to a case of herpes zoster of the small nerves supplying the helix, which he observed in a patient of Dr. 11. F. Damon. " There was a well-defined herpetic eruption over the anterior surface of the helix, which had been preceded for some days by considerable remittent pain in that part, which disappeared on the appearance of the eruption; in a few days the vesicles dried up and the disease had subsided." He also alludes to herpes zoster of the nerves supplying the tragus and meatus, and quotes from the case of zoster of these parts published by Dr. Anstie :3 " The disease began with acute pain in front of the tragus, recurring regularly four times in the twenty-four hours, and darting up into the meatus, the maxillary articulations, and on the side of the head; there was no tenderness on pressure or abnormal appearance in the ear; a point douleureux existed just in front of the tragus. On the ninth ' Herpes guttural en general, etc. L'Union Med., 65, 68, 70, 1866. 2 Transactions American Otological Society, 1874. 3 Practitioner. ORGANIC DEFECTS AND CUTANEOUS DISEASES. 237 day the pain began to diminish, and on the thirteenth, herpetic vesicles appeared on the auricle, which from irritation became ulcerated and very susceptible to cold, which set up the old neuralgic pain ; on the twentieth day all symptoms had disap- peared."1 Herpes Zoster ofthe Tragus.—I recently saw in a young lady, 18 years old, under treatment for slight pruritus of the external auditory canals, a very well-marked instance of herpes zoster of the right tragus. Sharp pain for several days, quite intense at times, preceded an eruption of vesicles, which finally became pustular, and then desiccated, without forming ulcers. The patient was pallid, though apparently strong and active. Treatment.—The treatment of this disease consists in the greatest attention to the general condition of the patient, and in local applications which will tend to prevent destruction of the deeper parts. Preservation of the vesicles is much more easily accomplished on the auricle than in the auditory canal. In the latter region, the tendency appears to be not to form crusts, but the vesicle soon bursts and a purulent discharge is then set up with considerable pain. In such a case, Gruber uses a solution of sulphate of zinc. In a second instance of this disease in the auditory canal, the same observer punctured the vesicle, leaving the epidermis as a protective covering ; but even in this case the treatment had to be supplemented by the use of solution of zinc. Artificial opening of the bullae on the auricle appeared to be followed by a much better result. The small, shallow ulcers, which form in the latter case, are cured by the use of simple cerate. Where the pain is great, diachylon salve, to which tincture of opium is added, has been found of the greatest bene- fit ; the salve being smeared on linen and applied to the in- flammed spots. The treatment recommended by Dr. Anstie in the case referred to (p. 23G) consisted in hypodermic injections of one-sixth of a grain, twice daily, in the region of the auriculo-temporalis, pro- tecting the painful external parts from the air by coating them with collodion, and the painful parts of the auditory canal by 1 J. O. Green, loc. cit., p. 569. 238 AURICLE. means of warm simple ointment or tallow, keeping the meatus closed by cotton. He also thinks counter-irritation, by means of mustard or cantharides over the occipital triangle, might prove beneficial by reflex stimulation. CHAPTER II. MORBID GROWTHS AND INJURIES. MORBID GROWTHS. The auricle may be the seat of various morbid growths, such as cysts, angioma, vascular naevus, fibrous tumor, sarcoma, and epithelial cancer. Xew formations of cartilage sometimes appear after frost-bite ofthe auricle, giving origin to numerous small, hard, and sensi- tive nodules, which may be both seen and felt throughout the cartilaginous structures of the pinna, (p. 225.) Cysts.—The simplest growth on the ear is a cyst. That form of primary cyst known as atheroma, developed in the subcutaneous tissues, may attain a very large size, in some in- stances reaching a diameter of several inches. Its growth is slow; in the concha there may be found the variety known as sebaceous tumor. In both forms, inflammation may occur, and a natural cure ensue. Treatment.—These growths should be extirpated by the knife, and their sacs cauterized. Angioma.—Angioma or the formation of new vessels, espe- cially the cavernous variety, may be found in the auricle. The origin of such a growth may be in the auricle, or may spread to it from neighboring tissues. These growths may present re- markable as well as threatening appearances in some instances, as has been shown in a case related by Dr. Chimani.1 In this instance the tumor first showed itself, shortly after the birth 1 " Aneurisma cirsoideum." See Blake's Report: American Otological Society, 1874. MORBID GROWTHS AND INJURIES. 239 of the patient, a strong, healthy boy. The new growth was at first 2 cm. in diameter, in front of the left ear, and of a soft consistence and bluish color. By the time the patient was five years old, the tumor had become as large as a walnut, from which time until he was fourteen years old the growth increased rapidly in size, and one year later, when brought to Dr. Chi- mani, at the Military Medical School of Vienna, the Josephe- num, the tumor included the greater portion of the left half of the scalp, was soft, elastic, slightly fluctuating, painless, pulsated distinctly, and could be diminished in size by pressure. The skin covering it was bright red, and of a higher temperature than the surrounding parts. Angioma of the lobule only, has been observed and reported by Dr. Charles J. Kipp.1 In this instance the growth occupied the left lobe of a man fifty years old, and seemed to have been caused by a frost-bite of the ear, twelve years previous, at which time he noticed a bluish spot on the outer side of the lobule of the left ear. Vascular Naevus Maternus.—That form of vascular growth known as " mother's mark" may involve the auricle, together with parts of the adjacent cheek and neck. In a negress thus affected, the lobule and lower half of the helix were especially large and liable to engorgement, while the general appearance of the auricle was elephantine and grotesque. All such vascular growths are painless, but are liable to feel hot and heavy after exercise. The rest of the auricle may be somewhat hypertro- phied, and if the growth invade the external auditory canal, the hearing will be impaired. Their vascular nature is very appa- rent by their color, their temperature, and compressibility, as well as by the pulsation which may be felt with more or less distinctness in all of them, and by the murmur which may be heard in some of the larger ones, as in the case reported by Chimani. In the latter instance the subjective symptoms were aggravated by the fact that the auditory canal was greatly implicated in the growth. There were headache, hardness of hearing, tinnitus aurium, and sensations of heat and beating on the affected side. Treatment.—The treatment of these vascular growths must 1 Transactions American Otological Society, 1875. 240 AURICLE. always be modified by their position in or about the auricle, and by their size. The treatment of angioma of the lobule of the auricle is com- paratively simple, but treatment of larger growths involving the entire auricle and surrounding parts, and extending into- the auditory canal, becomes of the greatest importance. It is even questionable whether heroic measures are ever justifiable in the latter instance. In removing angioma of the lobule, the method followed by Dr. Kipp1 is probably the best. I have used it with slight modifications, with entire satisfaction. It is to fasten the lobule in an ordinary entropion forceps, to control the hemor- rhage, and then make an incision parallel and close to the lower border of the lobe. The skin should then be dissected off the tumor, and when the latter is fully exposed, the knife should be carried behind it, and its connection with the subcutaneous tissue severed. Healing by first intention usually ensues, and the lobule heals without any deformity. For the cure of angioma, especially the larger forms, Gruber2 has recommended various forms of cauterization, vaccination, the application of diachylon plaster and tartar emetic (3ij-gr. xviij),3 the subcutaneous injection of liquor ferri sesquichlorati, and acupuncture. He gives the preference, however, over all these, to rapid extirpation of the new growth, and in order to prevent the necessarily copious hemorrhage, recommends liga- tion of the large vessels supplying the parts or the use of the galvano-caustic. Subcutaneous injections of chloride of iron were used by Chimani in the case referred to, with moderate success, but not enough to warrant the risks of inflammation and hemorrhage. The danger of the latter, as well as of sloughing, should deter the surgeon from adopting any form of treatment which would be likely to produce such results. Fibrous or Fibro-sarcomatous Tumors of the Lobule.— Tumors of various sizes have been found on the lobule as the result of piercing this part of the ear for the purpose of wearing ear-rings. 1 Loc- cit- 2 Op. cit, p. 409-410. 5 Zeissl: quoted by Gruber. MORBID GROWTHS AND INJURIES. 241 Gruber states that he has seen two cases in children, in whom small tumors, the size of a pea, appeared on both sides after the piercing of the ear several years before. In his opinion these tumors had originated from granulations which, springing from the hole in the lobule, had developed on their free surface skin and then become stationary. These tumors are composed, according to Billroth, of spindle cells and connective tissue. A similar variety of tumor has been observed among negroes, by several writers,1 and is attributed invariably to wounds in- flicted by the piercing of the lobule, or the tearing consequent upon the enormous rings the lobule is obliged to support. Some years ago, I observed two large tumors of this variety in a young and very fat negress (mulatto). There was no his- tory of the lobules ever having been torn by the weight of her ear-rings, which Ave re very large, nor of any wounding of the parts by the act of piercing. In this case it seemed that the growths had been brought about by the Aveight of the orna- ments. One tumor was as large as, and shaped like, an English walnut, with a large chestnut laid on it, and the other tumor was as large as the largest chestnut. I removed both tumors, and exhibited them at the Pathological Society of Philadelphia, where, in the remarks Avhich folloAved from the members, it appeared that these tumors of the auricle, apparently produced by the improper Avearing of ear-rings, had often been observed in this city, in negroes, and that they had usually grown again after removal, but the subsequent groAA'ths were just as benignant as the first. Their microscopic character Avas similar to that giATen by Billroth to the tumors described by Gruber. This peculiar tendency to benignant recidives has also been noted by Dr. P. F. Weir, of New York City; Dr. Bertolet, of Philadel- phia, and many others. Sarcoma of the Lobule.—M. Roudot2 has described a case of sarcoma of the lobule, in a peasant woman 42 years old. The tumor occupied the right lobule, was soft and ovoid, 5 mm. long, 1 Langaard, Wiener Med. Wochenscbrift, 1869.. M. J.. Bramley, Transac- tions of Medical Society of Calcutta, vol.vii., Saint-Vel,. Gazette des Hopitaux, 1864. 2 Gazette Med. de Paris, 1875, No* 26> 16 242 AURICLE. 3| mm. broad, and 8 mm. thick. It grew very slowly for twenty years; during the patient's fifth pregnancy, it developed very rapidly and included the entire lobule. The tumor appears to have been painless, for the most part, but sometimes during her menses the patient would complain of a burning pain in the auricle of the affected side. In addition to the entire lobule, the tumor also included part of the tragus. The new growth was reddish and flat, Avith some eroded spots ; on the hinder edge there was a pretty large ulcer: a second, smaller ulcer extended from the under part of the tragus out upon the skin of the cheek. The organ of hearing was otherAvise normal, and there were no glandular enlargements. The lobule, together Avith a small part of the tragus, was amputated, and the wound did well for several weeks, when the patient voluntarily left the hospital. Glandular Hypertrophy of the Lobule.—After inflamma- tion of the skin ofthe lobule ofthe auricle, there may remain a chronic hypertrophy of the glandular structures, of a nature similar to those chronic enlargements met Avith in the cutaneous structures elsewhere in the body, after being invaded by inflam- mation. This is fully illustrated in the following case :— Bridget G., age 22 years, a seamstress, states that at thirteen years of age she had an attack of erysipelas of the scalp, which involved the auricle to a marked extent. The auricle remained inflamed for six AATeeks, but then gradually lost all SAvelling, excepting at the lobule, which has remained about twice the natural size ever since. There has never been any return of the erysipelas of the scalp. At the time of first examination, the lobule, besides its enlargement, presented a livid, reddish hue, was shiny, scaly, slightly erectile when manipulated, but not sensitive. Its surface usually presented a flaccid appearance, like a partially withered grape. Treatment—The under cutaneous edge of the lobule was dissected up for a quarter of an inch, and then a V-shaped inci- sion was made, including the growth on the lobule. There was considerable bleeding from two or three spirting arterioles, which was finally controlled by ice. The edges of the cut were held together by a stitch; the wound healed by first intention, and without a trace of the incision. MORBID GROWTHS AND INJURIES. 243 The tumor thus excised, I submitted to Dr. Morris Longstreth, Pathologist to the Pennsylvania Hospital, in Philadelphia, who has kindly made most skilful sections, and written the folloAving descriptions of the microscopic appearances of the tumor:— " The tumor shows varied histological and histioid elements ; the preponderating constituent is an ill-developed epithelial cell, resembling the squamous variety and having a great diversity of outline. " First of all can be shown the elements of normal skin, the papillee with the covering corneous layers, and the hair-bulbs. There can be seen, in the deeper parts, the subcutaneous con- nective tissue, in which in places the vessels are large and numerous; around these vessels the fibrous tissues are denser and more abundant than usually seen in these parts; this fibrous tissue forms a sheath to, or a canal in Avhich, the vessel is distributed. In and around the sheaths of the vessels are seen, in many places, deposits of adipose tissue, arranged in lines parallel to the main trunks and also following some of the smaller branches. So far, the appearances shown in the micro- scopic sections correspond to the normal histological elements of the skin, the papillary layer and the hair-bulbs seem normal, whilst the deeper layers are hypertrophied or hyperplastic; the connective-tissue parts appear overloaded or crowded with granular (or cellular) elements. No distinct cells can be isolated here, and the structure altogether presents a very con- fused picture. " Between the dermic layers and parts further removed from the surface (viz., the parts which seem to constitute the tumor- mass proper) is a defining line; the line is not constituted of a bounding or limiting membrane, such as to be described as a capsule or basement-membrane; but there is to be seen a distinct differentiation of the one part from the other. This condition is Avell marked in some specimens. " The inner area shows the same confusion or want of distinct- ness of arrangement. The cells approximate likewise to an epithelial type; some appearing like ill-formed or undeveloped squamous epithelial cells; others resembling young nuclear (embryonal formative) elements found in the loAver strata of all membranous tissues; others again have the shape of columnar cells (perhaps this form may be due to close packing); still 244 AURICLE. others appear of an elongated or fusiform character, or else as rounded cells of small size with bipolar filiform appendages of great tenuity. In all this inner area there is no trace of blood- vessel structure, nor of a stroma or intercellular network. There is no appearance of stroma of any kind, save that of the filiform cell-appendages. " The nuclei of all these cells are of small size, and in a majority of instances so obscured by granular or fatty elements as to be scarcely visible. In some instances the cell-shapes, but not the cell-arrangement, approximate to that of the small spindle-celled sarcoma. This character cannot be maintained as the nature of the growth. There is no one type presented in such a degree as to lead to the classification under any histioid group. " The only solution which presents itself, and that a problematic one, is that the new growth belongs in the main to the glandu- lar structure, and with this has taken place a (sarcomatous ?) growth in the surrounding connective tissue; that, under the erysipelatous irritation to Avhich the lobe of the ear Avas sub- jected, in the first instance, some one or more of the glands became ectatic from the swelling and closure of the duct; and that, instead of its contents undergoing the accustomed degene- ration, the consequence ofthe erysipelatoid hypersemia, started by the erysipelas and maintained, in part, by the ectasy of the gland, there ensued an hypertrophy or hyperplasia especially of the underlying, more than of the superficial tissues. In other Avords, we have taking place an inflammatory new formation, in which especially participates the connective tissue, and this neAv-formed connecti\'e-tissue element has maintained, to a high degree, its hypervascular character (even to becoming somewThat erectile); and that, in this new growth, mixed elements share in the occu- pation of the territory; on the one hand, cells which present a type tending to the epithelial character, on the other hand, coming out more conspicuously in the deeper parts, cells Avhich in the fusiform character, verge towards the embryonal cells of a connective-tissue groAvth and give appearances calling to mind the sarcomatous new formation. "There is,, however, another element or character present which I cannot wholly pass over, viz., the glandular element. Not only is there to be seen the passing by insensible gradations from the papillary layer in Avhat wTe may regard as a part purely, MORBID GROWTHS AND INJURIES. 245 or nearly so, of subcutaneous connective tissue (however much this may be changed by overcrowding of cells), but this again passes over into an area of cells in Avhich there can be seen no stroma cells, some of which are columnar in character, that may well be held to have to do Avith the recess of a gland in the condition of ectasy. The only supposition under which the glandular participation in the neAv groAvth, as a Avhole, is tenable, is that the gland elements, and especially their secretion, under the influence of the permanently increased hypersemia, did not tend, as is their wont, to retrograde metamorphosis, in spite of the gland becoming ectatic and thereby retaining its secreting contents. Also, it must be evident that the inflammation-dis- turbances have something to do in producing a permanent alteration in the function of the affected glands—not a very diffi- cult supposition, and quite within the range of experience." Epithelial Cancer.—Epithelial cancer of the auricle has been described by Gruber,1 Wilde,2 Kramer,3 Toynbee,4 De- marquay,5 J. Orne Green,6 Gustav Brunner,7 T. Bryant,8 and others. It is said by Gruber to be the only malignant disease Avhich occurs in the auricle primarily. It generally appears as a small nodule or Avart in the skin of the auricle, which, being picked at in most cases, soon is found to be covered by yellowish scabs, the result of the hardening of a scanty discharge from the new growth. Beneath these crusts there is found an ulcer, with a not veiy rough base, somewhat disposed to bleed, and the edges of Avhich are hard and uneven. After a rather slow destruction of the superficial tissues, the deeper structures of the ear may be invaded. The auricle may be destroyed in this way, and then the deeper parts of the ear become the seat of the cancerous dis- ease. There is usually some pain, but it is not invariably severe; in some cases, however, it may be intense, as shown by Brunner. ' Ohrenheilkunde, p. 416. 2 Diseases of the Ear, p. 208. 3 Op. cit., p. 204, quotes Fischer, 1804, " Krebs am Ohre," and Kriigelstein, 1827, Allg. Med. Annalen des 19 Jahrhunderts. 1 Diseases ofthe Ear, p. 24. s Gazette des Hopitaux, Sept. 30, 18G9. 6 Transactions American Otological Society, 1870. i Archiv f. Ohrenh. Bd. v. p. 28. 8 Med. Times and Gazette, London, Jan. 6, 1872. 246 AURICLE. Wilde alludes to chimney sweep's cancer of the external ear, which is, however in no way peculiar excepting as possessing large amounts of pigment. The chronic inflammation of the cellular tissue of the auricle, alluded to by Kramer, is in all probability a description of cancerous degeneration of the appendage. Epithelioma of the auricle may interfere greatly Avith the hearing, the interference being proportionate to the advance of the disease into the auditory meatus. I have seen but one case of this disease in the auricle, and that occurred in a negress, fifty years old. She stated, when I first saw her, that the growth on the ear was about six months old, and had been caused by a bloAV on the auricle, from her son, Avith a loaded cane. I found the meatus almost entirely occluded by the growth, Avhich appeared to have started from the region of the tragus, and had progressed rapidly inward, on the superior Avail of the auditory canal, producing also some induration outward toward the zygoma, its entire size being about that of a small English walnut. The discharge was bloody and purulent, several drachms daily in amount, not very offensive, but of a peculiar odor. The ulcerated surface of the tumor pointed inward, filling up the auditory canal. The hearing Avas reduced to almost nothing. There had been no disease of the ear, previous to this, according to the woman's statement, which appeared to be reliable in all respects. Excision of the growth was advised, as it had groAvn rapidly from a Avell-defined centre, but the patient refused, and soon after disappeared entirely from my notice. Dr. Gustav Brunner,1 of Zurich, observed a case of primary epithelial cancer of the ear, in a female 56 years old, which proved fatal in the course of the year. The health of the Avoman had been good up to the time when a slight discharge came from the ear; previous to this there had been some itching in the ear, and she had scratched the organ Avith a hairpin, but there had been no deafness. For the slight discharge, she subjected herself to some kind of water- 1 Archiv f. Ohrenh., Band v. p. 28. MORBID GROWTHS AND INJURIES. 247 cure douche on the ear, and this was followed by intense earache and facial paralysis. Granulations in the mean time sprang up in the ear, Avhich upon manipulation bled freely; pain in the ear became intense and constant, and, as on consultation with Prof. Billroth, Dr. Brunner concluded that the morbid growth had already reached the inner Avail of the tympanum, no operation was advised. The ear Avas kept carefully cleansed, and the pain was eased by anodynes as far as it Avas possible. The auricle was at last dissected loose by the disease, and at several spots about the ear there was loss of substance. There was no post-mortem examination permitted. In the early stage of this case, pain was the chief diagnostic difference betAveen it and one of polypus or granulations in the ear. Microscopic examination of a piece of the granulating mass in the meatus revealed the true malignant nature of the growth. Treatment.—The only beneficial treatment of epithelioma of the auricle is immediate excision of the growth, even if to do this it is necessary to amputate the entire pinna, as was done by Dr. Thaxter, in the case reported by Dr. J. Orne Green.1 The hemorrhage which must naturally occur is to be controlled in the ordinary Avay by ligatures. Healing may be slow, and in those cases in Avhich the entire auricle has been cut off close to the skull, the granulations must be closely Avatched and prevented from closing up the external auditory meatus. This is best done by keeping some form of tent in the opening of the canal and by touching the granula- tions with caustics or by stimulating washes. The treatment will be eminently successful if the cancerous disease has not extended to the meatus and the drum; in the latter instance the disease may have advanced too far to be controlled by surgical interference. ■ Othematoma.—Othsematoma, or blood-tumor of the ear, is characterized by congestion and heat in the auricle, and a rapid effusion of blood betAveen the cartilage of the auricle and the perichondrium. The tumor, in the course of a few hours or a day, attains the size of a bean or an egg, the color ofthe auricle may remain natural or become purplish, and though the tumor 1 Loc. cit. 243 AURICLE. is somewhat hot and dense, fluctuation can be detected in it. There is some burning pain in the new growth, with a feeling of weight and distention. The earliest manifestations of the disease are rapid, but after the tumor is fully formed, it may remain apparently indolent for days or even Aveeks. At last it may rupture spontaneously, the most frequent mode of disap- pearance, or its contents may coagulate and absorption Avithout rupture take place, causing considerable permanent deformity, but much less than wiien the tumor ruptures spontaneously or is punctured artificially.1 Its occurrence is more frequently unilateral than ambilateral, but an attack on one side may be Fig. 62. Othematoma 1, and the Resultant Defokmity 2. (Gruber.) folloAved by an attack on the other,2 the lobule is never attacked in this disease of the ear. In an account of twenty-four cases of this disease, by E. R. Hun,3 sixteen Avere unilateral, but in four cases the disease on one side was succeeded by the disease 1 E. R. Hun ; American Journal of Insanity, p. 23, 1870. 