T H B DISEASES OF THE EAR. THE DISEASES OF THE EAR: . THEIR NATURE, DIAGNOSIS, AND TREATMENT. BY —- f JOSEPH TOYNBEE, F.R.S., FELLOW OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND; AURAL SURGEON TO, AND LECTURER ON AURAL SURGERY AT, ST. MARY'S HOSPITAL J AURAL SURGEON TO THE ASYLUM FOR IDIOTS ; CONSULTING AURAL SURGEON TO THE ASYLUM FOR THE DEAF AND DUMB; AND CONSULTING SURGEON TO THE ST. GEORGE'S AND ST. JAMES'S GENERAL DISPENSARY, LONDON. WITH ONE HUNDRED ENGRAVINGS ON WOOD SECOND AMERICAN EDITION. PHILADELPHIA: BLANCHAED AND LEA. 1865. ViVA philadelphia: Collins, Printer, 705 Jayne Street. THIS VOLUME IS DEDICATED TO THE dotation; of St. Stars s Hospital, f ottbon, WHO, BY ESTABLISHING AURAL SURGERY AS A DISTINCT DEPARTMENT OP STUDY IN THEIR HOSPITAL AND MEDICAL SCHOOL, EVINCED A DESIRE TO ELEVATE THE SUBJECT OP DISEASES OF THE EAR TO ITS DUE POSITION, AS A BRANCH OF PROFESSIONAL KNOWLEDGE BASED UPON CLINICAL OBSERVATION AND SCIENTIFIC RESEARCH. PREFACE. In preparing the present work, it has been my aim to produce a practical treatise on the Diseases of the Ear, having for its foundation the anatomy, physiology, and pathology of the organ. This volume, however, does not profess to give a complete description of the structure and functions of the Ear: it will be perceived that the domains of anatomy and physiology have only been entered upon when requisite for the elucidation of the pathology or treatment. And now, after twenty years' labor, seeing this volume complete, I cannot but regret that it is not more worthy of its subject, and of the intelligence of the Medical Profession, to which it is addressed. It only remains for me to continue to devote myself to my labors. And thus, while I sincerely thank the numerous members of the Profession for their generous assistance, in supplying me with the larger part of the means of research which I have enjoyed, I beg still further to solicit their aid. Long engaged upon another Work, in the shape of " Illustrations of the Pathology of the Ear," for which I possess a large amount of material, I nevertheless require much more. Indeed, even since this PREFACE. VIII volume has been passing through the press, two recent specimens, received from medical men in the country, have elucidated two entire series of preparations in my Museum. 1 I need scarcely draw attention to the beautiful illustrations in this volume, which, with two or three exceptions, were drawn from nature, on wood, by Mr. Ford. Few references having been made in the body of this volume, to the investigations on which it is founded, I have given, in an Appendix, a list of my published papers, together with their dates, so that the reader may refer to them when he thinks it desirable to do so. 1 It always affords me much pleasure to show my Museum to medical men. 18 Savile Row, January 20, 1S60 CONTENTS. Foreign bodies in the meatus—Mode of removal—Cases—Ceruminous glands —Their diseases —Accumulations of cerumen—Their causes—Table of two hundred cases in which cerumen was removed—Symptoms—Effects —Treatment—Mode of removal—The syringe and its use—Cases . . 6'8 ON FOREIGN BODIES AND ACCUMULATIONS OF CERUMEN IN THE MEATUS. THE EXTERNAL MEATUS {continued)'. CHAPTER IV. in exploring the meatus—Means of exploration—Lamps—Speculum— Mode of exploration 57 Anatomical observations—Osseous meatus—Membranous meatus—Objects ITS EXPLORATION. THE EXTERNAL MEATUS. CHAPTER III. Anatomical observations—Use of the external ear—Effect of the removal of the external ear (case) —Pathological observations —Malformations of the external ear, with absence of the external meatus (cases) —Supernu- ears—Inflammatory diseases—Chronic erysipelas—Chronic eczema—Cysts—Tumors—Deposits—Malignant disease . . . .42 THE EXTERNAL EAR. CHAPTER II. Neglect of the study of the morbid anatomy of the ear, the cause of our ignorance of aural surgery—Mode of investigating the diseases of the ear —Method of dissecting the ear 33 INTRODUCTION. CHAPTER I. X CONTENTS. CHAPTER V. THE EXTERNAL MEATUS {continued). THE DERMIS AND ITS DISEASES. 1. Acute inflammation:— a, Acute inflammation confined to the dermis — Treatment—Cases, b, Acute inflammation extending to the brain and its membranes—Treatment—Cases. 2. Chronic inflammation: — a, Chronic inflammation with hypertrophy and accumulation of epidermis—Treatment—Cases, b, Chronic catarrhal inflammation—Treatment—Cases. c, Chronic catarrhal inflammation, extending to the bone and to the brain—Treatment—Cases, d, Ulceration ' 88 CHAPTER VI. THE EXTERNAL MEATUS (continued). POLYPI. Causes of polypus—Symptoms—Three species of polypus: 1. The cellular raspberry polypus—Structure—Treatment with potassa cum calce— Cases—Treatment by removal with the lever-ring forceps—Cases. 