2 Laycock, case of Othematoma under care of Mr. J. Hutchinson, Med. Times and Gazette, Dec. 1862, p. 603. 3 Op. cit., p. 17. MORBID GROWTHS AND INJURIES. 249 on the other, the first haematoma subsiding usually before the second ear Avas attacked. The disease is more common in males than in females, only one of the above twenty-four cases being of the latter sex. Dr. I. Ray has informed me that he has never seen this disease in females, whereas he has constantly met it in males. He furthermore states to me, that, when in charge of insane asy- lums, he has constantly had cases of othsematoma on hand, two or three at a time in old cases of chronic dementia, a notice- able feature of whose malady is their entire harmlessness and docility. So great is this latter characteristic, that they are made kind of under-nurses in the asylum, which fact Avould tend to prove that the disease in them is caused neither by blows nor falls, as they are not likely to be struck by others, and are per- fectly able to take care of themselves. Etiology.—This disease of the auricle has been the subject of great discussion, as to its cause, nature, and significance. For- merly it Avas considered entirely the result of violence, but later Avriters have denied its purely traumatic origin, and have given to it an important significance, inasmuch as they have described an idiopathic A^ariety occurring most frequently or only in the insane,1 asserting as its cause a disease of the brain, some authori- ties even localizing; the exact seat of the cerebral disease in the restiform bodies.2 Others, while admitting its most frequent occurrence in the insane, still cling to the idea of its purely traumatic origin, being of the opinion that the Aveakened and often helpless condition of the insane, renders them most liable to \iolence to the auricles.3 In all probability there are tAvo4 distinct forms, the purely traumatic and the purely idiopathic: the first seen in well-knoAvn cases of violence to the auricle, as in boxers, and the insane Avho have been beaten by their keepers, themselves, or each other; and the second, so frequently seen in the paralysis ofthe insane, and in diseases of the restiform bodies as proven by experimental irritation of them in rabbits. Even in cases of insanity where 1 E. R. Hun ; American Journal of Insanity, vol. xxvii. 1870. 2 Brown-Sequard, Lecture in Univ. of Penna., Oct. 10, 1872. 3 Thurnam and Toynbee ; Toynbee on the Ear, London, 1868, p. 21. Von Troeltsch, English Transl. 1869, p. 50. 4 Gruber, Lehrbuch der Ohrenheilkunde, Wien, 1870, p. 281. 250 AURICLE. the latter variety is found, the first variety has been observed too, but the difference of the two forms is very apparent. It is also asserted that the purely idiopathic variety has been observed in the perfectly sane.1 Both Schwartze and Wendt have ob- served such cases.2 But even granting that at the time of the occurrence of the othsematoma in these cases the subjects Avere sane, they certainly presented grave symptoms, for their malady could but be regarded as indicative of disease of the brain, Avhich had not yet, 'tis true, culminated in insanity,3 but which would render their future sanity very problematical. " When we consider the intimate connection between the circulation in the ears and that of the rest of the head, we cannot but acknowl- edge that any disturbance in the circulation in the brain is prone to produce a corresponding alteration in the circulation of the ears. low, in all chronic cases of insanity, and especially in general paresis, we find a tendency to repeated congestions of the head, and under such circumstances it is natural to suppose that the bloodATessels of the ears become gradually dilated, so as to favor the occurrence of an effusion of blood."4 " It is," says Dr. Hun, " idiopathic, depending upon a patho- logical condition of the brain, and is incapable of being produced by violence alone."5 Some ofthe earliest writers on this disease called it erysipelas of the auricle; but of course that view Avas erroneous. This disease may make its appearance on the posterior surface of the auricle, though rarely,6 and is called by Kramer7 a perichondritis of the auricle. This author also asserted its frequent occurrence in the insane, but very rarely in others. He, however, states that Langenbeck had seen two cases in the sane, and Heyfelder one case in a healthy miller, in Avhom the tumor occurred with pain after epistaxis for several days.8 1 Roosa ; Treatise on Diseases of the Ear, two cases by Roosa, and one case by Loring ; also a case by Gruber. Lehrbuch d. Ohrenheilk. p. 283. 2 Archiv f. Ohrenheilkunde, vol. ii. p. 213, and vol. iii. p. 29. 3 Brown-Sequard ; Roosa; Treatise on Diseases ofthe Ear, p. 112, 1873. 4 Hun ; American Journal of Insanity, 1870, vol. xxvii. p. 24. 5 Op. cit., p. 28. 6 Allgemeine Zeitschrift fur Psychiatrie von Damerow, 1848, vol. i. ; Rau, Ohrenheilkunde, p. 167. 7 Die Erkenntniss und Heilung d. Ohrenkrankheiten, Berlin, 1849, p. 212. 8 Rust's Magazin, 66 Bd. 2 Heft, p. 297. MORBID GROWTHS AND INJURIES. 251 Dr. Kirkbride of the Pennsylvania Hospital for the Insane, and Dr. Curwin of the Pennsylvania State Lunatic Asylum at Harrisburg, are inclined to the opinion that othsematoma is usually the result of violence, and almost invariably confined to males.1 Dr. J. H. Worthington,2 chief physician to the Friends' Asylum for the Insane at Frankford, Philadelphia, who has observed and treated a large number of cases of this disease of the auricle, has never seen a case of this affection in a sane person, nor in a case of curable insanity. He always considers this affection of the ear as an evidence of the incu- rable form of insanity, such as he has described as " congestive mania." From the observations of Dr. Worthington it appears that othematoma is always associated with a tendency to con- gestion of the membranes of the brain or the cerebral substance itself, in Avhich opinion he is nearly in accord with Dr. Lay- cock,3 who thinks " that the states of the circulation, nutrition, and development of the tissues which make up the ear, lobule, and cover the helix, very commonly coincide with similar con- ditions of the encephalic tissues." That the origin of otheematoma may be purely nervous, is proven by experimental irritation of the restiform bodies. Brown-Sequard4 states that this variety of tumor is the result of disease at the base of the brain, and is usually found in the paralysis of the insane. It may be produced artificially in animals, and this he has done in less than one night, between the hours of ten in the evening and six o'clock in the morn- ing. He has performed such experiments, and kept the animal under his own eye, until the artificially produced tumor made its appearance. This he accomplished by an irritation applied to the restiform body, on the side corresponding to that of the tumor. In these cases the process thus excited in the ear may pass rapidly into gangrene, so powerful is the effect of the irri- tation of the restiform body. The lecturer also drew attention to the fact that these tumors usually occur, in the insane, on that side corresponding to the affected side of the brain, Avhich proves that they cannot be, at least not always, the result of 1 L. Turnbull, Clinical Manual of Diseases of the Ear, 1872, pp. 138-139. 2 Ibid. 3 Med. Times and Gazette, March, 1862, p. 289. 4 Lecture in the University of Pennsylvania, Oct. 10, 1872. 252 AURICLE. violence on the part of the patient or his attendants ; since violence of any kind would not be applied invariably to the side of the head nor to the ear corresponding to the affected side of the brain. Dr. Yeats,1 of the Coton Hill Institution for the Insane, Eng- land, believes that the cartilage is the seat of this affection, and that hence the lobule of the ear always remains intact. He has not found othematoma prejudicial to hearing ; on the con- trary, he has observed that the hearing became sharper in some instances during the disease. He has further observed that this affection of the ear is not confined to any particular form of insanity, although it is frequently found in dementia ; that it never occurs in the sane, and that the prognosis of mental recovery in those affected with idiopathic othsematoma is ex- tremely unfavorable. In all his experience he knows of but one case of insanity in Avhich recovery ensued after the appear- ance of this unfavorable symptom. The patient, a married female, thirty-three years old, Avas admitted to the aforesaid institution; thirteen months afterwards, in the midst of every variety of bad symptoms, othsematoma appeared, and, after running its course, disappeared. Finally, the patient began to show signs of mental recovery, and Avas discharged from the asylum perfectly restored to reason, after three years of insanity. With the evidence thus gained it would seem that the inevitable conclusion must be, that the occurrence of idiopathic othematoma is found either in the hopelessly insane, or in those about to become so from cerebral disease which has in- duced the affection on the auricle. The prognosis, therefore, in the case of one thus affected, becomes extremely unfavorable. Treatment—In the treatment of othsematoma the endeavor must be to alleviate pain, prevent as much as possible subse- quent deformity of the auricle, and to be guided in the treat- ment by the form of the disease, since it is manifest that surgical interference is, most usually, undesirable in the idiopathic form, occurring in the insane, but it may be demanded in the trau- matic form, or in the idiopathic form, should it occur in the sane. 1 British Med. Journal, June 21, 1873. MORBID GROWTHS AND INJURIES. 253 The pain in this disease of the auricle does not appear so urgent as to demand puncture of the tumor, at least not in the idiopathic form. It is evident, however, that if the pain caused by the distention of the parts in either form, especially in the traumatic variety, is great, it w?ould be advisable to puncture the tumor. Deformity is not only less likely to occur if the auricle is let alone until spontaneous absorption is brought about, but in the insane is of so little moment that the fear of its occurrence should never induce the surgeon to operate. Dr. Hun has observed, that, in those in whom spontaneous absorption or rupture has occurred, the deformity is very much less than Avhen the tumor has been opened by the knife of the surgeon, the least deformity occurring Avhen spontaneous ab- sorption is induced. Of course the form of the disease Avould have the greatest weight in deciding whether we should operate by incision or not; but, although the operation would not be contraindicated in the traumatic form by the cerebral condition of the patient, the most satisfactory results are said to be attained in those cases where spontaneous or induced absorption occurs. However, many prominent aural surgeons are in favor of early operation in all forms of othematoma. Gruber1 gives the result of his observations, in connection Avith Drs. Joffe and Schlager, as favorable to an early evacuation of the effu- sion, and the application of pressure to insure union in the walls of the cavity Avhich contained the blood. The instrument he uses is a trocar if the blood is still fluid, but if it is coagu- lated, he incises the tumor and removes the clot. He is totally opposed to the so-called antiphlogistic treatment by the use of " Goulard's solution ;" but recommends, for the thickening and deformity of the auricle, painting Avith tincture of iodine. Roosa inclines to the above treatment,2 but Eau,3 an author who appears perfectly conversant Avith all the literature per- taining to this subject up to the time of the publication of his book, is decidedly in favor of using, at the commencement of ' Lehrbuch d. Ohrenheilkunde, Vienna, 1870, p. 286. 2 Roosa, Treatise on Diseases ofthe Ear, etc., New York, 1873, p. 111. s Rau, Lehrbuch der Ohrenheilkunde, Berlin, 1856, p. 170. 254 AURICLE. the disease, cold lead-water pressings, which he advises to be used until the tumor begins to soften a little, then they are to be removed and warm fomentations of arnica are be used in order to favor resolution and absorption. He is of the opinion that incisions into the tumor are almost always injurious, yet they are preferable to the method of acupuncture as suggested by Speyer, for the former means removes more thoroughly the coagula. Saxe, according to Rau, recommended, after the inci- sion and the removal of the coagula, the application of dressings of alum and water (2 drachms to fsiv), and to cover the entire ear with cotton-Avadding. As we have already seen, Hun1 disapproves of incisions in any case of othematoma, and Kra- mer2 approves of general roborants and cool dressings at first, until the tumor begins to soften, then absorption may be pro- moted by the use of dressings of tincture of arnica. But he is opposed to all incisions and surgical operations in these cases. Dr. Kirkbride3 has found the application of ice and tincture of iodine most highly useful; the latter may be applied twice daily. But he has not found the ear disposed in any case to resume its original shape. Dr. Worthington4 disapproves of in- cisions as useless. Othematoma in the Sane.—Some writers have recorded instances of what they have termed spontaneous othematoma in the sane; but in most instances, the cause of this disease in the sane can be traced to various traumatic influences, as box- ing, and blows5 on the auricle from many other causes,6 burns, scalds,7 and exposure to intense cold.8 The more clearly trau- matic cases have also been termed spurious othematoma, to distinguish it from the truly symptomatic variety occurring in the sane. It is most frequently observed among males, though the case reported by Dr. Blake Avas that of a Avoman 30 years old, who had been struck on the ear in falling. In this instance, 1 Loc. cit. p. 23. 2 Die Erkenntniss und Heilung d. Ohrenkrankheiten, Berlin, 1849, p. 214. 3 See Turnbull, op. cit. p. 138-139. * See Turnbull, op. cit., p. 139-140. 5 C. J. Blake : Statistical Report of 1652 Cases of Ear Disease, 1872. 6 Trautmann: Cases of Ear Disease in Garrison, at Breslau, Prussia ; Archiv f. Ohrenh. Bd. ix. p. 183. ' C. J. Kipp: Transactions American Otol. Soc, 1873. 8 Gustav Brunner: Archiv. f. Ohrenh , Bd. v. pp. 26-28, 1870. MORBID GROWTHS AND INJURIES. 255 an abscess ensued in the injured auricle, and after painful sup- puration, discharged an ounce of pus. As this disease has been noted among soldiers in a garrison, it is fair to presume that it is the result of rough sport in which they receive severe bloAvs on the ear. iSTot uncommonly the traumatic variety of othematoma occurs among boys, receiving hard hits on the ear in playing foot ball, as stated by the late Mr. Hinton, of London. One of the most remarkable accounts of the traumatic origin of this disease is that given by Dr. Brunner, of a man forty years old, Avho,# in riding all night in a very cold raihvay car, fell asleep Avith the auricle against the window pane, to which, on waking the next morning, the auricle was frozen fast. The rarest instances of traumatic othematoma are those result- ing from burns or scalds, as in the case related by Dr. Kipp. The prevalence of this form of injury among boxers is so com- mon, that it is shoAvn in ancient statues of noted athletes, as pointed out by Virchow. Diagnosis.—The diagnosis will not be difficult, as the history and general condition of the patient Avill usually plainly indicate the traumatic origin of this variety of blood-tumor of the ear. Most of the symptoms are sthenic, AAiiereas the asthenic and indolent character of the tumor in the insane is very marked, and hence distinctive. Treatment.—The treatment of traumatic othematoma should consist in opening the sac if suppuration has ensued. But if the latter process shall not have taken place, the symptoms of heat, congestion, swelling, and pain must be combated as in the idiopathic variety, viz., by application of ice and iodine. If it be necessary to open the sac to e\^acuate the pus which may have formed, the cavity should be gently stimulated by injections of weak solutions of carbolic or salicylic acid, and the walls kept in contact by gentle compresses. It will be found that Avith proper management the auricle can thus be kept from much deformity. INJURIES OF THE AURICLE. The general surgeon is often called upon to treat a variety of wounds ofthe auricle, but it* is hardly in place to treat of them 256 AURICLE. here. Most of these are caused by quarrels, and are inflicted by weapons, blows, and bites. Those caused by weapons appear- to be somewhat peculiar to the countries where they occur, as in the French soldiers, Avhose auricles Avere so frequently injured by the yataghan in the battle of Constantina ;x in Ireland, auricles have been split and bruised by the blackthorn stick;2 and in Germany, the student's " schmiss" is often obtained by a sword-thrust or slash at the auricle. The treatment will consist in adjusting the Avounded and displaced parts, keeping them in position by a stiff dressing, and the attention to general principles of surgery. Traumatic Cleft of the Lobule.—A not uncommon injury ofthe auricle is one caused by tearing out the ear-ring, and thus causing a cleft of the lobule. This is produced most frequently by children in play Avith their mothers, but it is also done in fights between women. I have seen lately two sisters, both quarrelsome, in whom the lobules were cleft, one in three places, making four teat-like appendages, or fringe, said to have been caused by her babes, but the other woman acknowledged that in a quarrel with a female acquaintance, the ear-ring had been intentionally torn from her ear by her adversary. In both of these women the deformity had existed for several years. Treatment—If such cases are seen as soon as they occur, union by first intention can usually be effected; I have never seen any but chronic cases. Dr. Knapp, of NewT York, has lately suggested3 a very neat and practicable operation for removing the deformity in such cases, Avithout leaving the notch on the edge ofthe lobule, so common after operations on this part. This operation is a modification of the Mirault-Langenbeck operation for hare-lip, applied to the auricle, and consists in the folloAving method: If the left ear is to be operated on, let the patient recline to the right side. The surgeon may stand behind the patient, while an assistant with his thumb and index finger seizes and stretches the anterior part of the lobule. Then thrust a narrow-bladed scalpel through the anterior part near the lower end of the slit (at a, in the 1 Wilde, op. cit., p. 164. s n,id. a Archives of Ophth. and Otol., A'ol. iii. No. 1. MORBID GROWTHS AND INJURIES. 257 accompanying figure), sever a thin slice of skin along its edge, Avhen the other end of the slit is nearly reached (at c), make the slice a little broader, leave its end (at b) in connection with the auricle, then Fig- fi3. turning the knife, go backAvard about two lines, and cut across the detached slice (at c), thus forming a small flap. Now seize the long portion of the slice with a pair of forceps, and divide with the knife its other end (at a) by a slightly curved section. Without wait- ing long for the cessation of the bleed- ing, the edges of the wound may be gently but securely united by three in- terrupted sutures. The first is applied to the middle of the edges on the an- terior surface ; the second, about oppo- site the first, to the posterior edges. The curved needles need not penetrate more deeply into the substance of the lobule than about one-third of its thickness. By the third suture, the small flap (c b) left at the posterior part of the lobule, is made to bridge over the lowrer extremity of the gap. The needle, therefore, is first thrust through the free end (c) of the little flap, and then through the lower edge of the wound in the anterior portion of the lobule, the suture tied, and the operation is finished. No dressing is required. In three days the sutures are removed. In every case thus ope- rated on, immediate union has been obtained by Dr. Knapp. I have tried this method in several cases, and have found it the only means of preventing the notch so often seen in the lobule after it has healed. 17 SECTION III. EXTERNAL AUDITORY CANAL. CHAPTER I. CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. Otitis Externa Circumscripta consists in a circumscribed inflammation of the skin or subcutaneous cellular and fibrous tissues, terminating in a small abscess or boil, which, in dis- charging its contents, produces considerable destruction of the skin covering it. Its seat is not confined to any particular portion of the auditory canal, but as it is most likely to occur in a region rich in glands, it is apt to be found in the outer part of the meatus. It may, however, arise in the deeper cellular tissues and in the periosteum of the bony portion of the auditory canal. Circumscribed inflammation of the ex- ternal auditory canal may arise sporadically or epidemically, and, in the latter instance, it is a striking fact that the abscesses are confined to a particular part of the auditory canal.1 Bon- nafont2 has recorded such an epidemic, occurring in Paris, in May and June, 1863, and Gruber3 reports the occurrence of a similar endemic attack of this disease in the summer of the same year in Vienna, at Avhich time, the majority of the ab- scesses Avere found in the outer third of the auditory canal, near the tragus. Symptoms.—This disease is usually extremely painful, and is attended Avith fever and even considerable cerebral symptoms in some cases. The boils usually occur one at a time, but the series may amount to a dozen. Sometimes they appear to 1 Gruber, Lehrbuch d. Ohrenh., p. 297. 2 L'Union Medicale, 1863. 3 Bericht Allg. Krankenhaus, Vienna, 1863. CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 259 merge so fast into each other, that the ease gained by the dis- charge of one is hardly enjoyed by the victim until the throb- bing and burning pain of a new one AA^arns him that he must endure the torment of another. The auricle may become sensi- tive to touch and traction, especially if the abscesses are in the cartilaginous part of the canal, and the patient then cannot endure the ordinary pressure of the affected side of the head on the pillow. But such sensitiveness of the ear is not so likely to occur in this form of otitis externa as in the diffuse form. The severest pain and most distressing symptoms are found AAiien the boil is seated in the unpliable parts of the bony portion of the canal; intense distress, however, may be caused by a boil seated just within the opening of the auditory canal. Usually, the gravity of the pain and febrile symptoms Avill de- pend upon the depth of the abscess in the tissues of the auditory canal as Avell as upon its proximity to the drum-head. Small superficial abscesses do occur in the meatus Avithout any pain, a sense of discomfort and dulness of hearing; having; been the only cause of the patient's seeking surgical relief. More than one such case has been seen where the abscess had run its full course and was on the point of discharging Avithout having caused the patient any pain. But of course such cases are rare exceptions, and are explained by the superficial seat of the in- flammation. Hardness of hearing and deafness are prominent symptoms of furuncles in the auditory canal. In some cases the deafness is almost absolute, and the congestion being; so great, and extending consecutively even into the cavity of the tympanum, the deafness is the last symptom to disappear. But the patient can be assured of the ultimate return ofthe hearing in such cases if there has been no organic lesion of the drum- cavity, and as such a lesion is a very unlikely occurrence in this disease, there is every hope of the return of the hearing. Inspection of the auditory canal and membrana tympani is usually very difficult if the disease is advanced and the swelling of the meatus considerable. This difficulty is less likely to occur Avhen the disease is in the cartilaginous part of the ear, for it may be gradually stretched by the speculum. When the disease is in the bony portion of the canal, one can usually obtain a view of the drum-head only in the earlier stages of the disease. In such cases, if the abscess is seated near the drum- 260 EXTERNAL AUDITORY CANAL. head, it will be seen that the latter is more or less congested at that point nearest the abscess, and in many cases where the boil is near the periphery of the membrana tympani in its upper half, considerable swelling will be found in the region of the membrana flaccida or the folds of the drum-head. In such cases, at first sight, one may be inclined to diagnose the disease as myringitis, but the history of the case, and the compara- tively normal condition of the drum-head, excepting at the points of secondary congestion produced by the circumscribed inflammation of the canal, and the greater pain in the latter disease, will make the true diagnosis easy. When the abscess in the bony portion of the canal becomes fully developed, the view of the drum-head will be entirely cut off, and the deafness and tinnitus become great. After the discharge has occurred, the drum-head may be seen as a red, and somewhat sodden membrane, which, however, gradually, in a few days, assumes its normal color and outline, and the hearing will be found to be returning. Inspection of the auditory canal and drum-head by means of the ear funnel, unless carefully done, becomes very painful to the patient with this disease of the ear; but it is very important to examine the canal well, in order to determine the seat, the amount, and the stage of the disease, as well as to be assured of the absence or the presence of exostoses, cerumen, or other foreign bodies in the canal, which might interfere with the escape of the products of inflammation and greatly complicate the disease. Having established the presence of either or all of these complications,.one must mitigate the effects of the exos- toses, and remove, if possible, any other obstructions, such as cerumen, foreign bodies, etc., by the most gentle and thorough syringing, or by the most careful manipulation. If exostoses are in the auditory canal, care must be taken not to mistake such rounded prominences for the furuncles. This, in some cases, may proA'e to be no easy task, and, there- fore, as these growths, if congenital, are usually in both canals; if there be any suspicion that the affected ear contains such bony growths, the well ear should be examined, and if it con- tains them, caution should be observed in ascribing all the SAvelling in the diseased ear to the furuncles. However, as these prominent growths of bone are not very frequently seen CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 261 in the ear, they will not often be found as complications in circumscribed external otitis, but it is Avell to bear in mind the possibility of their presence in the affected ear. Etiology.—Perhaps no disease of the ear has so many asserted causes, yet so few Avell-explained ones, as boils in the external ear. No class nor condition of men appears exempt from it, and in many instances the disease continues to recur for a long time, owing to the fact that the cause, which must be removed before permanent recovery can take place, has not been found after the most thorough search. According to some authorities, a particular article of rich food has been the cause of the disease, especially in the more wealthy classes, Avhile anemia and poverty have most usually been considered fruitful causes of furuncles in the external ear. Fatigue and consequent debility from any cause may produce them ; and, it is not uncommon to find furuncles in the auditory canal of young devotees to fashion after a long and gay winter season Avith its round of parties and fatiguing attendants of late hours, bad air, indigestible food, and loss of sleep. I have never seen this disease in little children. Treatment.—Of course the best treatment for a boil or circum- scribed abscess is a poultice or some form of heat and moisture. But this is not easily applicable to such inflammations in the auditory canal, on account of the narrowness of the passage and the necessary blocking up of the canal which such a treatment might entail. It has, therefore, been deemed best to incise, as deeply as possible, a furuncle in the auditory canal as soon as the circumscribed abscess is detected, without waiting for pus to form in it. With the meatus lighted as well as possible by the aid of the forehead mirror, though in some cases direct light will be suffi- cient if the furuncle is not too far doAvn the auditory canal, and Avhile the head of the patient is allowed to be entirely free, the surgeon may make a thorough and deep cut into the small abscess, taking care that the patient is allowed to jump away from the operator rather than towards him, an end best gained by allowing the patient's head to be entirely unsupported, on the unaffected side, i. e. the side opposite to the operator. The knife is the quickest and surest way of escape from the pain of these furuncles in the auditory canal. It has also seemed 262 EXTERNAL AUDITORY CANAL. that in those cases where the knife has been used promptly on the first boil that makes its appearance, others are less likely to come, or if they come, to be less severe. This may be due to the sudden relief, given to the distended vessels of the skin of the canal by the free cut, at the outset of the inflammation. If the knife cannot be used, other means must be resorted to. Although poultices, in the strict sense of the term, cannot be applied to abscesses in the auditory canal, unless situated very near its mouth, and even then only in a limited way, the con- stant or oft-repeated use of warm Avater by gentle instillation, the aural douche, or some of the varied forms of irrigation, will be found very grateful to the patient and favorable to suppura- tion. The simplest and perhaps the best Avay of applying warm Avater as a dressing to any acute inflammation in the ear, and especially in the auditory canal, is to fill up the ear with Avarm water and allow it to remain there as long as possible, while the patient of course lies down with the affected ear uppermost. To the Avarm water thus used laudanum or morphia, preferably the latter, may be added. Magendie's solution may be repeated often in warm instillations (5-10 drops) to the affected ear, and will be found very quieting and perfectlj7 safe, even in children. A small dossil of lint or cotton soaked in glycerine or equal parts of glycerine and Avater, and small conical poultices of flax- seed (Roosa), will be found to act as excellent emollient dressings upon an abscess near the mouth of the auditory canal. The local abstraction of blood with two or three leeches, directly under the ear in the depression behind the lobule, or in front of the tragus, close to the ear, will also give great ease Avhen the congestion and pain are intense. This method has been found very grateful when the abscess is in the bony meatus near the drum-head. The removal of the discharge, which is often very copious, is of great importance. Some form of alkaline Avash will be found to act best as a cleanser after the contents of the abscess are being poured into the auditory canal. First of all stands warm water made slightly opalescent with castile soap, which should be applied by means of the syringe twice or thrice daily according to the amount of discharge. In the interval between the syringings, or just before them, CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 263 solutions of bicarbonate of soda, x-xx gr. to f.?j, and of biborate of soda, gr. x to f|j, may be instilled into the meatus in quantities of 10-15 drops warmed. These, by remaining in contact with the affected spot, will soften any hardened crusts of the discharged matters from the abscess and facilitate their removal by the syringe. Usually the Avail of the meatus becomes so tumid and macerated that syringing, no matter hoAv thoroughly done, will not give the perfect view one could desire of the diseased spot and the parts adjacent to it. In such a case the meatus should be gently Aviped out or SAvabbed out with a piece of cotton fastened to the cotton-holder. This is not painful if carefully done, and will usually give the best results so far as gaining a viewT of the abscess and the membrana tympani beyond. By this means, too, the everted edges of the ragged abscess may be pushed clown to something like a level with the Avail of the auditory canal, and the drum- head may then be seen. It has been said that syringing the ear will usually relieve the deafness caused by a circumscribed external otitis. This will hardly be so if the disease is seated near the drum-head, i. e. in the bony canal, for in such cases the congestion of the drum- head is too great to permit an immediate return to hearing by merely syringing. As has already been said, the occurrence of a small abscess or boil in the auditory canal, denotes that there is a tendency towards the occurrence of another or several in the same spot. Hence, the constitutional, as well as the local treatment becomes of the greatest importance. Perhaps no greater index of constitutional or blood derange- ment can be found in the form of furuncles, than in the occur- rence of them in the auditory canal. Hence, whatever is em- ployed for their cure, when occurring elsewhere in the body, should most surely be employed when they make their appear- ance in the auditory canal, for they are not only an evidence of the need of an alterative treatment, but they are intensely pain- ful and interfere with hearing. At the head of the list of remedies stand iron and quinine, while in some cases iodide of potassium has been found most efficacious in breaking up a tendency to the formation of boils. But there is no specific in this malady, and if one form of treat- 264 EXTERNAL AUDITORY CANAL. ment does not bring about the desired result, another must be tried, until the trouble disappears. Most frequently, the best results will be gained from those remedies which improve the general condition of the patient. Von Troeltsch strongly recom- mends the internal use of Fowler's solution in this disease.1 Local Treatment—Although local causes have very little to do with this disease of the auditory canal, it will be found ad- vantageous to combine a local treatment Avith the giving of medicine internally. The use of some soothing or mildly stimu- lating salve, as the case seems to demand, has been found appa- rently to diminish the tendency to recurrence of the abscesses and to favor an early return to healthy action on the part of the various cutaneous structures. As a soothing application, nothing is better than a little cold cream smeared on a camel's-hair pencil and then painted round the walls of the meatus. If a more stimulating ointment is needed, the following will be found to answer very well:— ty—Hydrargyri ammoniatf, gr. i-ij. Ung. aq. rosse, §j.—M. Ft. ung. S. apply to the ear with a camel's-hair pencil. A small portion of this ointment may be smeared on and around the affected spot, twice or thrice daily, by means of the hair pencil, for several days, until the skin of the auditory canal appears to be free from the tendency to the formation of these small and painful abscesses. If there is no return of the ab- scesses, the congestion soon goes from the drum-head, and the hearing will be restored. The granulations sometimes left by a furuncle in the ear are best treated by cauterization with solutions of nitrate of silver (gr. 10-100), applied by means of a little cotton on the holder, or by chloro-acetic acid, applied in the same Avay. As the granulations are distinctly marked centres of disease, touching them is much safer than instillations applied to them. As a rule, one may wait to see what course granulations origi- nating from a furuncle in the ear will take. They may fall off and be washed out, or they may grow and assume a polypoid nature. 1 Diseases ofthe Ear, 2d American edition, p. 102. CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 265 If they are found to be increasing in size, they should be touched as indicated above. If they are evidently not growing larger, or are diminishing in size, there had better not be any kind of caustic applied to them. Mild astringents and cleansing with the syringe are then sufficient. A fuller consideration of the best treatment for polypoid granulations and polypi follow- ing external otitis Avill be found further on, Avhere those forms of disease are specially alluded to. Diffuse Inflammation of the External Auditory Canal. —This disease has been called, preeminently, external otitis, be- cause it invades the entire external ear, not excepting parts of the auricle in some cases. Its only essential difference from the disease treated of in the preceding pages, otitis externa cir- cumscripta, consists in its diffuse distribution to the entire external ear. It is not possible to say with certainty in what anatomical portion of the structure of the auditory canal it has its seat. It has indeed been wisely said that " a simple ery- thema of the cutis in the auditory canal may be considered the lightest form of the disease, and a periostitis of the canal may be called the severest form."1 Just as the circumscribed inflammation in the auditory canal shows the peculiar tendency to narrow itself down to a very minute point, the true abscess, the diffuse form of otitis externa shows the peculiarity to spread rapidly to all parts of the exter- nal ear. A pure form of periostitis of the external auditory canal never occurs, for the disease is never confined to the periosteum, but from the outset all the neighboring layers of the wall of the canal are attacked. This is due to the fact that the skin of the canal is more firmly united to the periosteum than the peri- osteum is to the bone. Hence, an inflammation of the cutis readily extends to the periosteum and the bone, this being most probably the usual course of the disease. There is also a con- secutive form of external otitis found in cases of acute otitis media. Symptoms.—The subjective symptoms of diffuse external otitis are more severe in the primary than in the consecutive form. 1 Gruber, op. cit., pp. 3-4. 266 EXTERNAL AUDITORY CANAL. In the former instance pain, tinnitus, and deafness are the prominent and very distressing symptoms. Roosa has found that itching in the meatus is a constant but frequently disre- garded symptom of the approach of this disease. In general the subjective symptoms do not differ greatly from those of the circumscribed external otitis. In the so-called diphtheritic form the pain is said to be intense, continuing without any interruption day and night until the inflammatory product has assumed another character. (Gruber.) The deafness in diffuse external otitis is perhaps more marked and more obstinate then in the circumscribed otitis, while the tinnitus is very annoying in both. The consecutive variety of diffuse inflammation ofthe external ear is as a rule less painful than the primary variety. This fea- ture is most marked when the inflammation of the external ear is consecutive to purulent inflammation of the middle ear. The objective symptoms of diffuse external otitis vary Avith the position, cause, and grade of the inflammation, being more severe in the primary than in the consecutive form. When the inflam- mation is situated in the bony portion of the canal, the disease assumes the nature of a periostitis with intense and continued pain, wiiereas the symptoms are not so severe when the disease seems to be limited to the outer part of the auditory canal. At the beginning of the disease the skin of the auditory canal is more or less swollen and red, and, in some cases, portions of the cutaneous lining of the auditory canal may be excoriated or even exfoliated at certain points. Usually the redness and swelling are most marked in the bony portion ofthe canal, Avith of course great narrowing ofthe calibre of the canal, so that the latter appears to run to a point, thus assuming a conical shape. The skin of the fundus of the canal becomes puckered by the swelling, and one, perhaps more of the ridges thus formed will shut off the drum-head from view. The congestion and swelling Avill be greatest in the region of the vessels supplying the hammer and the membrana flaccida, but the entire drum-head soon loses its gray color and its con- tour, so that the Avails of the canal and the membrana tympani cannot be distinguished from each other by their appearances, as they are fused into each other. CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 267 All traces of the normal pyramid of light are lost, and the in- filtration in many cases is so great that the consequent pucker- ing of the drum-head will cause several shining spots to appear on the prominent points thus produced by the SAvelling of its layers, when light is thrown into the canal from the mirror. The appearance of the disease is somewhat changed when the layers deeper than the skin of the canal are more diseased than the cutis itself. In such cases the swelling of the structure beneath the cutis will push it so much out of place that the two sides of the canal Avill be made to touch each other, and not even the narrowest speculum can then be pushed between them so as to gain a view of the deeper part of the auditory canal and the drum-head. Very often in such cases, as the superficial layer of the skin of the passage is very little diseased and remains quite dry, it may be someAvhat difficult to say Avhether the disease is diffuse or circumscribed inflammation of the canal. HoAvever, in the former case we shall usually find more or less glandular swell- ing and tenderness about the ear, with pain on moving the jawT. A most important symptom in some cases is the redness and swelling, with some oedema, of the mastoid process. The glandular tenderness under and in front of the auricle is, howTever, a much more frequent attendant of this disease of the auditory canal, than the mastoid redness and tenderness. The discharge ofthe products of inflammation in this disease may occur from several points, but usually it comes from one only. In the former instance the disease manifests symptoms similar to those of circumscribed external otitis, AAiiereas, in the latter instance, the symptoms are peculiar to a true diffuse external otitis. In such a case, the discharge is remarkably copious, beginning as a discharge of colorless or bloody serum, and terminating in the course of a few days in a less copious purulent discharge. The amount of odorless bloody serum at the beginning of the discharge is so abundant in some cases, as to require the constant holding of a handkerchief to the ear, in order to protect the bedding or the clothing of the sufferer, and thus several handkerchiefs, in the course of the day, may be soaked Avith the discharge. The most marked instance of a floAv of this kind the author has ever seen, Avas from the ear of 268 EXTERNAL AUDITORY CANAL. a Japanese naval officer, from whom the discharge was very red as well as very copious, so reel, indeed, that the patient con- sidered it blood. It continued three days, and was succeeded by a light-yelloAvish discharge of purulent matter, exfoliation of epidermis from the fundus of the auditory canal and drum- head, with perforation ofthe latter in the postero-inferior quad- rant on the eleventh day. The brief mention of this case leads naturally to the statement that many cases of this disease, wiien situate in the bony portion of the canal, are attended with exfoliation of large pieces of epidermis and perforation of the drum-head from without inward. Perforation of the drum- head does occur frequently as a result of the ordinary course of the disease, but great caution in the use of the syringe should be observed at the stage of exfoliation, for fear of penetrating the drum-head by the force of the stream of water. The swell- ing and exfoliation of the soft parts of the canal may be so great as to increase the pain and distress of the patient by a further distention of the canal, and the renewed irritation of the diseased part may reproduce considerable feATer, which, however, subsides as soon as the exfoliated matter and dis- charge are removed. Where it is impossible to gain a view of the drum-head on account of the narrowing of the auditory canal, resort must be had to the catheter, the use of Politzer's bag, or Valsalva's method of inflation, in order to ascertain the condition of the Eustachian tube and middle ear. This is often of the greatest moment, not only in children in whom it is often difficult to make a perfect diagnosis in this disease, but also in adults, in order to determine whether or not the external otitis exists alone or is accompanied by deeper and more serious trouble in the drum-cavity. All the objective symptoms in diffuse in- flammation of the external ear are modified by their causes and the diathesis of the patient. Hence, peculiar symptoms may be expected in that form of the disease produced by the pre- sence of vegetable or animal parasites in the ear, in the diph- theritic form of the disease, and in any form in syphilitic or scrofulous individuals as well as in any traumatic case occur- ring in the more healthy, for in the latter instance the means by which the disease has been produced must be taken into CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 269 account, for almost invariably it will complicate and alter the symptoms. The diphtheritic form of diffuse external otitis is not only very rare, being unmentioned by many authorities, and, accord- ing to the best observers, is never a primary affection, but rather an occurrence in the later stages of the inflammatory process. This form of the disease is usually found in scrofu- lous subjects in whom the original inflammation has been either neglected or improperly treated. In all such cases, after the usual purulent discharge has lasted a longer or shorter time, there is a sudden increase of pain and fever, with the simulta- neous appearance of a Avhite diphtheritic membrane, Avhich adheres most closely to the inflamed structure, and wiien even lightly touched causes intense pain and some bleeding of the parts beneath, as shoAvn by Gruber. Moos,1 and G. A. Callan,2 have each reported a case of idiopathic diphtheria of the ex- ternal auditory canal. In children there is often found, at the termination of an attack of diphtheria, inflammation in the external ear. This rapidly extends in some cases, directly to the bone of the canal, and backAvards to the mastoid process. Pain is not a prominent symptom in these inflammations following diphtheria, and this fact will readily distinguish them from the truly diphtheritic form of external otitis in which the peculiar false membrane is found in the auditory canal. The form of the disease noAv referred to is one arising from the broken-down condition of the little patient, rather than a form of disease already de- scribed as the diphtheritic. In the former case the pain is not great, the SAvelling is considerable, and the tendency to attack the bone is marked. Fluctuation is soon felt over the mastoid region, and, after the evacuation of the pus, the bone beneath is felt denuded, and in some cases crumbling. Exu- berant granulations spring up around the opening made by the knife in the soft parts, and the peculiar depressed mouth of a sinus leading to dead bone soon begins to make its appearance. With a probe, a tract of bare bone corresponding to the region around the bony meatus may be detected. For Aveeks, no por- 1 Archives of Oph. and Otol., vol. i. No. 2, New York, 1870. 2 New York Med. Record, March 27, 1875. 270 EXTERNAL AUDITORY CANAL. tions of this diseased bone will come away, but at last the nearest edge of the dead tract will appear to rise up, so that a probe may be worked under it, and then gradually, day by day, the dead shell or scale of bone (for it is in many cases the outer Avail of the mastoid cells) will be found to be coming out through the sinus. This process is attended with more or less discharge from the ear, but if the sinus behind the ear is kept freely open, the discharge from the auditory canal will be very slight, and hence, granulations are not usually found in such a case, for the drainage is kept up from behind and away from the auditory meatus. During this process the patient has no pain, the discharge is not very copious, but there will be, from time to time, swelling of the glands in front of and under the ear, and down the tract of the sterno-cleido-mastoid muscle. These SAvellings are not painful nor very hard. They last for a few days and then usually disappear, though they may suppu- rate in the worst cases. Perhaps the form of inflammation over the mastoid, just sketched, may be due to the inflamma- tion of a gland which has become diseased by the diphtheritic poison. In badly fed and delicate children the diphtheritic form of otitis externa may pass into the gangrenous variety. According to Gruber, otitis gangrenosa is much more likely to occur in children than in adults. Although the external otitis occurring in diptheritic children may lead to necrosis in and about the tympanum, with exfoliation of large pieces of the posterior wall of the auditory canal, I have never seen such cases assume a truly gangrenous nature. Causes.—The causes of diffuse otitis may be purely idiopathic or local. The latter variety will be found the most usual, as cold, wounds, injuries of all kinds, furuncles in the auditory canal, and various inflammatory processes both within and out- side of the ear. The latter diseases attack the auditory canal from their nearness to it, as, for example, acute inflammation of the middle ear, some skin diseases, as eczema of the scalp and auricle, the acute exanthemata, and in rare instances pemphigus of the entire surface, may also attack the auditory canal and drum-head, as in a case seen by Von Troeltsch. The improper uses of all kinds of ear-picks, aurilaves, hair- pins, and tooth-picks, for scratching the ear or for the too CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 271 zealous removal of cerumen, are constantly found to have been the exciting cause of this very painful disease of the auditory canal. Some of the worst cases I have seen, especially among the patients in the infirmary, have been produced by the rough and persistent use of pins, which appear to have an especially bad influence on the glandular structures ofthe auditory canal. I have also observed that men very often make a very impro- per use of a quill tooth-pick in scratching the meatus with it. This practice I have known to excite a series of obstinate ab- scesses Avhich have at last passed into a chronic form of diffuse external otitis. This latter form of the disease is not very painful, but the itching and discharge are very annojing. There are constantly found a feAv writers disposed to attri- bute some cases of diffuse inflammation of the external ear to syphilitic or gonorrhceal causes. The disease in the former instance is attributed to papules, the secretion from which is irritating (Gruber); and other writers, among whom is Lincke, have endeavored to diagnose some forms of external otitis as syphilitic. The gonorrhceal form appears very doubtful, from the fact that there is no mucous membrane in the external auditory canal. Dr. Ladreit de Lacharriere1 has described and defended a form of acute syphilitic otitis which he considers purely a secondary accident, and to which he desires to call especial attention. These cases are said to be not uncommon, but the writer re- ferred to laments that no one but Triquet has devoted much attention to this or any forms of purely syphilitic disease of the ear. The disease described by de Lacharriere as acute syphilitic otitis appears to possess a very distinctive type, so much so " that it may be diagnosed as specific in its nature before the patients confess that they have had any other lesions of this nature." The characteristic signs are said to be the condition of the auditory canals, the nature of the secretion, the rapid onset, and the insignificant pain. The two canals are usually attacked at the same time. Their Avails are swollen, but not to the same extent as in the phlegmonous form of otitis. The skin 1 Annales des Maladies de l'Oreille et du Larynx, May, 187o. 272 EXTERNAL AUDITORY CANAL. is cracked and red, and the canal is so narrowed that any en- deavor to introduce a speculum will cause the patient suffering. From further description it may be gleaned that the discharge does not differ in quality, amount, nor in any respect from that of ordinary diffuse external otitis, excepting in having a very disagreeable odor. The premonitory symptoms are similar to those of ordinary otitis, for they consist in sensations of fulness in the ear, itching in the auditory canal, and a discharge occurring on the same day or a little later. The same writer says respecting the differential diagnosis in this disease that " it should never be taken for a simple otitis, the pain of Avhich is so intense, until the discharge is established; nor should it be confounded with herpetic otitis, which can always be detected by the presence of the peculiar herpetic vesicles. The affection which most nearly resembles it is eczema, in which, however, scanty secretion which does not run out will keep it from being confounded Avith the disease described as acute syphilitic otitis. " The disease usually lasts about as long as an ordinary attack of otitis, disappearing Avithout leaving any traces, excepting in some'feAV cases in which the subsequent deafness appears quite persistent either from a thickening of the drum-head or from a catarrhal condition of the tympanic cavity." It would seem, from this description, that this disease is a Avell-marked and independent one. Its symmetrical character, disagreeable odor, copious discharge, and attendant syphilitic history would certainly tend to place it among lesions secondary to the specific inoculation. When the catarrhal tendency in- duced by the specific poison is borne in mind, it would seem that the form of otitis just described might be consecutive to a catar- rhal process in the middle ear. Treatment.