2. The fibro-gelatinous polypus—Structure—Treatment—Cases. 3. The globular cellular polypus—Structure—Treatment—Cases . . .111 CHAPTER VII. THE EXTERNAL MEATUS (concluded). TUMORS. Osseous tumors—Structure—Two classes — Treatment—Cases—Molluscous • tumors —Structure —Effects on the bone —Treatment —Case—Conclusion of the subject of the diseases of the external meatus —Tabular view of the morbid conditions found in the meatus externus in 1013 dissections 136 CHAPTER VIII. THE MEMBRANA TYMPANI. STRUCTURE AND FUNCTIONS. The epidermoid layer—The dermoid layer—The fibrous layers: The radiate fibrous layer—The circular fibrous layer—The mucous layer—Tonsor ligament—Functions of the membrana tympani ...... 151 CONTENTS. XI CHAPTER IX. THE MEMBRANA TYMPANI {continued). The epidermoid layer—Dermoid layer— a, Acute inflammation—Treatment— Cases, b, Chronic inflammation —Cases, c, Ulceration —Cases. Fibrous laminae : a, Acute inflammation, b, Chronic inflammation, c, Ulceration. d, Calcareous degeneration, e, Relaxation of the membrana tympani— Treatment —Cases 164 CHAPTER X. THE MEMBRANA TYMPANI (concluded). Perforation, causes—Physiological observations—Experiments previous to the formation of an artificial membrana tympani—On the artificial membrana tympani—The mode of applying it—Cases—Rupture of the membrana tympani—Physiological observations —Pathological observations—Cases 186 CHAPTER XI. THE EUSTACHIAN TUBE. Anatomical observations—Physiological observations—Pathological observations—Seat of obstruction in the Eustachian tube: 1, The faucial ori- fice. 2, The tympanic orifice. 3, Middle part—Causes of obstruction: —1, Thickened mucous membrane. 2, Relaxed mucous membrane, a, Obstruction of the faucial orifice from thickened mucous membrane— The exploration of the tube—The otoscope—Treatment—Use of the Eustachian catheter and of the explorer—The excision of the tonsils— Cases, b, Obstruction of the Eustachian tube at its faucial orifice from relaxed mucous membrane —Symptoms—Treatment—Cases, c, Obstruction of the Eustachian tube at the tympanic orifice from thickened mucous membrane —Symptoms—Treatment—On the operation of puncturing the membrana tympani. first, that the tympanum may be generally a closed cavity so that the sonorous vibrations reaching it may be concentrated upon the membrane of the fenestra rotunda; and, second, that, as specially pointed out by Dr. Jago, sounds may be prevented entering the tympanum from the fauces. 1 PATHOLOGICAL OBSERVATIONS. Although from the preceding remarks there can remain little doubt 1 An examination of the faucial orifice of the Eustachian tube in other animals is corroborative of the view above advanced. In mammalia, the faucial orifice of the tube presents much variety both in structure and form. In the animals I have dissected belonging to the class ruminantia, there is an entire absence of cartilage at the orifice of the tube, and the aperture is guarded by a thin fold of elastic membrane ; it isbpened by the faucial muscles. In the carnivora the cartilage is prominent, and forms a distinct rounded projection. In the rodentia the orifice consists merely of a fissure in the mucous membrane of the fauces. In some of the mammalia the orifice is opened by the superior constrictor of the pharynx. In all the birds that I have been able to examine, the Eustachian tube was composed of two distinct portions, the membranous and the osseous ; and no cartilage entered into their composition. The membranous portion consists of a sac, which is common to both ears, the upper extremity of which receives the two osseous tubes, and the lower extremity opens into the cavity of the fauces posterior to the aperture of the nares. The muscles which open the Eustachian tube in the bird are the internal pterygoid, or rather s mall muscles distinct from the pterygoid, but accessory to them. The common membranous tube is situated between the internal pterygoid muscles, and the lateral surfaces of the tube are in contact with, and firmly adherent to, the inner surface of these muscles or their accessories, so that when the fibres are drawn from the median line the walls of the tube are s eparated, and a free communication exists between the tympanic cavity and the pharynx. 