—If wTe are able to begin the treatment of diffuse inflammation of the external auditory canal in the early stages of congestion and pain, the course to pursue will be to apply leeches around the ear, in front of the tragus, close to it, and under the auricle close up behind the lobule. From four to six large European leeches may be applied in this manner, the exact points to which they are to be applied being indicated Avith ink, for the guidance of the leecher if the surgeon does not wish to, or is unaccustomed to, put them on. Some authorities are also is faA'or of applying a leech to the wall of CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 273 the meatus near its mouth, the meatus being previously Avell stopped up with cotton beyond the point the leech is to be placed. The only disadvantage of this method lies in the liability of pro- ducing an abscess at the leech-bite. But depletion, thorough and copious, must be brought about in the first stages of this disease, and if leeches Avill not give the desired relief, thorough and deep scarification, especially by making a deep cut on the superior Avail of the meatus, should be promptly carried out. This is very much more painful than leeching, but it depletes the affected spot at once, and the bleeding may be kept up by syringing the auditory canal with very warm Avater. If, notwithstanding the leeching and scarification (if the latter is resorted to, as a second choice), the swelling and pain con- tinue, it will be necessary to apply heat and moisture. In this respect the treatment Avill not differ materially from that of cir- cumscribed inflammation in the auditory canal. Warm water should be constantly and gently applied to the affected auditory canal by irrigation or by instillation. When warm fluid applications are to be retained in the auditory canal, the best way to accomplish this is for the patient to lie down with the affected ear uppermost, as already stated Avhen dis- cussing the subject of furuncles in the auditory canal, and the fluids should be kept in the ear as long as they are warm and grateful to the sufferer. To the water thus used may be added various anodynes, pre- ferably, however, laudanum or morphia. Magendie's solution undiluted will be found to be the best anodyne application, be- cause it is the cleanest and most powerful, and, although it should never be resorted to in the undiluted state, unless the pain is very severe, it can be endured in large quantities in the ear, Avith- out producing any unpleasant narcotism, even in young children. It may be used in instillations of five or ten drops, every half- hour, until relief from pain is obtained, in children as young as three years of age, with the best results. I have frequently used it thus, without observing the least narcotism. The best way to prescribe it is in small quantities, thus:— [£.—Morphiee sulphatis, gr. iv ; Aqua},1 fl3ij.—M. S. Ten drops, warm, in the ear, as required. 1 For water, cherry-laurel water may be substituted. 18 274 EXTERNAL AUDITORY CANAL. The only caution to be observed is, that the apothecary read the quantity of water correctly, for it has happened that the quantity of "drachms has been read as ounces, with, of course, no worse result than weakening what Avould otherwise be a more powerful and more desirable application for the relief of pain. The object of the small prescription is, as will be readily seen, to prevent sixteen grains of morphia from being at the command of patients, when four grains will do just as Avell, with proportionately less risk. It is, perhaps, needless to say, that all forms of solid poultices of carrots, onions, fat pork, oils, etc., will only tend to aggravate the present sufferings of the patient, and almost inevitably leave behind them portions of the poultice, which, by undergoing decay, or becoming rancid, will lay the foundation of other evils, among Avhich will be found the aspergillus playing a prominent part. The secretion in the diffuse inflammation of the auditory canal may be very copious, and of a sanious nature. This must be carefully removed, and the ear kept as clean as possible by frequent and gentle syringing Avith pure Avarm Avater, to which a little castile soap or bicarbonate of soda may be added. If the secretion should be tenacious and tend to accumulate in large quantities, and syringing fail to remove it, it should be carefully and gently Aviped out with cotton on the cotton-holder. The cotton-holder should never be used by the inexperienced or inexpert hand, as in that case it will prove itself as unworthy an instrument as an aurilave, or sponge tied to a stick, Avhich pushes in much more than it brings out and never fails to do harm sooner or later. As the copious serous discharge, often tinged with blood, diminishes, the running from the ear may assume a yelloAV color and become thick, but much less in amount. This will be apt to assume a chronic tendency, and the deeper parts of the canal may be found red, disposed to bleed, and roughened into little hillocks. The discharge is so much thicker that it is not easily removed, and excites a tendency towards the groAvth of granu- lations near the membrana tympani. It becomes, therefore, extremely important to cleanse the ear at this stage and keep doAvn the granulations. I have found that the principle of aspiration applied to the CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 275 tumid and sluggish parts will not only cleanse them but stimu- late them into a healthy activity. After cleaning the ear as thoroughly as possible, by syringing and the cotton-holder, especially in those cases where the der- moid layer of the drum-head has been greatly inflamed, throAvn into hillocks, and suppurates freely at several 'points, I have seen through the Sigle pneumatic speculum, as I have sucked upon the India-rubber tube attached to its side, large drops of pus ooze from the openings in the dermoid layer in quantities sufficient to fill up the fundus of the auditory canal. By this means it is possible to cleanse the inflamed deeper parts much better than by any other means. It is surely the most rapid and perhaps the only immediate way of doing it Avhen pus has accumulated under the dermoid layer of the drum-bead or in deeper tissues of the skin of the canal, which enter into the structures of an abscess in the Avail of this passage. Whether the abscess be of the nature Avhich forms in circumscribed otitis, or the more diffuse and sluggish kind found at the subsidence of the diffuse form of inflammation of the auditory canal, this method of cleaning out the diseased parts may be used. At the same time that the pus escapes from the sodden parts in such a case as already alluded to, in Avhich aspiration is employed, I have observed that minute drops of blood start out from the excoriated parts everywhere in the canal. This acts as a stimu- lant to these parts, Avhich do not bleed when touched Avith the cotton-holder; but their bleeding upon gentle suction with the Sigle speculum reveals their true sluggish nature and will guide in the treatment. These are the cases Avhich demand the use of strong solutions of nitrate of silver, and Ave should not hesitate to apply solutions containing 60 to 100 grains of the caustic, every day or two, until the ear becomes more healthy : if neglected, granulations will soon spring up. At home, the patient should keep the ear carefully cleansed and use a solution of zinc, copper, nitrate of lead, and other astringents. But, as a rule, the zinc, in the form of the sulphate or acetate, combined with tincture of opium, in these cases of excoriation of the canal, will be found the best remedy. The following recipe is of value:— 276 EXTERNAL AUDITORY CANAL. R.—Zinci sulphatis, gr. v ; Tinct. opii, n\,xx ; Aquse destill. flgj.—M. S. Ten drops four times daily in the ear. It may be well to repeat the direction, that all applications to the ear must be Avarmed before they are dropped into the ear. When the disease is confined chiefly, if not entirely, to the external ear, as in diffuse inflammation of the external auditory canal, lead is frequently employed by the highest authorities. When granulations spring up in the canal, Politzer, in his clinic, prescribes instillations of lead-water and the application of crystals of sesquichloride of iron. These crystals are applied rapidly, in order to prevent their deliquescing, and after they are placed upon the granulations the canal is packed with cotton, and the Avhole retained for tAventy-four hours, if no discomfort and pain arise from the treatment. By this means, granulations may be made to disappear rapidly, when they are too small and numerous to be pulled out with an instrument. Hinton1 recommends the following formula for chronic forms of inflammation in the auditory canal:— fy.—Liq. plumbi diacetatis, uix-xxx ; Acid. acet. dil. w\ iij-x ; Liq. opii, n\, xx ; Aq. destill. adflgj.—M. He further states : "I have found the same lotion useful, at first, in the excoriated and swollen condition of the meatus that often coexists Avith affections of the tympanum in children, especially if neglected." In the treatment of granulations, as Avell as the roots or bases of polypi, after their complete extraction, nothing is equal to monochloroacetic acid. This is acetic acid in which chlorine replaces one part of oxygen. The preparation I have used for some years is made by Merck, of Darmstadt. By applying a drop of this on the cotton-holder to the granu- lations every other day, or three times a Aveek, they Avill rapidly disappear. The application of the acid is somewhat - painful for an instant, but a syringeful of warm water will 1 Questions of Aural Surgery, p. 95, London, 1874. CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 277 relieve it. The advantages of this acid are its promptness, thoroughness, and cleanness. It cannot, however, be applied by any one but the surgeon. It should be applied only to the diseased spot under thorough illumination of the meatus by the forehead-mirror. Some authorities speak in high terms of the efficacy of brushing granulations in the ear Avith tincture of opium. If polypi should spring up, with well-defined base or pedicle, they must be extracted by one of the various means described further on, and their attachment to the canal thoroughly touched for several days Avith monochloroacetic acid. In every case Avhere polypi are pulled out, the patient should be told before the extraction that it will be necessary to touch the base of the growth Avith the acid or some other caustic. The treatment just described is that adapted to the ordinary form of otitis externa diffusa with no Averse complication than polypoid granulations or polypi; there are, hoAvever, several other forms of this disease, as already stated, viz., the diphthe- ritic, the gangrenous, the syphilitic, and the parasitic. The treatment Avill be modified in the first three, by the fact that they are much more painful than the fourth. As the first three indicate a constitutional alteration and poisoning of the blood, their treatment must be largely of a supporting and alterative nature. Their names aa ill indicate the kind of blood- poisoning they are due to, and their general treatment must be conducted on the principles folloAved in the same diseases when they manifest themselves elsewhere in the body. Otomycosis.—The growth of either a vegetable or an animal parasite in the external auditory canal, may excite in the latter a form of diffuse inflammation, to Avhich the general term, parasitic otitis may be applied. Judging from the literature of the subject and my own experience, animal parasites are found in the external auditory canal much less frequently than fungi. No special name has been suggested for that form of diffuse external otitis excited by the presence in the auditory canal of animal parasites, but for that kind of aural inflammation excited by the growth of fungi in the auditory canal, the general term otomycosis has been suggested by VirchoAV. 278 EXTERNAL AUDITORY CANAL. The subject of animal parasites and insects accidentally lodged in the external ear will be considered under the head of foreign bodies in the ear, but we shall consider at this point that form of diffuse external otitis produced by vegetable parasites. The most common cause of this form of otitis externa diffusa is the growth in the auditory canal of that kind of fungus called Aspergillus. Its two chief varieties are A. nigricans and A. flavescens° the former of which is found in the ear twice as often as the latter. The ascomycete, i. e. the highest form of development of the Aspergillus, is, as we shall see further on, of very rare occurrence in the ear. Other kinds of fungi have been found in the auditory canal of man, viz.: the Graphium penicilloides, by Hassenstein and Hallier; the Ascophora elegans, by von Troeltsch; the Tricothecium, by Schwartze and Steu- dener; and the Mucor mucedo seu fuscus, by Boke. The Aspergillus is so very much more common in its occur- rence in the external ear than other fungus, that the aural in- flammation it produces is named by Wreden, of St. Petersburg, 3Iyringomycosis aspergillina, for he has observed that this vege- table parasite has an especial proclivity to grow upon the mem- brana tympani. Myringomycosis aspergillina has been most thoroughly de- scribed by Wreden,1 but before his works Avere published, Mayer2 and Pacini,3 Carl Cramer4 and SchAvartze, had described the occurrence of this form of parasitic disease in the external ear. Subsequent to the appearance of Wreden's papers, various authors5 have given fully detailed accounts of this disease and its successful treatment. In seventy-four cases of the disease observed by Wreden, only tAvo forms of fungi have been found, viz., the A. flavescens and the A. nigricans, excepting in one 1 Die Myringomycosis aspergillina und ihre Bedeutung fur das Gehororgan, 1868 ; and Myringomycosis aspergillina, 1869-1873, according to personal and foreign observations, Archives of Oph. and Otol., iv. i., 1874. 2 Beobachtungen von Cysten, mit Fadenpilzen aus dem ausseren Gehorgange, Miiller's Archiv, 1844, p. 401. 3 Supra una muffa parasitica nel condotto auditiv esterno, Florence, 1851. 4 Sterigmatocytis autacustica, a variety of Aspergillus, Vierteljahrschrift d. Naturforseh. Gesellschaft zu Zurich, 1859-60. 5 Schwartze, Von Troeltsch, Boke, Politzer, Gruber, Weber-Liel, J. Orne Green, C. J. Blake, Boosa, Bezold, Lucse, Nolting, Bezold, et al. CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 279 solitary case, in which there was found a fungus richly supplied Avith capsular sporangia or asci, and which, on account of its intense purplish-red color, was called by Wreden the Otomyces purpurea?. This fungus was examined by Woronin, a distin- "Fig. 64 Forms of Aspergillus flavescens removed from the Human Ear.—a. Unique form of double-headed fruit stalk from the ear of a man. B, C, D, E, and F. A'arious stages of develop- ment observed in a specimen taken from the external ear of a female affected with a growth of Aspergillus in both auditory canals. guished mycologist of St. Petersburg, who pronounced it to be essentially different from the Ascophora of Schenk, which belongs to the Mucorini. Upon further investigation, this proved to be the ascomycete or utricular form of the Aspergillus nigricans, the highest form of the "specific aural fungus" of Wreden. Its fertile hyphens were seen to have a double outline under the microscope, and at different places transverse septa, like the fructiferous hyphens in the varieties of Aspergillus which have already been found in the ear. The width of the broadest of them Avas 0.00572 mm. to 0.00715 mm. in diameter. The double-outlined Avail of the fungus is of a bright yellowish- red color, 0.00143 mm. thick. The fruit end of the hyphen is composed of a comparatively very large, red, round, vesicular sporangium, Avhich consists of a thick-walled capsule and a 280 EXTERNAL AUDITORY CANAL. number of round spores, Avhich completely fill its cavity. The diameter of the large sporangia is 0.0572 mm. to 0.06435 ; that of the smaller ones is 0.02145 mm. to 0.0429 mm. The thick- ness of the capsule Avail is 0.00143 mm. to 0.00214 mm. Dr. J. Orne Green1 has lately published an account of finding in the ear a similar fungus, which he calls Aspergillus rubens. Aspergillus is usually found growing at the fundus of the external auditory canal. It seems to seek the most secluded part of the canal, and hence is most likely to groAV first upon the membrana tympani, from Avhich it spreads outward over the entire auditory canal, forming a kind of false membrane in the shape of a glove-finger. This false membrane is composed chiefly of mycelial netAvork, with all forms of aerial fructifica- tion of the plant, and some epithelium from the auditory canal. The pseudo-membrane thus formed has been said to have a lardaceous appearance; it also resembles a piece of wet neAvs- paper lining the auditory canal. The sporangia are usua ly found on the surface of the false membrane turned towards the membrana tympani, and the wall of the auditory canal. Although the most perfect forms of growth of the fungus are usually found near the drum-membrane, I have seen specimens so flourishing at the mouth of the auditory canal, that the latter appeared to be sprinkled with bright-yellow pollen. In such a case, recently observed, the membrana tympani was not seriously implicated. Usually, however, the membrana tym- pani is injured by the aspergillus, but not permanently. An auditory canal Avhich has been the seat of inflammation is most liable to be invaded by the aspergillus. It seems that the remnants of the inflammatory disease, such as pus, dried mucus, epithelial ddbris or blood, form excellent soil for the growth of the parasite. It has been observed long ago, that an active discharge from the ear is unfavorable to the growth of aspergillus in the ear. Aspergillus cannot be in an auditory canal for any length of time Avithout causing the characteristic symptoms of its presence; an exceptional case Avould seem to be one reported by Moos.2 The growth of an aural fungus is usually confined to cutis of the membrana tympani, as shown 1 Proceedings of Boston Society of Med. Sciences, 1875. 2 Archiv f. Ohrenheilkunde, Bd. II. p. loo. CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 281 by Wreden, but, in very rare instances, the parasite may invade the fibrous layer of the drum-head, and finally take root in the cavity of the tympanum, as has been observed by Politzer1 and others. Symptoms.—The symptoms of this disease are a sense of ful- ness, .slight pain, burning, itching, tinnitus aurium, and hard- ness of hearing. The vessels of the malleus become congested, and in a day or tAvo the membrana tympani becomes hidden by a thick, Avhite, false membrane. The slight serous discharge which now sets in, marks the detachment of the false membrane, and the cessation of the pain. In some cases the cutis of the auditory canal becomes deeply inflamed, but not invariably. The pain may become intense if the parasite is not removed. Males are more frequently attacked than females, according to Wreden, Avho has seen fifty-one of the former, and tAventy-three of the latter sex, affected by fungi in the ear. In ten cases of this disease which have come under my notice in private, only three Avere females. So far, this disease has never been found in very young children nor in the very aged. The oldest patient I have observed with this disease of the ear Avas a man 67 years old. The folloAving case, in AAdiich a perfect mycelial tube-cast of the auditory canal Avas removed by the author, will supply all the typical features of an ordinary attack of the disease, and will be seen to agree in the main Avith the observations of others. The patient Avas under treatment for so-called chronic catarrh of the middle ears, complicated by ozsena. She stated that for more than a year she had had, from time to time, sudden attacks of pain in the left ear, Avhich lasted for a day or two with more hardness of hearing, and then suddenly ceased, with a slight Avatery discharge from the affected ear. The hearing then returned to its relatively normal state. When she told me this she Avas free from pain, and the drum-head and auditory canal Avere in the condition usually seen in a case of ordinary progressive hardness of hearing, Avith intact but opaque drum- head. Within ten days from that time, she came to me, stating that she had had, two days before, an attack of the pain already described, Wiener Med. Wochenschrift, 28, 1870. 282 EXTERNAL AUDITORY CANAL. and that there was still a little discharge from the ear. I exam- ined the ear and found the inner portion of the osseous auditory meatus and the membrana tympani covered with a false mem- brane looking like wet newspaper. I instantly inferred the presence of a fungus, and removed the false membrane very easily by means of a pair of forceps. The removal of the false membrane caused no pain, nor Avere the parts beneath it very red and sensitive. There was a slight serous discharge from the ear, a drop of Avhich I examined immediately upon a care- fully cleansed slide nnder the microscope, and found that it contained no pus, but myriads of brownish-yellow spores of the Aspergillus flavescens and vibriones.1 The tube-cast into which the mycelial false membrane had been moulded, was composed chiefly of thalli, and upon its sur- face Avere free spores and tufts of aerial fructification of the A. ■flavescens ; throughout the false membrane thus formed were scattered epithelial scales. The hyphens, or fruit-stalks, were not septate, and their large, bulbous ends, from which the spores rise, Avere a beautiful golden-yellow color, and resembled, in their general shape and appearance, an ordinary onion-top. In reference to the etiology of this case, it may be stated that the patient had lived for some time in a very damp house, the cellar of which was " covered with mould," but before she had come to live in that house she had never suffered from any fungus-disease in the ear, as far as she knew. The chronic disease of the ear may have predisposed the ear to a development of fungi, such a tendency having been found in other cases of chronic aural disease by Wreden and various observers. The hearing was impaired only from the onset of the pain until the false membrane Avas removed. Had I attempted to remove the false membrane during the pain, I might have found that its removal Avas difficult for me as well as painful to the patient. In this case, hoAvever, the cessation of pain, the easy removal of the false membrane, and the absence of redness 1 Pouchet (comptes rendus, 1864, p. 148) has found bacteria and vibriones in a discharge from the ear, attended "with itching. Hinton, Questions of Aural Surgery, London, 1874, p. 79. CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 283 of the subjacent parts, seem to indicate that nature had already commenced a process of loosening and removal of the fungus- cast of the parts of the ear attacked by the aspergillus. It has been observed by others that an attempt to remove the false membrane in these cases is usually folloAved by pain, sometimes bleeding. This must be because the false membrane has been touched in a stage of the disease earlier than the one called the natural process of loosening, in which the tube-cast alluded to was removed. All symptoms of the disease in this case disappeared under treatment which consisted chiefly in the use of instillations of absolute alcohol, several times daily, and persevered in for seve- ral Aveeks. The hearing, which Avas not normal before the for- mation of the false membrane, was found to have been unaltered by the disease, although the external auditory canal had passed through the various stages of the light diffuse inflammation incident to an attack of otomycosis. A vegetable parasite, seeking the most secluded spot in the ear for its growth, is most likely to be found on the drum-head, but fungi may grow on the Avail of the auditory canal and nowhere else in the external ear, as in a case of ascophora found by Von Troeltsch in a solitary patch on the wall of the external auditory canal. Aspergillus not only spreads from the drum-head to the Avail of the auditory canal and vice versd, but it perforates the drum- head sometimes and finds its way into the drum-cavity, as in the case reported by Politzer.1 The folloAving case is one of growth of aspergillus in the tympanic cavity: A young lady, 18 years old, applied in the autumn of 1872, to the author, for relief from a slight but con- stant discharg-e from the left ear. She stated that the discharge had never been attended by pain, that it was light colored and almost transparent. I found the external auditory canal free from disease of any kind, but the drum-head was destroyed excepting in the region of the tympanic folds; the malleus Avas still present. It Avas impossible to find out how long the fungus had been groAving in the ear, for Avhen it Avas first detected by the 1 Ueber pflnnzliche Parasiten im Ohre. Wiener Med. Wochenschr., 1870, 28. 284 EXTERNAL AUDITORY CANAL. patient's bringing me a flake, dotted with blackish spots, which she had removed from her ear, there were no subjective symp- toms difterent from those Avhich had been connected with the case for years, according to her statements. In order to allay a little itching in the ear, the patient had thrust a hairpin into the tympanic cavity, through the largely perforated membrana tympani, and had pulled out the whitish scale, studded with black spots, alluded to. The auditory canal Avas, and had been for months previous, free from all traces of anything of this nature or appearance, for she had been under constant treatment for the chronic dis- charge, which had obliged her to syringe the ear several times daily. That this specimen Avas pulled from the tympanic cavity was fully proven by the patient's using a hairpin again and bringing out in my presence more fungi on similar scales, which Avere instantly examined under the microscope. By the use of instillations of absolute alcohol thrice daily, and syringing the ear with Avarm Avater, all traces of the fungi and the discharge disappeared, and the ear remained free from itching and serous discharge for some weeks. Although the patient was living in affluence and perfect hygienic surround- ings, the itching and discharge again returned, but all the symp- toms Avere once more relieved by the use of alcohol-instillations in the ear with careful and thorough syringing. This case I mention as a proof that otomycosis is not neces- sarily a disease of the external auditory canal, although as a rule it is. In the case just narrated, perhaps we have a very rare exception, unless it can be sIioavii that in many cases a thin serous or sero-pnrulent discharge from the middle ear is kept up by the presence of fungi. Perhaps this case began as one of myringomycosis in which the fungus, after destroying the drum-head, excepting in the region of its folds, penetrated into the drum-cavity and flourished there. Etiology.—Respecting the etiology it may be stated that dampness of the dwelling, previous disease of the ear, and the use of oleaginous remedies for different aural diseases are the most fruitful causes of this disease. Otomycosis is said to be much more frequently met among the poor than in the richer classes of any country. My experience CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 285 is just the reverse. As the climate, and consequently the dwell- ings, of northern continental Europe are damper than in this country, Ave can account for the fact that this disease appears to be more frequent there than here, and therefore attention has been called most thoroughly to this form of aural disease by Avriters in Germany and Russia. Mr. Hinton, of London, has rarely found aspergillus in the ear; but Dr. Cassells, of Glasgow, has met Avith it frequently in his experience. Previous diseases of the ear, especially those productive of exfoliation of epidermis, and those Avhich have left behind them collections of dried pus or any of the products of inflammation in the auditory meatus, may induce a groAvth of vegetable saprophytes. It is now established beyond doubt, especially by the inves- tigations of Bezold,1 that the use of oil in the ear for pain is one of the most fruitful causes of the growth of fungi in the auditory canal and on the drum-head. Oils and all forms of grease put into the ear are usually forgotten Avhen the pain is gone for Avhich they Avere applied. They soon become rancid, and thus favor the groAvth of vegetable parasites, Avhich finally produce all the well-marked symptoms of otomycosis. The fact furnishes the strongest argument against the com- mon and senseless use of SAveet oil for all ear diseases. It is entirely useless as a remedy for pain, and worthless as a solvent for inspissated wax; for a little reflection will at once make it apparent that oil will not dissolve the semi-oleaginous ear wax, but that to soften and detach it we need only a slightly alkaline Avash. This is not only more efficient than oil, but cleaner and free from the danger of encouraging the groAvth of fungi. It Avould also be well for physicians to see that salves and ointments, which must be prescribed sometimes for aural maladies and applied to the auditory canal, are thoroughly Avashed out at last, when all further need of their presence in the canal has ceased. In some instances, though a pure form of aspergillus may invade the fundus of the auditory canal, a bastard form of aspergillus and penicillium may spring up nearer the meatus. 1 Die Eutstehungvon Pilzbildung iin Ohr. Monatschr. f. Ohrenh., Juli, 1873. 286 EXTERNAL AUDITORY CANAL, This has been observed by Hallier and Blake.1 I have fre- quently observed the pure forms of aspergillus, but never any bastard variety of fungus in the ear. Treatment—Many high authorities in this country regard thorough and frequent syringing the ear with water as sufficient to destroy vegetable parasites. While this is indispensable, it is not entirely sufficient, and must, therefore, be aided by a more poAverful parasiticide. One of the best and most soothing parasiticides is hypochlorate of lime (gr. ij-aq. fl.Sj), as recom- mended by Wreden. Next to this, according to the same authority, Fowler's solution, used locally, is the most efficacious. Dr. J. Orne Green found in his own case, that hypochlorate of lime Avas more soothing than either carbolic acid or solutions of soda. Bichloride of mercury, acetate of lead, solutions of veratria, tincture of iodine, and solutions of tannic acid have been recommended as parasiticides by various authorities. Having observed that a solution of bichloride of mercury, gr. j to fl3J of water, excited nausea, dizziness, and vomiting, I have refrained from ever using this drug, in any way, as a local application in the ear. Of course, a chief element in the treatment of inflammation in the external ear, caused by the growth of fungi, must be the removal of the patient from the source of the spores of the fungus. If it should appear that the spores are acquired from fungi groAving in a damp dwelling, then the patient should be removed from such influences. It Avould also be well to see that the particular room or bedding occupied by the patient is not mouldy, and hence the source of the disease in his ear. The masses of fungus which have collected in the ear—--and these may be so great as to extend from the fundus of the auditory canal to the meatus externus—should be removed as quickly as possible. The detached masses are easily extracted from the ear; the adherent ones can usually be pulled aAvay by gentle traction, or a safer plan Avould be to go on with the use of the parasiticide until the layers of the fungus are spontaneously detached, Avhen they can be syringed out. 1 Dr. C. J. Blake ; Parasitic growths in the meatus auditorius externus, Transactions American Otological Society, vol. i. p. 170, 1871. FOREIGN BODIES, 287 Since, in cases of otomycosis, inflammation is usually present, nothing but the most soothing remedies should be employed. Warm water is absolutely an essential means of cure. This should be syringed into the ear, or allowed to flow in from the aural douche. After the ear is thus perfectly cleansed, instilla- tions of alcohol and of hypochlorate of lime should be employed freely in the ear. The former may be used in its absolute state or diluted; the latter, in the strength of two grains to the ounce of water. It is recommended that the latter be used freshly mixed each time of application to the ear, on account of the chlorine and oxygen set free. So far, I have given the prefer- ence to alcohol, either alone or diluted with Avater, If the skin in the auditory canal is broken, alcohol may burn at first, but it has never in my experience increased the inflammation, and it always destroys the parasite. CHAPTER II. FOREIGN BODIES IN THE EXTERNAL EAR. Animate as AATell as inanimate bodies are frequently found in the external ear, where they become of great surgical importance from the annoyance, inflammation, pain, and deafness which they are very apt to produce, as well as from the fact that they may find their Avay into the middle ear, Eustachian tube, or even into the internal ear. Their source may be either from within or from Avithout, Under the first class may be placed: abnormal collections of ear- Avax from the ceruminous glands; masses of horny epithelial scales, forming the so-called Keratosis obturans of Wreden; and collections of stiff hairs from the tragus and auditory canal; also clotted blood, inspissated aural discharges, scales of dead bone, and, in one sense, many of the new formations of the external ear. But, of these varieties of foreign bodies, only the first three should be considered here, and the remainder are discussed elsewhere. Under the second head may be classed all animate or inani- mate things small enough to have gotten into the external ear. 288 EXTERNAL AUDITORY CANAL. The manner in which they may get into the ear is extremely varied. Foreign bodies of this class are most frequently found in the ears of children, where they are placed usually in play, by the victim or its companions; or foreign substances may be thrust into the ears of adults and of children, by accidental or intentional violence. Animate bodies fly or craAvl into the ear of man. FOREIGN BODIES ORIGINATING IN THE EAR. Collections of Cerumen in the Ear.—According to Petre- quin, the cerumen consists mainly of fat and combinations of potash and fatty acids in the following proportions: In 100 parts of cerumen are found: 10 parts of Avater, 26 of fat, 38 of soapy combination of potash soluble in alcohol, 14 of a similar combination insoluble in alcohol, and 12 of entirely insoluble organic matter, Avith traces of chalk and soda. The name cerumen is probably a corruption of a word com- pounded of cera and aurium, the wax of the ear. The word cerumen, however, does not appear in modern Latin dictionaries. The appearances of an impacted plug of cerumen in the external auditory canal are not very varied. Usually, they are easily recognized, but now and then, especially Avhen the im- pacted mass is due to sIoav accretion by the daily pushing in and smoothing doAvn of its layers by the toAvel or fingers of the patient, it will not be easy for the unpractised eye to recog- nize the mass at once as one of cerumen, for, in some cases, the impaction has so completely adapted itself to the fundus of the meatus and the drum-head, as to resemble a dark and polished membrana tympani. In many cases such a polished mass of cerumen may be regarded as a someAvhat abnormally colored drum-head, and treated as such, the deafness dependent upon the impaction of the wax being attributed to other causes, and in some way connected Avith the " discolored membrana tym- pani." Such failures in diagnosis lead to curious results. It is, indeed, not uncommon to find patients suffering from impaction of cerumen in the auditory canal, being treated for some other aural affection Avhich they do not possess. Thus, the Eustachian catheter and instillation of nitrate of silver have FOREIGN BODIES. 289 been applied to relieve the deafness which a proper syringing would have speedily cured. The mere fact that the drum-head is hidden from siglit should be sufficient proof that an abnormal obstruction has occurred in the auditory canal, and this alone ought to be considered as the probable cause of the unpleasant symptoms for which the patient seeks relief. These unfortunate failures in diagnosis are but the natural result of the unwillingness on the part of most medical men to devote any time to the study of diseases of the ear, but they are mistakes which might be prevented if the general medical eye were at all familiar with even the appear- ances of a normal drum-head and meatus. In fact, many an ear might be saved if the physician first consulted could frankly state to the patient the nature and locality of his aural disease, although he might be unwilling to assume the treatment of it. The rapidity Avith which masses of cerumen accumulate in the external auditory meatus varies greatly. In some indi- viduals, I have removed second and third obstructive plugs in the course of a few months. In other cases, judo-ino- from statements of the patients, the plug must have been accumu- lating, and giving some annoyance in the way of tinnitus and deafness, for years. As a rule, the deafness caused by a plug of cerumen in the auditory canal is of sudden approach, although the foundation of the offending mass may be much anterior to the hardness of hearing. In most cases the aggravated deafness comes on suddenly after a bath. In such cases, the patient thinks that Avater has gotten into his ear and is still there, or just after washing out the concha or meatus in the morning, a little more forcibly than usual, the patient finds that he can- not hear so Avell. In the former case, the mass which has, up to the time of the bath, permitted the sound Avaves to pass it, becomes SAvollen by the water which has gotten into the ear, thus cutting off all approach to the drum-head. In the latter case, not only the Avater, but the patient's finger, by pushing the plug further in, has contributed to the onset of the hardness of hearing. Etiology of Rapid Formation of Cerumen.—There are many opinions respecting the cause of a rapid and abnormal secretion of cerumen, such as is seen in all AATalks of life. As the ceru- 19 290 EXTERNAL AUDITORY CANAL. minous glands are really perspiratory glands modified, it is reasonable to suppose that a large amount of cerumen is in some way connected with the perspiration. Large amounts of ceru- men are found in the laboring classes, whose perspiratory system is of course very active, and I have obserATed that in persons leading a life of ease, in Avhom large and rapid masses of ear- wax are sometimes formed, the perspiratory glands in the axilla are unusually active. But I am not prepared to say that when- ever the axillary glands are unusually active we are sure to find large amounts of ear-wax in such cases. After certain acute processes in the ear, as for example furunculi in the canal, or an otitis media acuta, which has healed rapidly, I have ob- served a tendency to a rapid formation of normal wax in the ear. This is apparently due to the stimulation of the circula- tion of the meatus consequent upon the acute inflammatory aural disease. It is held by some1 that quinine, Avhich affects the nerATous structures of the inner ear, may also have great influence over the sound-conducting parts of the ear, i. e. the external and middle ears, and that therefore the secretion of cerumen is stimulated by this drug. The amount of cerumen is sometimes increased, after a tonic course of treatment for the general health, in certain cases of deafness. But the repeated formation of obstructive masses of cerumen in the auditory canal appears to be an idiosyncrasy in some cases, and is probably unexplained yet. The only apparent connection between it and other glan- dular activity has already been mentioned as possibly occurring in some cases in which active perspiratory glands and abnormal accumulations of wax have seemed to be united. But in such cases great care must be taken to discriminate between impac- tion of cerumen and keratosis obturans, a disease to be described hereafter. When the onset of hardness of hearing in cases of impacted cerumen is rapid, it will usually be found that the mass has formed without the knowledge of the patient, and is in no Avay due to his endeavors at cleansing the auditory canal. When the deafness due to impacted cerumen has been coming on sloAvly for months, sometimes for years, it will usually be 1 Roosa; Transactions American Otological Society, 1872. FOREIGN BODIES. 291 found that the patient has been in the very bad habit of swab- bing out his ears, most commonly Avith the rolled-up corner of a towel, and sometimes with that most pernicious and repre- hensible implement, a piece of sponge fastened to a stick, and sold by the druggists under the high-sounding name of an " aurilave." In these cases the plug will be found well packed in and moulded to the fundus of the auditory canal and drum- head. Such masses are not very hard to remove, considering the long period of their accumulation; they are usually found to contain large quantities of short fibres of cotton or linen from the towel used in the efforts to cleanse the ear. Impaction of cerumen by attempts at cleansing the meatus not only occurs among adults, but is found among children, Avhose over-anxious attendants are constantly swabbing out the meatus of their charges, with a corner of a towel, or Avith other means.1 Such cases may sometimes result in Avhat may be called a chronic ulcer of the bony portion of the auditory canal, or in the groAvth of a large polypus from an ulcerated spot on the Avail of the bony meatus very near the drum-head. In these cases of artificially impacted epidermis and cerumen, the foreign mass usually assumes the form of a hollow cast of the auditory canal, or a glove-finger, Avith a cast of the drum- head on the tip. These cases are usually stubborn, and in some instances threaten the integrity of the bony structure of the auditory canal. In a case which I saw recently, not only a polypus sprang from the ulcer in the auditory canal, but the drum-head Avas ulcerated through, and Avater passed into the pharynx Avhen syringed into the external ear. The patient, a boy eight years old, Avas carefully watched over by his nurse, Avho used daily the so-called aurilave, upon the little patient's ears. The impacted mass of epidermis and cerumen at last excited pain in the ear, and upon removal ofthe mass, Avhich came out in the glove-finger shape, the skin of the auditory canal was found to have assumed almost the appear- 1 Similar conditions ofthe ear have been observed by Mr. Hinton of London. See supplement to Toynbee on the Ear, London, 1868, p. 429. 292 EXTERNAL AUDITORY CANAL. ance of a mucous membrane. The most ulcerated portion was at the anterior Avail near the drum-head, and the latter was perforated largely at the postero-inferior quadrant. The dis- charge was rather thick and dark-colored, not very copious, somewhat offensive, but the hearing was very little altered. Under daily syringing and mild astringents the membrana tympani closed up, and the patient disappeared from my treat- ment for six weeks, at the end of which time, Avhen he was brought again to me, the membrana tympani was found to be still intact, but from the ulcerated spot in the canal near the drum-head, a polypus, the size of a small pea, Avas detected in the furrow between the drum-head and the anteroinferior part of the bony canal. The polypus was removed, the discharge ceased directly, and the hearing became normal. Treatment—The treatment of simple impaction of Avax in the ear consists in the use of the syringe, as explained already (p. 175). Cretaceous Bodies in the External Auditory Canal.— According to Rau1 cretaceous masses in the auditory canal are the rarest kind of foreign bodies found in the ear. But accounts of such bodies being scattered throughout the Avorks of other Avriters, the}^ appear not to have been very uncommon. Du Verney and Leschevin2 appear to have had frequent ex- amples of them in their experience, and in Williams' Treatise on the Ear3 (London 1840), the statement is found, on the authority of Autenrieth of Tubingen, that " in the bodies of almost all old people there is found, in the innermost part of the meatus auditorius externus, a firmly attached lump of indurated ear-wax, which, in old age, acquires a disposition to crystallize, partly in an earthy form," and also that " Morgagni has found the cerumen of the hardness of stony matter." But these bodies are not frequently met in the present clay. I am 1 Ohrenheilkunde, pp. 3C7-368. The authorities given are, Thorn. Bartho- lini, acta medica et philosoph. Hafuiensia ann. 1671 et 1672, 4 T. I. p. 82. L. C. F. Germanni, de miraculis mortuorum libri ties. Dresd. et Lips., 1709, 4 Lib. 3. Tit, 3. Sect. 50, p. 1090. Du Verney, p. 156. C. J. Myller, miscell. nat. cur., Dec. 2, Ann. 6, Obs. 262, p. 326. Collomb, CEuvres Med. Chirurg., Paris, 1790, p. 304. 2 Lincke's Sammlung, I. No. 1, p. 29, 1835. 3 p. 184. FOREIGN BODIES. 293 not aware of any record of such a case in modern literature, nor have I ever met such cases in the many hundreds of ears of old people I have examined in various infirmaries. But, since it is a Avell-knoAvn fact that mineral substances, such as potash, chalk, and soda, enter into the composition of the cerumen, it is not improbable that now and then stone-like bodies are found in the auditory canal, Avhich owe their existence to the mineral elements of the cerumen. If they were once more frequently met Avith than in the present day, and such appears to be the case, it can be accounted for only by the greater prevalence of the custom of syringing and cleansing the ear among the laity at the present time. Treatment.—If such bodies should be found in the ear, the treatment of them may be effected as detailed in the general summary at the end of this chapter. Laminated Epithelial Plug in the External Auditory Canal.—This obstructive disease of the external ear has recently been described by Wreden1 of St. Petersburg, and named by him keratosis obturans, in contradistinction to ceruminosis obturans, the impacted plug of ear-Avax, with which it has often been confounded, though differing from it very widely. The latter disease, as its name implies, consists of a mass of inspis- sated cerumen, but it is easily removed by proper syringing, and the ceruminous nature of the mass removed from the ear is recognized, among other features, by the rapidity Avith which it dissolves in Avater. Keratosis obturans, however, recently described as a separate and special disease of the ear, is a collection of epithelial lami- na?, derived from the cutis of the external auditory canal, of gradual accretion, causing great deafness, and very obstinate in its resistance to removal. Every one Avho has had any extended experience in removing from the ear impacted endogenous masses, usually of cerumen, must have noticed that now and then a peculiar mass is encountered, requiring a piecemeal re- moval by patient, and careful use of syringe and forceps, and which, after lying a long time in Avater, Avill not dissolve as ordiuarv ear-wax does. It is such exceptional masses that ' Archives of Oph. and Otol., 1874. 294 EXTERNAL AUDITORY CANAL. Wreden has investigated, and, finding that their composition is not of cerumen but of the horny elements of the cutis, he has proposed for them the name of keratosis obturans. These obstructive bodies are not confined to any age or sex. Wreden states that his attention Avas first called to their pecu- liar nature by meeting a very adherent one in the ear of a little o-irl. In this case he Avas so fully impressed with the suspicion that he Avas dealing Avith a wad of soft Avhite paper, maliciously placed in the ear by the young patient, that he accused her of the deed, and, although she denied it, he was not convinced of the truth of her denial until the microscope revealed the fact that the mass he had Avith great difficulty removed Avas com- posed of epithelial elements arranged in peculiar laminse. Upon inspection of an ear containing such a mass as has been de- scribed, a'thin layer of ordinary cerumen may be seen covering the outer surface of the plug, and hence the impression often gained that the case is one of ordinary ceruminous impaction. But continued syringing, by its barren results, soon conAances the operator that he has encountered no ordinary obstruction. The first case of this disease I had the opportunity of ob- serving occurred in July, 1874, since which time I have seen seA^eral cases in private as well as in the infirmary. The patient Avas a banker, sixty years old, suffering from sudden and intense deafness in the occluded ear, with some tinnitus and vertigo. The auditory canal was almost entirely blocked up by the dense, horny mass, Avith the outer end covered by cerumen. The patient stated that ten years previous he had been liable to attacks of pain in the auricle, especially about the lobe, Avhich Avere folloAved by a crop of vesicles and pustules, probably a form of herpes zoster. Since then he has had no pain in or about the ear, but at times he has noticed, Avithout any appa- rent previous cause, a thin and somewhat offensive discharge. At first sight I thought the case one of impacted cerumen, mingled possibly with inspissated mucus and pus, but the utter failure of the attempts with the syringe to move the impacted mass at the first sitting convinced me that the case was one of those described as keratosis obturans. Owing to the fact that the auditory meatus was rendered abnormally tortuous by two large exostoses of the canal, one above, the other below, it required patient and careful picking FOREIGN BODIES. 295 and syringing for half an hour for eight days before all of the foreign body was removed, with, at last, a restitution to nor- mal hearing. From statements of the patient it appeared probable that similar though smaller and less annoying plugs had been removed from the same ear before, by himself, but he could not give any idea as to the length of time the present one had been forming, as the onset of deafness, the only symptom first attracting his attention to the ear, had been almost instan- taneous. This patient had a slight return of the disease, one year after the above attack, but it was entirely removed by soak- ing the mass repeatedly for twenty-four hours with a solution of bicarbonate of soda (gr. xx) in glycerine and Avater, aa f^ss. Usually in these cases of keratosis in the external ear, no part of the mass comes away as a coherent plug, but the whole must be broken doAvn and removed in small pieces. In the case narrated, hoAvever, about half of the mass was removed as a Avell-defined plug. When the horny and laminated mass was first washed out of the ear, it was perfectly Avhite, and resembled a set of layers of Avet tissue-paper slightly separated from each other by the buoyant effect of the Avater. When pressed upon, it had the tough leathery feel of a Avad of wet paper, Avhich peculiarity will always distinguish it from the ordinary cerumen-plug of soft and greasy consistence. As insolubility of the removed mass is one of the distinctive features of this peculiar aural disease, a mass may remain as long as five months in glycerine and Avater without undergoing change. I exhibited such a mass at the Philadelphia Patholo- gical Society, in December, 1874. This specimen, for several months longer, lay in the same preservative fluid, and still there was no dissolution of the mass. Of course, had the mass been formed of ceruminous elements, it Avould have melted doAvn almost instantly, and distributed itself throughout the fluid. This resistance to solution Avill readily account for the diffi- culty of its removal from the ear. Etiology.