218 THE DISEASES OF THE EAR. that the faucial orifice of the Eustachian tube is ordinarily closed, except during the act of deglutition, it is requisite to perfect hearing that the tube should be pervious, and that there should be a constant interchange of air in the cavity of the tympanum. If the Eustachian tube becomes impervious, the air that was in the tympanum at the time of the closure gradually disappears. It is not easy to decide whether it is absorbed, or whether by a kind of exosmose it passes through the membrana tympani; but whatever the cause, in a space of time, varying in different cases from a few hours to a day or two, there is no doubt that the air in the tympanic cavity becomes partially exhausted. The effect is to produce an increased concavity in the external surface of the membrana tympani ; a forcing inwards of the chain of ossicles; pressure on the contents of the labyrinth; and a very serious diminution of the hearing power. The morbid conditions of the Eustachian tube found in 1523 dissections were as follows :— Containing mucus 10 Containing mucus, lining membrane congested, 2 Containing mucus, lining membrane thick, 2 Lining membrane congested, ......... 5 Faucial portion, mucous membrane red and soft, ..... 2 Bands of adhesion connecting the walls, 3 Stricture in osseous part 1 Stricture in cartilaginous part, . . ....... 2 Very large, ............. 2 The causes of obstruction of the Eustachian tube may be thus classified. 1. At its faucial orifice; a thickening or relaxation of the mucous membrane. 2. At its tympanic orifice; thickening of the mucous membrane, or a deposit of fibrin. 3. In the middle part of the tube; a collection of mucus, a stricture of the osseous or cartilaginous portions, or membranous bands connecting the walls. 1. Obstruction of the Eustachian tube at its faucial orifice takes place— (a.) From thickened mucous membrane. (b.) From relaxed mucous membrane. THE EUSTACHIAN TUBE. 219 (a.) OBSTRUCTION OF THE FAUCIAL ORIFICE FROM THICKENED MUCOUS MEMBRANE. In these cases there is usually enlargement of the tonsils, or hypertrophy of the mucous membrane of the nose and fauces. If the obstruction occurs in a young person, the mucous membrane of the nose is commonly so thick as to offer some resistance to the easy passage of air, and to lead to the habit of breathing through the mouth; a habit which at night is carried out to a marked degree, and the patient often snores loudly. Upon examining the fauces, the tonsils are sometimes found enlarged, and the faucial mucous membrane is thicker than natural. In the adult the latter condition is observed, but the tonsils are less frequently affected. The deafness comes on usually rather rapidly, often subsequent to a cold, and, after remaining for a time, suddenly vanishes with a loud crack in the ear. This amelioration often accompanies the acts of yawning, gargling, or other strong muscular effort of the fauces. The improved hearing which thus results rarely continues long; sometimes it lasts for a few hours, in others for a day: a variation which probably depends upon the intervals which elapse before the air disappears from the tympanic cavity. The amount of hearing depends upon the quantity of air in the tympanum. Sometimes the patient has to be loudly spoken to close to the ear; at others a distinct voice is heard at the distance of two or three yards. There is frequently complaint of a sensation of weight or pressure in the ears, which often extends to the head, when heaviness and great depression of spirits are experienced. The latter symptom is very marked at times, but entirely vanishes with the removal of the obstruction. It possibly may originate from the pressure exerted upon the contents of the labyrinth by the forcing inwards of the membrana tympani and ossicles. A peculiar symptom sometimes met with in this affection, and for which I am unable to account, is the improvement which takes place during the temporary position of the head on a pillow, or even if it be turned round and kept looking backwards. Irritation is often complained of in the external meatus; sometimes the dermis of the meatus becomes much congested, and eventually pours out a discharge; and where it happens that the irritation is still greater, a polypus forms, and there is a large quantity of mucus secreted. When a patient presents himself for advice, 220 THE DISEASES OF THE EAR. with obstruction of the Eustachian tube coexisting with polypus or the sympathetic discharge from the meatus, unless the case be most carefully examined the real disease is apt to be overlooked, and considered to be an affection of the meatus only. On inspecting the membrana tympani, it will be found very concave, of a dull leaden hue, and its surface of an unnatural, glassy aspect, the triangular spot being larger than natural. Sometimes the membrana tympani is so much drawn inwards as to approach the stapes, which is distinctly discernible through it; in other cases, the membrana tympani is somewhat opaque, and its outer surface uneven and irregular. The exploration of the Eustachian tube. —The method of doing this is so important to a thorough examination, as to require to be treated in detail. In a paper read before the Medico-Chirurgical Society in 1853, I pointed out a simple mode of