—!N"o cause has been suggested for the occurrence of this disease of the external ear, and, although among the lami- nas composing these masses Wreden has sometimes found vege- table spores, he is not inclined to ascribe the origin of the mass to the irritative presence of a fungus in the auditory canal. 296 EXTERNAL AUDITORY CANAL. I have observed that the Avails of the auditory canal in these cases is not healthy, but presents a more or less roughened sur- face, with inflamed hillocks, and it may be a chronic inflamma- tion of the skin of the canal, Avhich predisposes it to this peculiar and sIoav exuviation of its horny elements, which being retained in the canal, at last form into this extremely tough and resisting plug. Treatment.—In cases shoAving a decided tendency to recurrence or renewal of these groAvths in the ear, care in preventing an accumulation of the horny laminoe, by close watching and speedy removal of the slightest amount of scales, will greatly simplify the disease and the treatment. The solution of soda already mentioned (p. 295) will be the simplest and the best loosener of the plug from the Avail of the canal, but sooner or later recourse must be had to forceps and blunt probes, for this disease seems to furnish the exception to the rule never to use anything more forcible than the stream from the syringe for the removal of foreign bodies from the ear. Of course the greatest care must be observed in the use of such instruments, and no one but the most experienced surgeon is justified in attempting to remoAre such a mass by instrumental means. It is with great caution that I advise their use, and still greater caution that I use them ; but as I have resorted to them, and only by their use succeeded in removing the keratosis, I must, in these cases, give their due to such instruments. With perfect illumination of the meatus, proper instruments and cautious movements, added to a thorough knoAvledge of the use of the implements and the part to be operated on, success must attend their application. The forceps, represented in the wood-cut, same size as origi- nal, is made to open and close very gently, and, being slender, cannot take a very firm hold upon the impacted mass of kera- tosis, but it is strong enough to pick off and lift away portions of the obstruction. The loss in strength caused by the narrow- ness of the branches of the instrument is fully compensated in the greater illumination gained by its slender shape, and it is also a much safer instrument than the stronger, thicker, and stiffer forceps usually made for removing foreign bodies from the ear. For removing objects more delicate than masses of FOREIGN BODIES. 297 keratosis obturans, it is of the greatest value. It is just as necessary to have such a delicate instrument as this to lift things from the ear, as it is to work with delicate and very pliable forceps in manipulating small objects undergoing pre- paration for microscopic use. In fact most aural instruments are too large. Illumination of the canal has too often been sacri- ficed to the strength of the instrument. Fig. 65. Prof. Gruber1 recommends forceps Avith branches quite as delicate as these, but much shorter. The longer branches enable the operator to keep his hand much more easily out of his oavu light. I fully agree Avith those Avho earnestly deprecate the use of any other instrument than a syringe for the removal of foreign bodies from the ear, as Ave shall usually find that Avhere a syringe will not remove the foreign body no other instrument will serve our purpose. But like all other good rules, it has its exception. The forceps of course must never be tried until all other means have proved of no avail, and then only in the hands of the most experienced and under the most perfect illumination ; for any manipulation of the ear resembling a blind grappling after the foreign body Avill most surely prove disastrous. Un- ' Lehrbuch d. Ohrenheilkunde. 298 EXTERNAL AUDITORY CANAL. fortunately the proper occasion for the use of the forceps is almost invariably in an emergency, and is performed by the most unexperienced hands. An examination into the facts of the case, moreover, where they must be used, will usually reveal that originally they were not needed, and the simplest syring- ing at the outset Avould have rendered the use of any other instrument unnecessary. The only justifiable use of forceps at the outset may be in a case of keratosis obturans, but even in such cases all instru- ments must be used with the greatest caution in conjunction with repeated and thorough syringing. The accidents happen- ing to the ear, from the ignorant use of instruments for the removal of foreign bodies, are very numerous and are increasing in number all the time. Ingrowing Hairs from the Tragus, resting on the Mem- brana Tympani.—Sometimes, though rarely, the growth of hair on the tragus may be so copious as to block up the external meatus or pass into the canal and rest upon the drum-head. Such cases have been observed and reported by Dr. Weir,1 of XeAv York. In some instances the entire auricle, especially at the helix and tragus, may be the seat of excessive and almost ludicrous pubescence. In such cases of excessive amounts of hair near the auditory canal, loose hairs may get into the auditory passage, or masses of them block it up so as to induce hardness of hearing. The symptom of single hairs on the drum-head Avill be a scraping sound heard only by the patient whenever the jaAvs are moved. If cerumen aid in the matting of the hair about the external meatus, considerable deafness may be the result. Treatment.—Epilation may be applied to the hairs on the tragus as a preventive means. If the hairs have led to obstruc- tion in the canal, the foreign mass must be removed on general principles. 1 Transactions American Otological Society, 1870, p. 30. FOREIGN BODIES. 299 FOREIGN BODIES FROM WITHOUT. Inanimate Objects.—From time immemorial children have pretended to place various kinds of seeds, beads, etc., in one ear and bring them out at the other, for the amusement of them- selves or their younger and more ignorant companions. The latter are often victimized by attempting to imitate the deeds of the elder children, and succeed only as far as inserting the foreign body. Some time ago, I removed a honey-locust bean from the ear of a negro-boy, thirteen years old, Avhere there is every reason to believe the bean had been introduced two years before. The bean Avas in a perfect state of preservation, and had given no trouble to the boy, Avho said he had been induced to " put it in his ear, because he had seen the big boys do the same thing, pretending to remove it again through their noses." He had tried the experiment and failed, but, as the inserted bean never gave him any pain, he had never told any one of it, "for fear of parental punishment." While examining the ear for purposes of comparison with another, I discoA^ered the bean, Avhereupon the boy told the above tale. The bean Avas finally lifted out by forceps with the greatest ease. Children are very fond of stroking their faces and various parts of their body Avith beads or any similar object Avith a polished surface. It is while thus amusing themselves, by stroking their ears, that beads, etc., often slip into the audi- tory canal. The variety of such bodies found in the ear is end- less, being Avads of paper, all kinds of seeds, and small beans, beads, round tips of pencils and penholders, pieces of slate-pen- cils, and little stones, buttons, etc. Usually the foreign body is placed in the ear by the victim ; sometimes it is pushed in there slily by his playmates. Sometimes during quarrels various long objects, such as straAvs, pencils, pen-holders, bodkins, etc., are thrust into the ear maliciously, both among children and adults. I remember a case in which a Avoman, having a grudge against a man, Avatched her chance to box his ear, during the time he scratched his ear with a pen-holder, such being his custom. The opportunity offered itself, the man received his box on the ear, and the pen-holder, being pushed suddenly into the canal, penetrated the drum-head. While this could hardly be called a foreign body which 800 EXTERNAL AUDITORY CANAL. remained in the ear any length of time, it serves to show how the ear may be injured by even a short presence of a foreign body in it. Foreign bodies remaining some time in the ear are usually found among little children, as already stated, or if a foreign body is found in an adult, it will often be found upon inquiry to have been put there during childhood. I have in my cabinet a specimen illustrative of such a case. It is a blue bead seven mm. in diameter, four mm. in thickness, and perforated at its centre, removed with a mass of inspissated cerumen from the right meatus auditorius externus of a Avoman 68 years old. The patient was entirely unaware of its presence in her ear, and, of course, could give no account of its mode of getting there. It was in all probability placed there in her childhood and forgotten, as it produced neither pain nor deafness. Later, hoAvever, the accumulation of cerumen became so great as to cause deafness, and the removal of the obstructive mass to relieve the deafness led to the discovery of the blue bead. Upon closer inspection of the bead by the patient, she stated that she could recall having played with just such beads Avhen she was about eight years old, and such being the case, it is fair to presume that the bead had quietly rested in her ear for sixty years, one of the longest periods of retention of a foreign body in the ear on record. Dr. LudAvig Mayer,1 in an article on foreign bodies in the ear, mentions four cases in Avhich the foreign substances were in for four years, tAvo for twenty years, one for forty-five, and one for over sixty years. The case I have just narrated would of course be a rival of the last one named in Mayer's list. Deleau states that he once removed a small snail-shell from the auditory canal of a woman, Avho knew nothing of its pre- sence in her ear.2 The same author relates having removed from the ear of a boy five years old another shell (pucellage), after it had caused pain and distress by its presence in the ear for a year. Marchal3 extracted a coral bead, Avith a ragged surface, from 1 Monatsschr. f. Ohrenheilkunde, Jahr. IV. No. 1. 2 Gazette Medicale de Paris, tome ii. 1834, No. 11, pp. 161-163. 3 Revue Med. Francaise et Etrangere, Jan. 1844. FOREIGN BODIES. 301 the ear of a military officer fifty years old, in whose ear the bead Avas placed Avhen the patient Avas fifteen years old. Some time since I removed by a few gentle streams from the syringe a small pearl shirt-button from the ear of a little girl six years old, after I had given her ether. Before she came to me her ear had been very roughly handled by picks and probes, but not once sj^ringed. As she had become very nervous about the painful treatment of the ear, I gave her ether, and the ease Avith Avhich I syringed out the button only served as another proof of the folly of instrumental picking, probing, pulling, etc., to remoA^e a foreign body from the ear. The ear had commenced to discharge when I first saw her, and the canal Avas greatly swollen, yet the syringing brought aAvay the offending body. Yet Ave hardly dare call such a body offend- ing; that term should be applied to the heroic treatment with curettes, etc., to which the unfortunate little victim had been subjected. All kinds of corrosive and scalding fluids, melted metals, etc., are not only exceedingly painful but threaten the life ofthe suf- erer if poured into the ear. Morrison1 records a case of death folloAving the instillation of nitric acid into the ear. Rau2 states that melted lead poured into the ear of a drunken man produced deafness Avith purulent discharge and paralysis of the corre- sponding half of the face, and became so firmly imbedded in the ear that as late as seventeen months after this accident the metal could not be removed. A case similar to that reported by Rau recently occurred in St. Mary's Hospital, Phila., during the service of Dr. Schell. Within a short time I have seen the evil effects of scalding fluids upon the ear. The case Avas that of an Irish girl, 20 years old, avIio had been induced to pour boiling oil into her ear for some slight trouble in it. The agony which ensued Avas intense, and, although the acute symptoms had ceased entirely when I saAv her, the drum-head Avas Avhite and thick, like a piece of heavy paper, and the hearing was gone. It Avould seem almost superfluous to mention such folly, but the general ignorance respecting the delicacy of the ear demands such recitals as Avarnings. ' Wilde, page 378. 2 Ohrenheilkunde, § 319, and Med. Chirurg. Zeitung, 18)2, No. 39. 302 EXTERNAL AUDITORY CANAL. While considering fluids which have proved highly injurious to the ear, it may be well to consider briefly some of the odd and, in a measure, irritating fluids placed in the ear for the cure of otorrhcea, deafness, etc. As these fluids have usually done no harm, beyond causing a loss of time and money to the patients, the recital of them may afford another proof of the general ignorance of the nature of ear diseases, and a universal tendency towards doing the improper thing for this delicate organ. Among a large number of patients from the ignorant classes frequenting the dispensaries and infirmaries in our city, I have rarely met one, whose malady Avas of any duration, Avho had not tried applications of human urine, woman's and coav's milk, cow-dung, rabbit's fat, neats-foot oil, Harlem oil, the juice of clams and oysters, eagle's gall, etc. Only one man, forty years old, mentioned the imaginary excellence of eagle's gall, but he had spent considerable time and money for more than a year in his endeavors to obtain this coveted cure, and, at last having succeeded in getting it, he had applied it for a long time to his ears. As the man had brought on, by his life of a hunter, an obstinate and progressive form of middle-ear catarrh, it is needless for me to state that his disappointment Avas great at the want of success on the part of his long-sought remedy for deafness. A curious and self-inflicted irritation from a foreign body in the ear occurred in the case of a young printer, finally applying for relief at the author's clinic in the Philadelphia Dispensary in 1872. The young man stated that two weeks previous to his call at the dispensary, he had placed the core of a roasted onion in his ear, for a slight earache. The pain soon ceased and the onion core was forgotten or " supposed to be absorbed" by the patient, until the secondary irritation, discharge, and hardness of hearing caused by its presence in the auditory canal, dreAv the patient's attention a second time to his ear. Without any further attempt at self-medication, he applied at the dispen- sary for relief, and, upon examination, I found the auditory canal entirely blocked up by the swollen and rotten remains of the onion core. The walls of the canal were irritated and excoriated, and a horribly stinking discharge poured from the ear, while the mechanical deafness was great. One good syringe- FOREIGN BODIES. 303 ful of Avarm water removed the offending mass, restored the hearing, and revealed the fact that the drum-head, though deeply macerated, was still intact. With the use of an astrin- gent wash for a few days, this man regained a sound ear. Sometimes the foreign matter is entirely harmless of itself, and might remain in the ear indefinitely, Avithout exerting an injurious effect. The efforts at its removal, made by the igno- rant, are the true cause of injury to the ear. This is illustrated in the following case:— On the 30th of April, 1872, Mr. E. S., a machinist, 39 years old, consulted me for pain and deafness in the left ear. He stated that three days previous,' Avhile crossing a street, a horse had splashed mud in his ear, which at that time was perfectly sound. Upon returning to the shop where he Avas employed, his ear Avas examined by some of his comrades, Avho said they saAV " something in the ear," and proceeded to extract the foreign matter with " chips and mechanics' small tools." This of course caused the patient great suffering, for he said " several little white pebbles were taken out" (probably ossicles, as there Avas no trace of them in the ear Avhen 1 examined him), and great deafness ensued in the thus roughly handled organ. The pain increased, and a large, red, hard tumefaction appeared under the left auricle and extended to the angle of the inferior maxilla. The patient, naturally a very strong and powerfully built man, was very pale, anxious, and bathed in cold 'sweat Avhen I made the first examination. There was no discharge from the ear at the time he presented himself to me. My large testing Avatch, audible at least forty feet, Avas heard by this man only about two and one-half inches. He heard my voice only when I spoke very close to his ear, and this probably, only by bone conduction. The tuning-fork, vibrating on the vertex, Avas heard by the patient very distinctly in the affected ear. Upon inspection I found the meatus in this case uninjured. A small piece of black street-mud Avas adherent to the antero- superior quadrant of the periphery of the membrana tympani. The membrana tympani Avas found to have been entirely de- stroyed, excepting a very narroAV peripheral band, and there AATas not a trace of an ossicle visible, all of these important structures having, Avithout doubt, been torn out by the ignorant endeavors of the man's friends to remove the mud Avhich had been splashed 304 EXTERNAL AUDITORY CANAL. into the ear. The inner Avail of the tympanic cavity was fully exposed to view, revealing healthy, pale, shining mucous mem- brane, slightly abraded on the promontory. By the Valsalvan method of inflation air passed through the perforation Avith the characteristic whistle. TAventy days later I saw the patient again at the dispensary. He had been hard at Avork ever since the injury, not excepting Sundays. He had entirely neglected to follow any of the simple directions I had given him, viz., to apply three large leeches to the swollen glands near the auricle, and to remain quiet. The pain and tumefaction had disappeared, however, and the patient Avas ruddy and cheerful once more. No air passed through the perforated drum-head at this visit, and the hearing distance remained permanently unaltered. Upon inspection I found the edges of the perforated membrane adherent to the promontory and inner Avail of the tympanum, the former appearing to pro- ject into the meatus in consequence of the excessive retraction of the small remnant of the membrana tympani around it. It is interesting to notice the sudden and great loss of hearing in this case, as showing the comparatively greater importance of the destroyed ossicles than of the perforation and destruction ofthe drum-head. A simple accidental perforation ofthe mem- brana tympani or drum-head, rarely, if ever, causes such a degree of deafness as was found in this case, in which the evulsion of the ossicles must be regarded as the real cause of the great deafness. The impaction and long retention of foreign bodies in the ears of children may lead to deaf-dumbness, which may be cured by removal of the obstructions in the external auditory canals, as was shown in a case observed by Dr. Sara E. Brown1 of Boston. In this case, twenty-eight small gravel stones Avhich had lain in the external auditory canals for seven years Avere re- moved, and recovery of the hearing ensued. This child, a lad of sixteen years, Avas an inmate of a school for feeble-minded chil- dren, where he had been placed in consequence of his retarded mental development, following his deafness. After the pebbles were removed, the lad became more intelligent in expression, and he regained the use of his speech, which he had begun to lose at the age of nine years, when he placed the gravel stones in his ears. 1 Archives of Oph. and Otol., vol. iii. pp. 88-90, 1874. FOREIGN BODIES. 305 Animate Objects in the Ear.—Usually, insects which are found in the ear have craAvled or flown in during the sleeping hours of the patient. Of course this is most likely to happen to those who sleep upon floors or on the ground. Bakers, Avho, working at night and becoming very tired, lie down on the floor of the bakery, ahvays infested with roaches, are very apt to be aAvakened by the presence of a roach in the ear. The peculiar elongated shape of this insect permits it to Avedge itself in the auditory canal, Avhich holds it tightly enough to prevent its escape but not to kill it. It therefore is apt to make most violent endeavors Avith its front feet to escape, and in so doing it scratches and scrapes upon the deeper parts of the auditory canal and drum-head. Such movements are productiA'e of great annoyance and pain to the patient, and if the animal is not removed, severe inflammation will be set up. Fleas, too, often find their way into the ear, and by their poAverful leaps against the drum-head, Avhich produce a noise said by the patients to resemble thunder, cause intense discomfort to the sufferer. Very recently, Dr. Gassner1 found the Dcrmanyssus avium, or chicken-louse, in large numbers, in the ear of a cow, where the parasite had excited a well-marked otitis externa. Von Troeltsch, to whom this specimen Avas sent, after consulting the literature pertaining to the natural and pathological history of such parasites, makes the folloAving statement: "This animal, the Dcrmanyssus avium, has never been found in the ear of man ; it Avould be Avorth Avhile, however, to look for it in the pus escaping from the ear, as Avell as the water used for syringing certain diseased ears." Chicken-lice might fall into the external ear of man from chickens flying suddenly and swiftly above his head. I examined, in the early part of the summer of 1875, an intelligent man's ear, and found large cicatrices in the mem- brana tympani, Avith greatly diminished hearing. The patient stated that in his boyhood, Avhile playing in the fields, the so- called devil's darning needle or dragon-fly had thrust itself, or its long pencil-like body, apparently accidentally, into his ear. Instantly, great inflammation and pain were set up in the organ, ' Von Troeltsch, zur Lehre von den thierischen Parasiten am Menschen, Archiv f. Ohrenheilk., vol. ix. p. 193. 20 306 EXTERNAL AUDITORY CANAL. and the hearing power was ultimately nearly lost. It seemed probable, from the statement made by the young man, that a portion ofthe insect's body must have broken off and remained in his ear, but it cannot be said positively that such was the case. M. Gudrin reported to the Society de Chirurgie the case of a soldier, who had returned from Mexico, suffering from facial neuralgia and other affections, which were relieved upon the escape of an Ixodes hominis from the sufferer's ear.1 I syringed, not long since, from the ear of a little boy two years old, a dead fly, which was totally enveloped in a kind of epithelial cyst. The mother of the little patient informed me that a year previous, in the summer time, the child had been attacked suddenly Avith pain, as she supposed, in the ear, and that his sufferings were so intense as to produce convulsions. The meatus was entirely occluded by the encysted fly; but upon removal of the foreign mass, the membrana tympani was revealed as perfect, and the hearing became normal. Dead flies are sometimes syringed from the ears of children afflicted with otorrhcea, to Avhich they are attracted by the odor of the discharge, but in most instances produce no pain or sub- sequent trouble by their presence in the ear. I Avashed three from the ear of a little girl not very long ago—one the first day I saw her, in very warm Aveather, and two more on the following day. But there was no subsequent irritation caused by their having flown into the ear and died there. In some instances, however, maggots groAv in the ear after it has been invaded by flies. Heine2 and Blake3 have published accounts of the groAvth of maggots in the ear, and the latter authority has described minutely the apparatus by which these creatures maintain a hold in, and wound the canal and drum- head. The former writer describes a case of a little girl two years old, subject of a chronic otorrhcea, who had gone to sleep in the hot sunlight with the diseased and offensive ear exposed to the incursion of the flies, and in consequence thereof maggots had sprung up in the ear. 1 Hinton, op. cit., p. 78. 2 Lincke's Sammlung, ii. p. 181. 3 Living Larvae in the Human Ear. Archives of Oph. and Otol., vol ii No. 2. FOREIGN BODIES. 307 In the course of a few days, fat, white maggots, with heads spotted black, were seen in the fundus of the auditory canal. Oil Avas poured into the ear, and as each maggot came to the surface of the oily bath, it was seized with forceps, and thus all trouble was removed from the ear. Heine states that he has never failed to remove maggots and all living creatures from the ear, by means of oil in a very few minutes. But the majority of surgeons have not been so fortunate. One of the earliest if not the first case of transformation of the maggot through various stages to the fly, after its removal from the ear, is recorded by Dr. Kuntzmann,1 Avho said, although he had frequently seen and read of maggots in the ear, he was not aware that any surgeon had brought about the perfect trans- formation of such creatures when found in the ear. The case he reports is that of a boy six years old, the son of a poor woman, who was brought to him on 17th July, 1811, for a terrific pain in the ear, which had already lasted fourteen days Avithout any cessation. Bloody pus Avas found exuding from the auditory canal, Avhich was greatly swollen. Otherwise the boy Avas healthy. Twenty-four hours after the boy was first seen, quantities of living bodies were detected in the ear, and six large, fully-developed maggots were extracted Avith the forceps. The pain then ceased, and all symptoms disappeared in a few days with syringing and mild astringents, and the hearing remained perfectly normal. Each maggot Avas seven lines long and one line thick; their color Avas whitish-yelloAv; they consisted of several soft rings Avhich fitted one within the other; on their heads they had two broAvn, horny hooks, curved downAvard, between which Avas the so-called dart (Reaumur), which Avas not exactly like that of the common house-fly maggot, but curved, yet not so much as the tAvo hooks. This was the only distinctive feature be- tAveen the two varieties of larvae. Tavo of these maggots were obtained by the author quoted, and placed in a confectioner's glass jar, in Avhich dry and care- fully sieved earth Avith a piece of meat was placed to furnish 1 Hufeland's Journal der practischen Medicin, August, 1824, S. 108-111. Lincke's Sammlung, ii. p. 178. 308 EXTERNAL AUDITORY CANAL. food for the worms. They did not attack the food, but instantly buried themselves in the earth and on the second day were found to have passed into the chrysalis state. " The chrysalides were brown, cylindrical, tapering each way to a blunt end, immovable, and consisted of several rings, like all chrysalides of the fly." On the fourteenth day after their transformation into the chrysalis, fully developed flies escaped from the shells, which Avere described as " very beautiful, gray and black flies, Avith silver-gray head and beautiful, bright, cinnabar-red eyes; the bright redness of the eye was lost after death, and the color then became dark-brown." These flies Avere then presented to Count Von Hofmannsegg, Avho placed them in his cabinet, Avhere they proved to be unique specimens, theretofore undescribed. Prof. Illger pronounced them to be a new species of the class Tachina, and named them Tachina signata. To the Tachina signata found in this case may be added the larvae of the Muscida sarcophaga (Blake and Gruber) and the Muscida lucilia (Blake). The pain excited by the presence of larvae in the ear is intense, and drives the sufferer to frenzy and even into convulsions. They are usually found in ears previously affected Avith a more or less offensive otorrhcea, though in the case related by Dr. Kuntzmann the ear attacked by the larvae was entirely healthy before invaded by the fly Avhich deposited the noxious egg. The pain attending the presence of maggots in the ear is easily explained by the investigations of Kuntzmann and Blake.1 The latter authority placed the larvae in a glass vessel con- taining a piece of raAv meat soaked in Avarm water, and then observed the movements and actions of the larvae under the microscope. He found that the apparatus by which the maggot makes and retains his hold is composed of a delicate horny frameAvork, armed with tAvo hooks, of a stout horny nature, articulating with the aforesaid frameAvork. By a repeated ex- tension and retraction of the hooks, the animal pierces and tears the softest and deepest tissues it can lay hold upou. Hence it is 1 Archives of Oph. and Otol., ii. No. 2. FOREIGN BODIES. 309 found always in the fundus of the auditory canal and sometimes in the tympanic cavity. Treatment.—From the investigations of Blake and others it appears, that, since maggots retain such firm hold upon the structures of the ear, after they once get in there, syringing and instillations of fluids which would not injure the ear are insufficient to kill and dislodge such creatures. Blake, Gruber, and others are of the opinion that nothing short of actually seizing the maggots Avith suitable forceps, and pulling them out, Avill satisfactorily remove them from the ear. As Avill be seen from the cases of Heine, Kuntzmann, and others, already recited, Avorms or maggots may be smothered by oil Avhile in the auditory canal, or they may be syringed out, or they may even crawl out voluntarily, but these are excep- tional cases. Sometimes maggots do not appear willing to seize flesh Avhen placed in their Avay, but burroAv immediately in the earth, as already stated in Kuntzmann's case, and I have observed that a mass of maggots which Avere just extruded from a fly shoAved no tendency to seize some meat which Avas given them, but, on the contrary, burroAved betAveen it and the sides of a glass vessel containing it and them. As maggots are extremely hard to kill tw any fluid not in- jurious to the ear, I obtained some for experiment, from a fly, by causing her to extrude her brood of 50 to 60 liA^ing creatures about 2 mm. long. These I placed in a glass vessel with the dead fly and nothing more, and after twenty-four hours found them still alive. I then placed a little piece of cold roast-beef, softened in Avater, into the glass for the maggots to live upon. In tAventy-four hours later I found them active and grown to be 5 mm. long, and their alimentary canals stained by the broAvn juice of the roast meat. In order to try the effects of some easily obtained fluids innocuous to the ear, upon the maggots, I placed a maggot, No. 1, in a feAv drops of refined kerosene oil. It craAvled repeatedly from the oil and continued to live, though constantly thrust back and kept submerged in the oil. This maggot Avas finally killed in another Avay. Maggot Xo. 2 I placed in a saturated solution of salicylic acid (bleached, prepared by Hance Bros. & White, of Philadel- phia). This one died in a half hour. 310 EXTERNAL AUDITORY CANAL. No. 3 I placed in alcohol, and it died in five to ten minutes. No. 4 I placed in ether fortior (Squibb), and killed it by this means in tAvo minutes. No. 5, 6, and 7 I placed in chloroform, and they were instantly killed. Dr. Roosa has found chloroform vapor, as well as Labarraque's solution of chlorinated soda, fatal to the life of these creatures.1 An eighth specimen I placed in hydrant water, which seems, as Dr. Roosa has also observed, to make them more lively at first, and they continue to live and work their savage hooks for a long time, even in a glass vessel where they can gain no hold. Water appears not to have the slightest effect in arresting their work wThen they have once gained a hold in the soft, moist tissues of the ear. Even after they have been killed by various applications to the ear, the forceps may be required to detach them, so firm is their hold. Calomel sprinkled over them has been said to kill maggots in the ear; also solutions of tannin have effected their destruc- tion. Foreign Bodies in the Eustachian Tube and Middle Ear.—In Mayer's article2 on foreign bodies in the organ of hearing, we learn that three Avere found in the Eustachian tube. One of these bodies, a barley-corn,3 was found imbedded in the bony portion of the tube, but projected as far as the faucial end. The other tAvo Avere lying in the Avide faucial end ofthe Eusta- chian tube. The imbedded barley-corn was found at a post mortem, the cause of death not given. Bougies not uncommonly break and leave portions behind them in the Eustachian tube. When the bougies are armed Avith cotton, feathers,4 hairs, etc., this is more likely to occur. In two cases, recited by Mayer, laminaria bougies broke off, and remnants Avere left in the Eustachian tube. ' Treatise on Diseases ofthe Ear, p. 1G6. 2 Monatsschrift f. Ohrenheilkunde, Jahrg. IV. No. 1. 3 Prof. Fleischmann's Case. Hufeland's and Ossan's Journal, June, 1835, pp. 25-28. 4 Hecksher of Hamburg. Mayer's Article, loc. cit. FOREIGN BODIES. 311 In some instances the foreign body is rudely pushed at last, by endeavors at its extraction, into the middle ear. One of the most interesting of such cases is given by Deleau,1 Jr. It is that of a little boy, who placed a small gravel-stone in his ear, in play Avith his comrades. The unskilful endeavors Avith a curette to remove the body, in conjunction with the struggles of the boy, ruptured the drum-head, pushed the gravel- stone into the tympanic cavity, produced hemorrhage and in flammation of the ear, temporary paralysis of the corresponding side of the face, and excessive photophobia in the eye of the paralyzed side. This much, happened while the boy Avas still in the provincial town Avhere the accident occurred. He was brought to Paris, two weeks later, and Deleau examined the ear carefully, found the pebble seated in the cavity of the tympanum, with its only visible facet in the same plane with the drum-head. By gently touching the body it Avas found firmly grasped by the swollen mucous membrane of the middle ear, and being so near the chain of bones all traction upon the pebble was deemed highly im- proper. Deleau now wished to use forceps composed of several branches, but the patient positively refused to permit any further manipulation of the ear from Avithout^ but consented to the introduction of a firmly fitting catheter into the Eusta- chian tube. The third injection of water through this instru- ment threAV the offending pebble into the concha. The otitis in this case soon disappeared, but there is no positive statement as to the condition of the hearing. Among the rare instances of this occurrence, is one observed by Moos.2 Before Prof. Moos saAV the case, an unsuccessful endeavor had been made by a physician to remove a coffee bean from the external auditory canal, under chloroform. After unskilful manipulation the beau disappeared from view. Puru- lent inflammation set in, perforation of the drum-head occurred, the incus exfoliated, and numerous polypi Avere developed. The latter Avere removed, and, by syringing, together with antiphlo- gistic treatment and the use of astringents in the ear, the bean ' Lincke's Sammlung, i. pp. 153-157. Gazette Med. de Paris, 2d Series, tome ii. 1834, No. 11, pp. 161-163. 2 Archives of Oph. and Otol., vol. iii. pp. 103-107, 1873. 312 EXTERNAL AUDITORY CANAL. came into view, though it had passed into the tympanum and could not be seen by Prof. Moos at the first examination, immediately after the removal ofthe polypoid growths. Upon the authority of Itard and Andry, Rau mentions a case in which an ascaris wandered from the alimentary canal, through the pharynx, into the Eustachian tube. Sudden and powerful coughing in haemoptysis may force blood through the Eustachian tube into the tympanic cavity, where irritation and pain may be set up in consequence of the foreign matter thus brought in contact with the tympanic mucous membrane.'1 Treatment; Removal of Foreign Bodies from the Ear.—When a foreign body is said to be in the ear, the surgeon should first satisfy himself that such is really the case before he begins any operation for its removal. Grave errors have occurred from the neglect of the surgeon to assure himself on this point. When it is fully decided that the statement of the patient or his friends is really correct, that a foreign substance is really lodged in the ear, if the latter has not become irritated and swollen by the attempts of others at the removal of the foreign substance, usually a gentle syringing, the patient's head being inclined towards the affected side, that gravity may aid our efforts, will bring away the foreign body. In order to carry this out in very young children, already alarmed by the acci- dental entrance of the foreign body, we may have to resort to etherizing the patient. In any case, when syringing will not remove the foreign substance and the ear is at all inflamed and swollen, nothing more forcible than syringing should be at- tempted until the local irritation in the ear is allayed. Too often the attempts at removal of a foreign body from the ear are far more injurious than its presence in the ear. After all irritation is allayed, which can often be effected, though the foreign body is still in the ear, syringing may be resorted to, and usually with success, in removing the foreign substance. If this fails, and it appears that other means are demanded for the removal of the impacted foreign body, the greatest care and skill are noAV needed, in order to avoid » Eindringen von Blut, in die Paukenhohle bei Hamioptoe. Archiv f. Ohrenh., Bb. xi. p. 21. Dr. Kiippe. FOREIGN BODIES. 313 injuring the ear. A great many plans for removal of foreign bodies impacted in the ear have been suggested. Voltolini1 recommends the use of the galvano-caustic for the removal of foreign bodies Avhich, by unskilful manipulation, have been forced from the meatus into the tympanic cavity and have become imbedded there. By this means, he has cut up and removed piecemeal a bean which had been pushed through the membrana tympani and pressed into the drum-cavity. A bean cannot be properly cut up, however, until it has been softened by repeated injections of Avater. Then momentary gloAvings of the finest silver wire cautery will char the bean, and the offending body can be gradually removed after several repetitions of the operation, on different days. But no one not extraordinarily familiar with diseases of the ear, as well as with the use of the galvano-cautery, should attempt such an operation. Voltolini has very justly said the most that can be asked of the general practitioner is not that he shall remove a foreign body such as this from the ear, but that he shall recognize its presence and leave it alone. It cannot be too often brought to mind that it is not the presence of a foreign body that causes ultimate harm to the patient, but the unskil- ful endeavors to get it out. Among the various ways of removing impacted bodies from the external ear should be mentioned the agglutinative method. It has been recently revived by Dr. Lowenberg,2 of Paris. This method was fully described by Riverius3 and Celsus,4 and is also given by Rau.5 It consists in smearing Avith glue or some equally tenacious substance, a piece of linen, cotton cloth, or the like, firmly attached to a handle, which is brought into contact with the foreign body in the ear, and then allowed to remain until perfect adhesion takes place. Then, in most instances, the foreign substance can be lifted out Avith the above-named instrument. This method was employed in this country, some years ago, by a layman, Mr. Eli Whitney Blake,6 1 Ueber fremde Korper in der Paukenhohle und deren Entfernung. M. f. 0., No. 5, 1876. * Berliner Klin. Wochenschr., No. 9-10, 1872. s Opera Med. Francofurti, M.DC.LNXIV., Cap de Surditate, p. 261. « Strasbourg edition, 1806, p. 342. 6 Op. cit., p. 375. 6 C. Hooker, Boston Journal, 1834. 314 EXTERNAL AUDITORY CANAL. of Conn., for the purpose of removing a foreign body from the ear of a boy employed in his carriage factory. A somewhat similar method is to apply to the foreign body a piece of adhesive plaster fastened to a string, and then warm the minia- ture disk by means of a burning glass. When adhesion has taken place, traction on the string may remove the foreign body attached to the adhesi\-e plaster. This method is one suggested by Dr. E. H. Clarke, of Boston. Removed of foreign bodies from the ear by incision through the bony meatus from without and behind the auricle was proposed by Paul of ^Egina, but entirely rejected by Fabricius of Aquapen- dente.1 Recently, in the case of an impacted bone pencil-head in the tympanic cavity, Dr. Israel2 separated the auricle from its posterior attachment to the mastoid portion of the osseous auditory canal, and, after a crescentic incision had freed the periosteum, the latter with the auricle was drawn forcibly forward, and the foreign body seized and removed through the opening thus formed. Before Dr.. Israel saw this case, unskilful manipulation had driven the foreign body from the external auditory canal into the tympanum. The case then began to manifest very curious nervous phenomena. After the more acute inflammatory symptoms consequent upon the introduc- tion of the foreign body and the endeavors at its extraction had subsided, the patient complained of great pain in both arms, the trunk, and the hips, while the head and ear were free from suffering. Left pupil dilated; fibrillar twitchings in the orbi- cularis of the left eye and the left levator alae nasi. Excessive hyperalgesia of the skin in the painful parts of the body caused the patient to scream when touched. On the left side all the symptoms were more pronounced than on the right side. A day later vomiting and irregular pulse; contraction of the left hand forced the fingers upon the palm; the latter was overcome only by painful and forcible extension. Subcutaneous injections of atropia J mgrm. relieved the con- traction, the hyperalgesia, pain, and inequality of the pupils. The hyperalgesia returned, however, and toothache set in. After the removal of the foreign body from the tympanum, all nervous phenomena vanished. 1 Leschevin ; Lincke's Sammlung, i. No. 1, p. 25. « Berlin Klin. Wochenschr. No. 15, 1876 ; also M. f. O. No. 7, 1876. RESULTS OF INFLAMMATION AND INJURY. 315 CHAPTER III. RESULTS OF INFLAMMATION AND INJURY. Abscesses in the external auditory canal may lead to an eva- cuation of their contents through the duct of Steno,1 or through the cleft found in the posterior superior part of cartilage of the auditory canal as described by Poorten, after the occurrence of otitis externa circumscripta.2 Caries of the meatus may follow inflammation of the middle ear ;3 in such a case described by Blake a portion of the mastoid wall of the osseous meatus, one inch long and half an inch Avide, came away. Mr. Toynbee met with a case of chronic inflammation ofthe external auditory canal which extended to the bone and brain, producing death.4 But these are not the commonest results of inflammation in the auditory canal. Those more likely to be met are now about to be described. Chronic Circumscribed Ulceration in the External Auditory Canal.—Chronic diffuse inflammation of the external auditory canal sometimes ends in the formation of distinct and circumscribed ulceration at one spot in the passage. From this diseased point an inflammatory process may be communicated to the tympanic cavity, and hence ulceration in the external auditory canal becomes of importance. Ulceration on the Avail of a patulous auditory canal must not be confounded with those cases of secondary inflammation of the skin of the canal, mentioned by Kramer,5 " which result from caries of the meatus and of the tympanic cavity, or from destruction of the membrana tympani Avith disorganization ofthe investing mem- ' Hribar ; Wiener Med. Presse, No. 161, 1871. 2 Monatsschr. f. Ohrenheilk., June, 1872. s C. J. Blake, Trans. Am. Otol. Soc, 1872. * Diseases ofthe Ear, 1868, p. 73. 5 Diseases of the Ear: Sydenhan Soc, London, 1863. 316 EXTERNAL AUDITORY CANAL. brane of the tympanum. In such instances the meatus tumefies, becomes indurated like cartilage, smooth, and dark red; the opening closes up till it will only admit the head of a pin ; there is a thin acrid discharge, and on introducing a probe, bare, rough, and carious bone may be felt in the deeper part." The ulcers especially alluded to here are found in the unyielding skin of the bony portion of the auditory canal, and by their general features of chronicity and sluggishness remind one of the ordi- nary leg ulcer. They throw off a scanty, dark-gray or greenish discharge, somewhat offensive, which shows a tendency to form a dark crust around the mouth of the canal. Sometimes the discharge seems to have ceased, but in a few days it returns again, and, if allowed to run on, the disease wrill tend to form polypi and to attack the drum-head. The latter becomes congested, all its normal features are lost, and upon syringing the ear, water may pass into the nose and throat. The hearing up to this time may not be much impaired, for the middle ear has remained intact. Upon the occurrence of the perforation, however, the hearing is endangered. In any case, therefore, where there is found a discharge from the ear with an intact membrana tympani, the most careful search should be made for the cause, and, if an ulcer is found in the bony portion of the external auditory canal, to it the treat- ment should be directed. Itard,1 when speaking of erysipelatous diseases of the external ear consequent upon erysipelas of the head, alludes to vesicles Avhich form in the auditory canal, and upon breaking, are con- verted into true ulcers, which suppurate for a long time. Others, including N. R. Smith,2 Williams,3 Wilde,4 Rau,5 Toynbee,6 and Roosa,7 allude Avith more or less distinctness to an ulceration of the meatus, as a separate and chronic form of aural disease. Etiology.—The causes of this disease are often obscure. But » Maladies de l'Oreille, Paris, 1821, p. 168. 2 Supplement to translation of Saissy on the Ear, Baltimore, 1829, p. 218. a Treatise on the Ear, London, 1840, p. 116. 1 Aural Surgery, American edition, Phila., 1853, p. 199. 5 Lehrbuch d. Ohrenheilkunde, Berlin, 1856, p. 179. e Diseases ofthe Ear, 1868, pp. 79-80. i Treatise on Diseases of the Ear, 1873, p. 144. RESULTS OF INFLAMMATION AND INJURY. 317 it will generally be found that a neglected inflammation in the canal has run at last into the chronic disease here described. Treatment.—The treatment should consist in removal of any irritant Avhich keeps up the ulcer, and in stimulation of the inflamed spot. The latter is best accomplished by cauterization by means of strong solutions of nitrate of silver or of chloro- acetic acid, conveyed to the ulcer by means of cotton on the cotton holder. All discharges are to be most carefully cleaned out by syringing, and the general health of the patient examined into and built up if necessary. As scrofulous children are liable to be the subjects of this kind of local trouble in the ear, iron and cod-liver oil will play a most important part in the treat- ment of such ulcerations, Avhen occurring in them. In the interval betAveen the applications of the above local remedies, which of course are to be effected by the surgeon two or three times a Aveek at the outset, the patient's ear should be cleansed at home several times a day, and a mild astringent Avash applied by instillation to the auditory canal. The hearing is not usu- ally affected in the early stages, but it will be, unless the disease is arrested. The prognosis is favorable if the ear is attended to in time. Cholesteatomatous Tumors in the Auditory Canal.— Cholesteatomatous or pearly tumors are said, by Lucae and others, to occur frequently in the external ear. They do not appear to be common in this country. Dr. Kipp1 has given an account of the occurrence of this disease in both ears of a man 27 years old. These cholesteatomatous masses are usually found in ears which have been the seat of chronic suppuration, but in which the latter process has apparently run its course. In such cases, the mucous membrane of the middle ear, as well as the cutaneous lining of the external auditory canal, seems to retain a tendency to the exfoliation of large masses of epithelial scales, which, accumulating in the ear, undergo a fatty degeneration and give rise to various symptoms, among Avhich the more prominent are pain at times in the ear (but this is not a promi- nent characteristic of these formations), nausea and dizziness, with occasional vomiting. The hearing is of course impaired 1 Archives of Oph. and Otol., vol. iv. 318 EXTERNAL AUDITORY CANAL. by the mechanical hindrance offered by these masses, Avhich may be so large as to cause absorption of the bone of the audi- tory canal and a consequent widening of this passage. Even greater irritation than this may ensue as a consequence of the presence of such collections in the ear, and the bone structures on which they press may become carious. The soft tissues thus pressed upon ulcerate and become covered with granulations in some instances, and the membrana tympani and ossicles under- going erosion, the entire tympanic cavity is occupied by the cholesteatomatous layers. The microscope reveals these forma- tions to be lamellated in structure, the layers of Avhich are composed chiefly of flattened epithelial cells and crystals of cholestearine. In addition to these elements Dr. Kipp has found, in these cholesteatomatous masses, " fatty acids, and minute shining bodies, some round and others irregular."1 Treatment—The treatment of such accumulations should con- sist first in the complete removal of the obstructive mass. This may require some patience, for the removal of the more external layers often reveals the presence of deeper and fresher ones, and in some cases new ones seem to form during the treatment. The latter tendency is best combated by an alterative astrin- gent, as solutions of nitrate of silver, sulphate of copper, and zinc. The softening and removal of these masses is hastened by the use of solutions of bicarbonate of soda in glycerine and water. Exostoses of the Auditory Canal.—Exostoses, or bony groAvths of a rounded, hillock-like shape, are frequently found in the external auditory canal. They are covered by the skin of the canal, are entirely painless, and the only annoyance they give is due to their encroachment upon the calibre of the canal. Their size varies from that of a merely distinguishable elevation on the wall of the canal to that large enough to occlude the canal and produce deafness. The skin covering them is a little paler than that of the canal. Etiology.—These osseous growths may be congenital, or they may be the result of chronic inflammatory processes in the i See Dr. Mathewson's Report on the Progress of Otology, Transactions of American Otological Society, 1875. RESULTS OF INFLAMMATION AND INJURY. 