ascertaining whether the Eustachian tube was pervious, and one which, as a general rule, is successful, without having recourse to the catheter. It has already been shown, that during the act of deglutition, with the mouth and nose closed, a small quantity of air is passed through the Eustachian tubes into the tympanic cavities; a process that is attended with a sensation of fulness in the ears. The entrance of air into the tympanum can be distinctly heard by means of an elastic tube about eighteen inches long, each end of which is tipped with ivory or ebony; an instrument which I have named the Otoscope. One end of it is to be inserted into the ear of the patient, and the other into that of the medical man, who must take care that no portion of the tube touches any neighboring body. When the patient swallows a little saliva, the mouth and nose being closed, if the Eustachian tube be pervious, at the moment that he feels a sensation of fulness in the ear, the surgeon will hear most distinctly a faint crackling sound, produced apparently by a slight movement of the membrana tympani. This crackling sound is that most usually heard; but in some instances where the mucous membrane of the tympanum is thick, a gentle flapping sound will be detected in its place. If in a case of suspected obstruction of the Eustachian tube, the otoscope fail to reveal any sound during the act of deglutition; if no sound be heard when the patient makes a forcible attempt at expiration with mouth and nose tightly closed; and if the history of the case, the symptoms and appearances, agree with those already laid down as appertaining to obstruction of the Eusta- 221 THE EUSTACHIAN" TUBE. chian tube, I think the surgeon is justified in affirming that the tube is obstructed, and has no need to resort to the use of the Eustachian catheter. Doubtless, in many cases, a person is unable Fig. 77. The Otoscope. to force air into the tympanum, although the pervious condition of the Eustachian tube is shown by the test of the otoscope, and this may depend upon a peculiar arrangement of the lips of the tube which causes them to be pressed together by the compressed air. There are other cases also where the tube may be proved to be pervious by the patient forcing air into it during an attempt at expiration, although the act of deglutition with closed nostrils does not call forth any sound appreciable by the otoscope; but it is rare indeed for a pervious tube to resist both of these tests. I have, however, met with such cases; but, as their history, appearances, and symptoms have concurred in showing that no obstruction of the tube existed, it has not appeared necessary to introduce the catheter. In certain cases the membrana tympani may be seen to move during an attempt at expiration, even though no sound could be heard; the patient, therefore, should always be asked whether he perceives any sensation in the ears during the above-named processes. Is the Eustachian catheter then useless as a means of diagnosis ? Notwithstanding its frequent use by surgeons in Germany and in France, I am disposed to think so. By paying attention to the points just laid down, it is my opinion that a case of obstruction of the Eustachian tube can always be diagnosed without the aid of the 222 THE DISEASES OF THE EAR. catheter. Respecting its use as a remedial agent, I shall speak hereafter. That the cause of the obstruction of the Eustachian tube at its faucial orifice is the thickening of the mucous membrane, is proved Fig. 78. The Surgeon using the Otoscope. by actual dissection, by the coexistent thickening ot the mucous membrane in other parts of the fauces, and by the results of the remedial measures adopted for its relief. An opinion formerly obtained a certain degree of credence in the medical profession, that enlarged tonsils frequently press upon and close the Eustachian tube. There can be no doubt this opinion is erroneous. To convince himself that it is so, the surgeon has only to make an examination of the relative position of the tonsil and of the trumpetshaped extremity of the tube; when he will find the tonsil situated from an inch and a quarter to an inch and a half below the tube, and placed between the palato-glossus and palato-pharyngeus muscles, the latter muscle entirely separating the tonsil from the tube: he will also find the Eustachian tube close to the base of the skull, against the basilar process of the occipital bone, and surrounded by the tensor and levator palati muscles, the function of which is, as already shown, to open the tube. Repeated examinations have convinced me that even should the tonsil enlarge to its greatest possible 223 THE EUSTACHIAN TUBE. known extent, it never reaches the Eustachian tube; for, together with the enlargement of the tonsils, the palato-pharyngeus muscle also hypertrophies, and effectually separates the two organs. Nay, further, in the cases seen by me, where the tonsils have been the largest, there has been no deafness; a fact which must also have been observed by other medical men. Often, in a case of obstructed Eustachian tube in one ear, the tonsil has been comparatively small on the deaf side; while on the opposite side, where there has been no deafness, the tonsil has been large. There is no doubt that obstruction from hypertrophy of the mucous membrane of the faucial orifice of the Eustachian tube may coexist with enlarged tonsils; but the mere coexistence of two affections must not be confounded with cause and effect. TREATMENT OF OBSTRUCTION OF THE FAUCIAL ORIFICE OF THE EUSTACHIAN TUBE BY THICKENED MUCOUS MEMBRANE. Cases of this disease, when uncomplicated with any affection of the tympanum, ordinarily yield to the use of general remedies and applications to the fauces, without touching the outer ear. The object to be aimed at is the reduction of the congestion and hypertrophy of the mucous membrane surrounding the orifice of the tube, so as to allow the muscles again to exercise their function of opening it; and for this purpose considerable patience and perseverance are doubtless frequently required; since in many strumous persons, especially if young, the tendency to congestion and thickening is very great. General Remedies. —The most efficient of these are abundant and active exercise in the open air, and warm clothing. Flannel should be worn next to the skin. In youths the flannel jacket, extending from the neck to the ribs, may not only be worn, but, in cold weather, in front, when the chest is exposed, a small additional piece of flannel may be worn suspended from the neck. The throat should not be wrapped up with handkerchiefs, comforters, boas, &c, as they only serve to weaken it, by keeping it warm for a certain time, and then, on their removal, leaving it exposed frequently to a colder air, within doors than had prevailed without, thus bringing on relaxation of the mucous membrane. Where a single tie-handkerchief is worn within doors, no addition is needed on going out; and where in 224 THE DISEASES OF THE EAR. children the throat is left bare within the house, a small silk handkerchief, loosely tied, is all that is required without. I have been thus particular on these points, because experience frequently convinces me of their great importance. The surface of the body should be daily sponged or rubbed with a coarse towel that has been dipped in cold water, and then wrung out. As the children who suffer from the affection under consideration have usually a languid circulation and deficient nervous energy, the towel bath appears to be a remedy advantageous in both respects. The towel should be very coarse, and only one part of the body should be rubbed at a time. The skin, especially that of the neck, throat, and spine, should be brought to a ruddy glow. This bath may be used either in the morning or the evening, but once daily is sufficient. If the patient be so very delicate that he cannot well bear the slight shock produced by the cold towel, tepid water may be used. In addition to this bath, indeed to supersede it, especially in youths of from fourteen to sixteen, by whom it is not likely to be carried out effectually, the tepid or cold plunge-bath may be resorted to. When it can be practised, sea-bathing should not be neglected, but in all cases of entire immersion it is advisable to wear an oil-skin cap, to keep the head dry: and this, not because the application of water to the head is objectionable, but because there is so great a difficulty in perfectly drying the hair, and the slow evaporation from it is often decidedly injurious. Plunging into a fresh-water river in warm weather is not prejudicial. In the treatment of the cases in question, too much stress cannot be laid upon the necessity of exercise, bracing air, and cold bathing. I have known them to overcome the most obstinate cases of obstruction of the faucial orifice of the Eustachian tubes, where all local remedies and medicines had given slight or only temporary relief. Care should also be taken as to the diet of the patient: pastry, sweets, fat, &c, should be avoided; vegetables may be sparingly partaken of; and the principal food should be bread, especially that containing the bran, meat, and light puddings, as rice, sago, &c. Children should not be overworked in their studies, should retire early, and their sleeping-rooms should be airy and well ventilated (it is a good plan to leave the bedroom door ajar during the whole of the night); and, above all, it is important that the head should be kept above the