319 middle and external ear. They are frequently found in those who have been afflicted for a long time with discharges from the ear, though they are also very often found in those whose ears are otherwise normal. According to some authorities, exostoses of the meatus in some instances are plainly of a syphilitic origin. They may develop in the auditory canal at the same time Avith exostoses on other bones, as shown by Gruber, but he does not consider that all such bony groAvths in the canal have a specific origin. Contrary to the rule in other parts of the body, they are usually painless in the auditory canal. He has described several cases in which hyperplastic growths of the bone of the meatus were associated Avith a similar affection in the bony portion of the Eustachian tube, without, however, possessing any syphilitic origin.1 Usually, the causes of exostoses in the auditory canal are obscure, although in many cases Toynbee's theory, that they are due to the rheumatic and gouty diatheses, may be satis- factory. As far as my experience goes, they have been met more frequently in such diatheses than in any others. Dr. C. T. Blake2 has described a peculiarity observed by Prof. Wyman first in the crania of Hawaiian Islanders, and subse- quently in the crania of Peruvians, consisting of exostoses of the external auditory meatus occurring uniformly on the supe- rior and inferior lips of the lamina forming the posterior wall of the passage, the same peculiar groAvth being described by Weiker as occurring in the crania of American Indians. Out of three hundred and thirty-four Peruvian crania examined by Prof. Wyman, these groAvths were found in six, and in various degrees, from a small pedunculated groAvth on the superior lip of the lamina to double groAvtlis on both lips nearly occluding the orifice of the passage. It was noticeable, moreover, that these groAvths were nearly uniform in size and shape on both sides. Out of eight Peruvian crania, belonging to the collection of Mr. Blake, in the Warren Museum, but one presented this peculiarity, and then only in the form of an elongated ridge upon the posterior Avail of the meatus on one side. The suppo- sition that aquatic habits might have to do with the presence 1 Lehrbuch der Ohrenheilk., p. 412 and 576. 2 Report on Progress of Otology, 1874. 320 EXTERNAL AUDITORY CANAL. of these growths, though applicable in the case of the Hawaiian Islanders, would not apply to the Peruvians, living as they did in a tract of country remote from the sea and remarkable for its aridity. That the occurrence of these growths is coincident with the development of the wall of the osseous meatus, as sug- gested by Dr. J. 0. Green, is further supported by the fact that the location of the growths was a constant one. The treatment of exostoses in the external auditory canal will be referred to further on. Osseous Closure of the Auditory Canal.—The considera- tion of exostoses in the auditory canal leads naturally to the consideration of osseous closure of the canal and the deafness Avhich ensues. Such a closure of the auditory canal may be congenital or acquired. In a case of the former kind, described by Knapp,1 the closure of the auditory canal, on one side only, Avas associated with rudimentary development of the auricle. The acquired form appears to be the commoner, and this fact should lead to a most careful treatment in those diseases of the ear attended with ulceration and granulations in the external auditory canal. If such growths are found in the auditory canal, great care on the part of the patient should be observed in not picking at or irritating them in any way. Acquired bony closure of the canal has been observed and described by Bonnafont,2 Dr. L. B.,3 Mathewson,4 and others. In the cases named, operations for relief of the deafness Avere performed successfully. The only case of bony occlusion of the auditory canal Avhich has come under my notice presented itself in the right ear of a man 58 years old, and from the history of the case it may be called one of acquired bony occlusion of the auditory canal. At eight years of age the patient was operated on in the Pennsyl- vania Hospital, for polypus of the left ear. After repeated attempts at extraction of the polypoid growth, which were fol- lowed by severe cauterization Avith solid sulphate of copper, 1 Transactions American Otological Society, 1870, pp. 86-87. « L'Union Medicale, May, 1868; also Gazette des Hdpitaux, No. 64, 1867. 8 Archiv f. Ohrenheilkunde, Bd. x. p. 110. * Report of 1st Congress of International Otological Society, New York, Sept. 1876. RESULTS OF INFLAMMATION AND INJURY. 321 great pain and total loss of hearing, he was removed by his parents from all further treatment. In 1874, about fifty years after the above-named operations, an examination of the ear revealed a shallow meatus, closed at the bottom by ordinary skin. Nothing resembling a drum-head Avas visible. The skin at the fundus of the shallow auditory canal moved under the Sigle pneumatic speculum. The hearing was reduced to no- thing for external sounds, per aerem. Bone conduction, how- ever, very good on the occluded side. Tuning-fork on the vertex heard best in the occluded ear. Eustachian tube Avas found to be pervious to air by Politzer's method, and the ordinary cathe- ter. The patient, a man of more than ordinary intelligence, Avas fully conscious of the entrance of air into his right tympa- num, by artificial inflation, as well as whenever he SAvallowed As he was desirous of having an operation on the occluded ear for relief of his deafness, I made an exploratory incision Avith a paracentesis knife, but found that beneath the skin of the fundus of the canal, there Avas a bony partition cutting off the external from the middle ear. Considering- the asre of the patient and the good condition of his left ear, I was unAvilling to perforate the bony septum in the auditory canal; but it is probable that such an operation might have been carried out Avith success in this case. The pathology of this case most probably consisted in acute inflammation, folloAved by suppuration, which Avas allowed to become chronic. Then there ensued a groAvth of polypi, for the extraction of which, several rough and painful operations Avere undertaken. Subsequently, the excessive granulation-tissue be- came organized into a bony septum, covered by a reflection of the normal cutis of the auditory canal. In Dr. A. H. Buck's A'aluable contribution to the "ultimate forms of granulation-tissue in the ear,"1 it is stated that " a mass of granulations may become covered with skin or mucous membrane, and its central portions undergo a change into true osseous tissue." Respecting this form, Dr. Buck says " it AA'ould be difficult, particularly in this locality, to determine Avhether a real transi- tion from granulation-tissue to bone takes place, or whether 1 Transactions of American Otological Society, 1874. 21 322 EXTERNAL AUDITORY CANAL. simply the local irritation assumes a new phase, the cellular hyperplasia or formation of granulation-tissue ceasing and bone being formed." I am of the opinion that the closure of the canal I have just narrated was caused by a transformation of a mass of granulations into true bony tissue, at a point about half-Avay doAvn the auditory canal. Since the subcutaneous and submucous tissues of the ear are, at the same time, periosteal coverings, it is reasonable to suppose that such acquired osseous occlusion as has been described cannot be so very rare, but often escapes recognition. Treatment—Exostoses in the external auditory canal demand no treatment, unless they occlude the canal and cause deafness by this obstruction. Then they may be bored through or cut away, as has been suggested and performed by several operators. Dr. Mathewson, in the case referred to, p. 320, used successfully the dental lathe as the motive power to turn the drill. The skin is to be removed in these cases before the bone is operated on, and to do this, Dr. Mathewson has employed the instrument known among dentists as the scaler. The bony growth was then perforated at several points near its centre, Avith the smallest of the drills, about one and a half mm. in diameter. This was easily done, and then larger drills, two and a half to three mm. in diameter, were used to widen the opening thus gained in the bony diaphragm. The hemorrhage Avas not excessive, though there Avas enough to slightly interfere with the operation. But the auditory canal Avas kept syringed and swabbed out, so that in half an hour a complete canal to the drum-head Avas made. The granulations Avhich arose subsequently were combated Avith nitrate of silver, and in the course of a few weeks the drum- head could be seen at the fundus of the canal. The discharge gradually ceased, and the hearing became normal. As Dr. L. B., of Hamburg, gives an account of an exostosis in his own auditory canal, and the operation on it, by Dr. Knorre, of the same city, the case demands more than a passing notice. The first symptom of deafness occurred in the patient's forty- third year, in 1868, after a bath. On attempting to pick the ear, to free it from Avater which was supposed to have lodged there, an obstruction was felt by the patient, which he seized and roughly pulled upon. This caused considerable pain and RESULTS OF INFLAMMATION AND INJURY. 323 inflammation, with diminution of hearing. Upon consulting Dr. Knorre, the obstruction Avas pronounced by him an exostosis near the membrana tympani. Mild astringent treatment Avas advised to allay the discharge and inflammation excited by the patient; the hearing then gradually grew better, and four years of undisturbed hearing were enjoyed. In 1873, the hearing began to groAv worse, apparently Avithout any exciting cause, but the bony tumor was found to be increasing in size; Dr. Knorre then proceeded to remove the bony obstruction by boring and chiselling. The obstruction Avas overcome by successively re- moving parts of it with a drill and chisel, touching the bony growth Avith hydrochloric and sulphuric acid, burning it Avith a red-hot knitting needle, and filing down the free surface of it by means of delicate files, smooth on one side, such as are used by jeAvellers. Most of this treatment Avas attended with severe pain, so that intervals of rest were rendered necessary on account of the tenderness of the ear. The operations for removal Avere commenced in June, and hy the following January the free surface of the growth had been so much removed as to give a free space betAveen it and the opposite Avail of the auditory canal, and the hearing became once more normal. The patient attributed most of the success to the chiselling performed by Dr. Knorre; the other operations were performed by the patient himself. Other forms of acquired obstruction in the external auditory canal may be partial or total, and they may consist of cutaneous bands, diaphragms of skin or bone, and of horny groAvths. Dr. Engelmann,1 of St. Louis, has described a case in Avhich a bridge-like band of skin stretched across the external auditory canal, from one Avail to the other. This, he thought, Avas proba- bly clue to a union of tAvo granular surfaces. Dr. A. H. Buck, of Xcav York, has described a similar case.2 Dr. Roosa3 found, in a case of chronic suppuration of the middle ear, a cartilaginous band stretched across the outer portion of the canal. Upon division of this band, it Avas found to contain " scales of bone which seemed to come from the posterior portion of the canal." ' Archiv f. Ohrenh., vol. ii., N. F. 2 Transactions American Otol. Soc, vol. i. p. 536. » Ibid., 1870, p. 90. 324 EXTERNAL AUDITORY CANAL. Cutaneous Closure of the Auditory Canal.—Cutaneous closure of the canal at any point appears to be more frequent than bony closure of the same. It may be congenital or acquired. This kind of obstruction in the canal is not ahvays recognized at once, especially if the diaphragm of skin is stretched across the canal near the fundus; in such a position, the obstruction may so closely resemble a thickened drum-head as to lead to some confusion in diagnosis. Dr. Morland' has described a case of congenital imperforation of the auditory canal, caused by a cutaneous diaphragm in the cartilaginous portion of the canal, with hyperostosis of the bony portion. In this and in other cases the imperforation Avas not discovered until disease and deafness in the other ear drew at- tention to the imperfect hearing in the imperforate ear. In this case, the external ears Avere Avell formed. The occlud- ing cutaneous layer in the auditory canal appeared to be a " perfectly natural and smooth extension, or prolongation from the common covering of the auricle. It was not red nor un- even, nor as if thickened by previous or existing disease; but white and uniform in appearance Avith the surrounding skin." After the patient Avas etherized, a crucial incision of the occluding cutaneous diaphragm was made, and the four result- ing flaps were removed with small curved scissors. An aperture, " about as large as a croAv-quill," Avas made, through Avhich a probe Avas cautiously passed, until it impinged against w7hat was probably the drum-head. The lining of the meatus ap- peared normal, but there Avas considerable hyperostosis in the bony portion of the canal. No view of the inner portion of the meatus could be obtained. A piece of compressed sponge was then inserted, and subsequently sponge-tents Avere inserted, and the ear cleansed every few days, by the family physician of the patient. By Dr. Morland's advice, a gold tube was also worn in the meatus, and the ear healed in two months, with good hearing. Dr. A. H. Buck2 has recorded the case of a young woman, 26 years old, affected with otorrhcea in the right ear in childhood, in whose right auditory canal he found ua smooth parchment- 1 Transactions American Otol. Soc, 1870, pp. 31-34. 2 Ibid., vol. i. pp. 536-537. RESULTS OF INFLAMMATION AND INJURY. 325 like membrane of slight but uniform concavity, outwardly." It had a translucent appearance, with no evidence of being pro- vided Avith vascular supply, and it was tough and decidedly thicker than the membrana tympani. When this was pressed upon by a probe it yielded Avith a crackling sound, audible even to the by-standers. This horny diaphragm was continuous with the skin of the meatus at all points. A free crucial incision was made through this membrane, and it Avas found to lie about a line on the outer side of the normal plane of the membrana tympani. Through the incision thus made by Dr. Buck, the red and succulent mucous membrane of the promontory Avas all that could be seen at first beyond the diaphragm. As an evidence of the vitality of the false membrane, it is stated that " at the end of the examination a glistening border of bloody serum was noticed along the cut edges of the triangu- lar flaps. At a subsequent visit it was ascertained that the malleus was still present, its tip being adherent to and covered by the tissues of the promontory. The short process of this ossicle could be distinctly recognized at the inner edge of the base of the false membrane, which had now become " a simple constriction with sharply cut edges." Dr. Buck states that subsequent to his publication of this case, he learned from Dr. Simrock, of lSreAv York, that the latter had seen three cases of false membrane, resembling the one just quoted, in one of Avhich the membrane lay much nearer the external orifice of the auditory canal. In some cases polypoid groAvths, invading the same transverse plane of the auditory canal, may groAV together, and skin forming over them, a diaphragm is formed, which stubbornly occludes the canal at that point. Beyond the diaphragm the passage may be normal. In some cases an orifice is found in the centre of this dia- phragm, and by dilatation of this the diaphragm may be reduced to a constriction simply, and then the latter carefully Avidened.1 In such a case the constriction may be overcome by an appli- cation of nitric acid, made only once, as in the case of Dr. Buck referred to. 1 See case by Dr. Buck, Transactions American Otolog. Soc, vol. i. p. 538. 326 . EXTERNAL AUDITORY CANAL. Dr. C. J. Blake1 has met tumors of a horny nature in the audi- tory canal. These growths closely resemble the cornua humana. (See p. 231.) Epileptiform Symptoms from Irritation in the Auditory Canal.—It is Avell known that irritation set up in the auditory canal by the presence of a foreign body will produce epileptiform and even paralytic symptoms. This is amply confirmed by the experience of Fabricius Hildanus, Toynbee, Yon Troeltsch, Wilde, Hanclfield Jones, Hillairet, Moos, and others. It therefore becomes of the highest importance to examine the ear among other organs in a case of epileptiform disease of doubtful origin. The possibility that the ear or a foreign body in it may have something to do with the case in question should lead every physician to examine this organ or have it examined. It would be but safe to examine the ear as often as the pupil of the eye. Ear-COUgh.—Ear-cough, a name recently applied by Dr. Fox, of Scarborough, England, to a peculiar reflex cough, excited by irritation of the external auditory canal, was known to medical men a long time ago. In the celebrated case, given by Fabricius Hildanus (1596), among the various reflex neuroses mentioned as the result of irritation of the external auditory canal by the presence of a glass bead, Avas a peculiar dry cough. Tissot2 wrote of this peculiar cough as generally knoAvn in his time, and narrates an instance of it in " a French gentleman wTho consulted-him for total deafness, but Avhose external audi- tory canal he could not touch, without occasioning a violent cough (toux tres forte), Avhich was absolutely uncontrollable." He also states that Etmuller (Francofurti, 1696-97) had ob- served, that, by touching the external auditory canal with a probe, one could produce a dry cough, which the latter attrib- uted to the " sympathy betAveen the nerves of the ear and those of the trachea." Pechlin3 regarded the peculiar cough (ear-cough) arising from 1 Trans. Amer. Otolog. Soc, vol. i. p. 538. 2 Traitfi des Nerfs et de leurs Maladies. Paris et Londres, 1780, pp. 54-56. 3 Observationum Physicomedicarum Tres libri, Io. Nicol. Pechlini, Ham- burg}, anno M.DC.XCL, Lib. 2, obs. 45—quoted by Tissot, op. cit., p. 55. RESULTS OF INFLAMMATION AND INJURY. 327 irritation of the external auditory canal as a common occurrence, but mentions as a rarity a peculiar reflex sympathy (" consensus") existing between the ear and the stomach (Pouie et Pestomac), a striking example of Avhich he observed in a military officer, who vomited considerably, whenever his extremely sensitive external auditory canal received the slightest touch even of the finger. With the object of ascertaining the percentage of those subject to this sympathetic peculiarity, Dr. Fox carefully examined one hundred and eight persons: males, thirty-seven; females, forty- five ; sex not noted, twenty-six. His conclusions are as folloAvs:— "1. From amongst the unknown group of idiopathic coughs, may happily be rescued from obscurity a cough Avhich is excited by an irritation of the meatus auditorius externus in certain individuals. " 2. The persons referred to are those who possess a hyper- sesthetic condition of the nerve supplying that canal, and in whom any slight titillation of this nerve induces a feeling of tickling in the throat. " 3. This hypersesthetic state generally exists in both ears, sometimes, hoAvever, only in one, and occurs in about twenty per cent, of those examined. " 4. Its existence can usually be traced to childhood, and is probably a congenital peculiarity. " 5. The nerve of the ear concerned in the production of ear- cough, is not a branch of the vagus, as Romberg and Toynbee have affirmed, but is a branch of the auriculo-temporal branch of the fifth cranial nerve. " 6. This sympathy between the ear and the larynx is an example of a reflected sensation, in Avhich the connection be- tAveen the nerves involved takes place in the floor of the fourth ventricle. " 7. Vomiting is occasionally, but rarely, the result of the application of an irritant to the nerve distributed to the audi- tory canal." Sometimes otitis externa diffusa will also produce the most obstinate ear-cough. The attacks may not be frequent, but they are severe and distressing, not uncommonly ending in vomiting. 328 EXTERNAL AUDITORY CANAL. Bleeding from the Meatus.—Hemorrhage from the ear occurs not uncommonly from traumatic causes which apparently produce no further lesion. A physician informed me recently that, slipping suddenly, he struck his mastoid process violently on a projection of some kind in his office. The blow was fol- loAved by hemorrhage from the meatus, but by no further trouble. Hemorrhage from the meatus, connected with injuries to deeper parts of the ear, Avill be considered further on, Avhen alluding to injuries.of the internal ear. Bleeding from the ear has been observed in some instances of suppressed menstruation. It may be preceded by pain and a sense of fulness in the ear, to which it will give relief.1 Treatment.—If the bleeding is due to an injury limited to the skin of the external canal, a mild styptic may be required. In any event the blood must not be allowed to form permanent clots or crusts in the meatus. 1 Hinton; Questions of Aural Surgery, p. 97. SECTION IV. MEMBRANA TYMPANI. CHAPTER I. ACUTE AND CHRONIC INFLAMMATION, INJURIES, AND MORBID GROWTHS. Acute Myringitis.—In many cases it may be of great clini- cal convenience to speak of an inflammation of the drum-head; but, anatomically, it is not easy to describe such a disease of the ear. By many it is regarded as one of the rarest of aural maladies, and some authors deny its existence. Being so intimate in structural relation with the external auditory canal on one side, and with the tympanum on the other, it is to be supposed that disease in either of these parts may very easily extend to the drum-head; but as the middle or fibrous layer is the only layer peculiar to the drum-head, and as it has no nervous and vascular supply of its own, it may indeed be said in safety that a true myringitis rarely if ever occurs. Nevertheless, it is often observed that an inflammation of the external auditory canal may localize itself in the outer layer of this important partition between the outer and middle ear. Perhaps, too, an inflammation of the mucous membrane of the middle ear may localize itself on the inner surface of the drum-head. Hence, clinicalPy, many of the best observers pre- fer to tabulate myringitis among the diseases of the ear, for the fact is that an inflammation of the skin of the external canal or of the mucous membrane on the inner surface of the membrana tympani, having culminated in the drum-head, will produce such modifications in that membrane as to demand attention someAvhat different from that obtained if the inflammation occurring in these constituent structures had localized itself elsoAvhere. 330 MEMBRANA TYMPANI. Hence it is found that Dr. Blake and Prof. Gruber1 have drawn especial attention to this disease, as far as it can be termed an independent one, in their clinical teachings. The latter repeats what he has stated in his treatise on the ear, that as an idiopathic disease myringitis is of. rare occurrence; as a secondary event very frequent, Symptoms.—A typical case of so-called myringitis is character- ized by pain and tinnitus, but not intense hardness of hearing. Upon inspection it will be seen that the membrana tympani is congested, usually very greatly if the disease has advanced, but that its position is not abnormal, and that the adjacent wall of the auditory canal is little or not at all congested. At the same time the Eustachian canal may be found entirely free, and, if the membrana tympani be cut through, it will be found that there is no secretion in the tympanum. Hence, then, there may be an inflammation localized in the membrana tympani, the external auditory canal and the middle ear being free from inflammation. It would seem but fair to give the name of myringitis to such a disease, and mark out for it a special treat- ment. By further watching such a case, it will be found that the membrana tympani becomes gradually thicker from infiltration, and at last pus Avill be found on the outer surface, without the existence of a spontaneous opening in the membrane. By wiping aAATay this product of inflammation, the outer surface of the membrane will be found very red, in some cases almost raw, and it will bleed if touched roughly. This condition of breaking down may go on to a perforation by erosion, apparently from without inAvard, and an ulcerated spot may at last form on the outer surface of the drum-head. The hearing in the mean time, however, does not suffer as it does when the tympanic cavity is affected by disease. As I have assured myself, by means of the catheter and by incisions through the drum-head, that the tympanum is free from disease in all such cases as could be termed myringitis, which I have seen, I am disposed to consider so-called myringitis an inflammation usually, if not ahvays, of the dermoid layer of the drum-head. I have seen so many of these cases, arising from external cold, 1 Monatsschr. fiir Ohrenheilkunde, Nos. 9, 11, and 12, 1875. INFLAMMATION, INJURIES, MORBID GROWTHS. 331 that I am inclined to the above view of their nature. If the mucous surface only of the membrana tympani is inflamed, it is not easy to make such a delicate diagnosis, and, furthermore, there is no proof that inflammation would remain localized on the inner as it does on the outer surface of the membrana tympani. Doubtless, localized inflammation does occur on the inner surface of the drum-head, but the symptoms it produces are not as distinctive as those produced by inflammation of the dermoid layer. The symptoms of acute myringitis may be learned from the following case, which will also show the clinical significance of the disease:— A gunsmith, a large, healthy man, 40 years old, complained of some earache, considerable deafness, and marked tinnitus in his left ear, all of Avhich he attributed to exposure to cold air on that side of the head for several hours, AAThile at Avork. On inspection, the membrana tympani was found reddened, dry, scaly, and somewhat thickened, i. e. it looked more like a piece of thick sheepskin than the delicate normal drum-head. The hearing was found to be $% in. for small Avatch. Tuning-fork, on vertex, heard best on affected side. The position of the membrane did not seem altered, but, as the latter looked thick, and as I suspected there might be retained secretion in the tympanum, the membrane AAras incised: nothing but air came whistling through the cut Avhen Valsalva's inflation Avas per- formed. The hearing improved slightly. The perforation healed in a few hours, and the next day the hearing Avas reduced again to g00 for the watch. The pain, though slight, continued ; the membrane looked more SAvollen; the tinnitus Avas still annoying. In the course of two or three days, the man presenting himself at the infirmary, the membrana tympani was found to be covered with a film of pus, beneath which the membrane Avas quite red. The pain had now become less. Under instillations of zinc and opium, the secretion ceased, the drum-head healed, and the hearing returned, Avithout there haviiio; been any symptom of disease, excepting in the dermoid layer of the membrana tympani. Differential Diagnosis between Acute 3Iyringitis and Acute Otitis 3Ic