bedclothes. To overcome the very prevalent habit of breathing through the 225 THE EUSTACHIAN TUBE. mouth, whereby the cold air keeps up a constant irritation of the faucial mucous membrane, the patient should be directed to sit down quietly for a certain time daily, and practise the habit of nasal respiration. Although it 'may at first seem difficult, the mucous membrane of the nose soon yields, and the air passes freely.' Medicines. —All medicines that impart tone to the system, may in turn be resorted to. Cod-liver oil, iron in various forms, iodide of iron, iodide of potassium, creasote, and the mineral acids and vegetable bitters, will be found useful. Local Treatment. —The most efficient local application is undoubtedly the nitrate of silver, which may generally be used in a solid form. Messrs. Weiss have made for me a caustic holder, the end of which is capable of being turned at such an angle, that the caustic may be passed behind the soft palate, and applied to the mucous membrane of the orifice of the tube, as well as to that of the fauces. Should the tonsils be enlarged, the solid nitrate of silver may be rubbed over their surface, and over that of the faucial mucous membrane, about once a week; and it should produce considerable irritation and a copious flow of mucus. Stimulating gargles are also to be used; those combining acids and astringents are of service. Iced or cold water is often beneficial; and in order to insure the application of the cold water to the orifices of the tubes, as well as to improve the condition of the mucous membrane of the nares, the water may be drawn up through the nose, and passed out by the mouth. When there is much congestion of the faucial mucous membrane, a leech or two, a stimulating liniment, or a vesicating paper, may be applied over the region of the tonsils. The use of the Eustachian catheter. —It was, and is even now, the custom of some surgeons to pass the .Eustachian catheter repeatedly in cases of obstruction of the Eustachian tube. Now, what is the effect of this procedure ? If the mucous membrane be not much thickened, air is blown into the tympanic cavity, and the power of hearing is improved. As soon, however, as the catheter is withdrawn, the tube again closes, and its muscles have not the power to reopen it; while the air which has been forced into the cavity soon disappears, and the deafness returns. ' The patient again seeks relief from the same process and with the same result; 1 Many years ago I pointed out the peculiar erectile tissue of which the nasal mucous membrane is composed, not only in man, but in most mammalia ; this tissue renders it a most efficient natural "respirator." 15 226 THE DISEASES OF THE EAR. for if the mucous membrane is allowed to remain in its existing state, no permanent relief is to be hoped for; on the contrary, the repeated use of the catheter tends rather to increase than diminish the congested state of the membrane. Under certain circumstances, however, the Eustachian catheter is of great value. The judicious course respecting it is to use the above-named plans for the purpose of reducing the hypertrophy of the mucous membrane, which will, in the majority of cases, effect the cure of the disease. If, after pursuing these measures for ten days or a fortnight, no amelioration ensues, the Eustachian catheter may be introduced and air blown through the tube into the tympanum; an operation which may at times possibly facilitate a cure by the removal of mucus from the tube, or by liberating the lips of the faucial orifice. Several days, however, should elapse before the operation, if required, is repeated, and this will seldom be the case. The mode of applying the Eustachian catheter. —It has been already stated that the orifice of the Eustachian tube is posterior and external to the posterior aperture of the inferior nasal meatus. The catheter used by me is not quite so large as an ordinary crowquill ; and as the outer part of the Eustachian tube is oval, it has been recently suggested by me that the extremity of the catheter should be of the same shape. The end of the catheter taken hold of by the surgeon should be rather larger than that which is to enter the tube, in order that the end of the explorer, or the nozzle of a syringe, may be fixed in it. This end having a ring on the side opposite to the concavity of the curved end, is to be taken in the right hand of the surgeon, the patient being seated in the chair before him, and then the instrument, with the point downwards, is to be made to glide backwards, by the side of the septum nasi, until the curved end reaches the cavity of the fauces, when it is to be pressed backwards against the mucous membrane of the posterior part of the fauces. It is next to be drawn slightly forwards, and then rotated outwards, so that the extremity may turn upwards and catch the orifice of the Eustachian tube, which can be distinctly felt, and will prevent the further rotation of the instrument. The catheter is now to be pressed slightly outwards and backwards, when the surgeon will feel it to be embraced by the tube. For the purpose of securing the instrument, a frontlet bandage, with a pair of forceps attached, has been used; but it may be dispensed with in all ordinary cases: for the surgeon has only to transfer the catheter to 227 THE EUSTACHIAN TUBE. his left hand, and while holding it lightly, so as not to cause pain to the patient (as the use of the frontlet invariably does), insert into the dilated end of that instrument the small end of the explorer or of the syringe. The explorer, which in my hands has entirely super- Fig. 79. The Explorer, and the Eustachian Catheter into which it fits. seded the use of the air-press, consists of an elastic tube, about eighteen inches long, one end of which has a flat mouth-piece of ivory, with one or two deep incisions upon it, to enable it to be easily held by the incisor teeth of the operator, while the other end has a small portion of steel tubing attached to it, which fits accurately into the further end of the catheter. When the catheter has been properly fixed, as directed in the tube, and held there by the left hand of the surgeon, one end of the explorer is to be placed in his mouth, and the other in the catheter, and held there also by the left hand. With his right hand, thus left at liberty, the surgeon is now to take the otoscope and introduce one end of it into the ear of the patient, who may hold it there, the other end being held by the surgeon in his own ear; or the tube may be made so light as to remain there without being held, leaving the operator's right hand still free. The medical man next proceeds to blow air gently through the explorer, at the same time that he listens through the otoscope to ascertain whether the air enters the ear, and if it does, what is the peculiar sound it produces. When the tympanum is unobstructed by mucus, the air is heard to pass in a stream against the inner surface of the membrana tympani, but when mucus is present, a peculiar gurgling is heard; and if the mucous membrane itself is thickened, a peculiar squeak or bubbling is also perceptible. It is 228 THE DISEASES OF THE EAR. not advisable to blow with force into the ear, but rather to make a few gentle successive puffs, attentively listening during each, to detect the kind of sound that may be heard in the tympanum. Fig. 80. The Surgeon using the Eustachian Catheter and the Explorer. Sometimes no air enters, the mucous membrane being too thick to allow it to pass; and, under such circumstances, it is unwise to attempt to force the air into the tympanum. Great mischief has, indeed, frequently resulted from such a proceeding; the mucous membrane having been lacerated, and the air been driven into the submucous tissue, causing extensive emphysema. Nay, still more serious results have occurred, the patient having been killed instantaneously, perhaps through the effusion of air through the fenestra rotunda (the membrane having been lacerated) into the labyrinth, and the shock upon the nervous system causing instant death. Nor need it be a source of surprise that the effusion of air into the labyrinth should prove fatal, since even the forcible distension of the tympanum, while blowing the nose frequently, produces giddiness by pressure upon the labyrinth. The excision of the tonsils. —On the supposition that the tonsil, when enlarged, pressed against and closed the faucial orifice of the Eustachian tube, the operation for excision, or partial excision, of the tonsils, has long been practised for the relief of deafness. Al- THE EUSTACHIAN TUBE. 229 though, as already shown, the tonsil, however hypertrophied, cannot cause occlusion of the Eustachian tube, still the removal of a portion, in cases where it is much enlarged, is sometimes of service by diminishing the congestion of the mucous membrane at the orifice of the tube; and it perhaps also operates beneficially by allowing the muscles of the tube to act more freely. This operation is, however, very rarely required; and the best rule to follow is never to excise a portion of the tonsil, which appears to have important functions, independent of the fauces, unless it evidently interferes with the general health of the patient, or unless the obstruction of the Eustachian tube resists the other measures already indicated. CASES OF THE OBSTRUCTION OF THE EUSTACHIAN TUBE BY THICKENED MUCOUS MEMBRANE, AT ITS FAUCIAL ORIFICE. Case I.—Master M. J., aged 15, was brought to consult me, on December 4, 1852, on account of a very serious diminution of the hearing power, in both ears. He was in tolerable health, but pale. About a year previously, after suffering from a bad cold, he became dull of hearing, and since then has been able to hear only when spoken to in a loud voice, within the distance of a yard or two. Occasionally he has felt a sensation as of something bursting in the ears, which has been followed by slight, but only temporary relief. Upon examination, the mucous membrane of the fauces was found very thick and red, and both tonsils greatly enlarged. The right ear. —Watch heard only when in contact with the ear; the membrana tympani being opaque, of a leaden hue, and more concave externally than natural, while, instead of the usual triangular bright spot, two bright spots were perceptible, showing that the membrane was deprived of its ordinary evenness of surface. Upon listening with the otoscope while the patient swallowed, the mouth and nose being closed, and while he tried to force air into the tympanum, no sound was heard. The left ear was in a very similar state to the right; the watch, however, could be heard at a distance of two inches from the ear. Feeling assured from the history of the case, the symptoms, the condition of the throat, the appearances of the ear, and the negative results following the use of the otoscope, that the Eustachian tube was closed at the faucial orifice, especially as there was no indication of disease in the tympanum, which might lead to 230 THE DISEASES OF THE EAR. the supposition of the tympanic orifice being affected, I did not use the Eustachian catheter, but proceeded at once to apply a solution of nitrate of silver to the mucous membrane of the fauces, and to the orifices of the Eustachian tubes. Three grains of the sulphate of iron were given daily in combination with ten grains of sulphate of magnesia, and slight counter-irritation was kept up over the region of the tonsils. As a remedial measure, the catheter was not resorted to, as it was evident that the hypertrophy of the mucous membrane had slowly come on, and it was not probable that it could be otherwise than slowly improved. The first effect of the treatment was a slight improvement of the hearing, although the tube remained impervious; an improvement which probably depended upon the diminution of the congestion in the mucous membrane of the tympanum. By the end of January, the hearing power of the right ear had greatly improved; and in the middle of February, the air passed freely through the Eustachian tubes during the act of deglutition, and the patient heard quite well again. Case II. Obstruction at the faucial orifice for two months. —W. W., Esq., aged 52, being strong and in good health, consulted me on July 26, 1853. He stated that two months previously, after a bad cold, he became slowly deaf in both ears, so as to require persons to speak loudly to him within the distance of a yard. On the 24th, after yawning, he suddenly experienced a crack in the left ear, and as suddenly heard well; but this improvement only lasted for a day, and then the deafness slowly returned. He has had three similar attacks during the last ten years, but in about a month's time the hearing usually returned after a cracking sound in the ears. At times, on throwing the head back, he has found the hearing power in the right ear much improved. On examination, the mucous membrane of the fauces was red and hypertrophied. Right ear. —Hearing distance three inches; the meatus was red and hypertrophied, the membrana tympani more concave than natural, its surface uneven, and instead of the single triangular bright spot, there were two smaller spots. Eustachian tube. —The otoscope did not detect any air entering the tympanic cavity during the process of deglutition, or upon an attempt at a forcible expiration with closed nostrils. Left ear. —Watch heard only when in contact with the ear; the membrana tympani was in a similar state to that of the right ear, THE EUSTACHIAN TUBE. 231 and the long process of the incus could be seen through it. The Eustachian tube was impervious. By the use of stimulating gargles and a liniment over the ears and throat, the patient entirely recovered in the course of a fortnight. Case III. Obstruction of the faucial orifice: catarrh from meatus: tonsils very large: cure without excision. —Master B., aged 16, was brought to consult me in August, 1850. His general health was not very good, and he was subject to glandular enlargements. History. —The right ear has always been slightly dull, and for two or three years it has been worse. The left ear lately has also become so dull, that he requires to be spoken to distinctly within the distance of a yard from the head. Has had several attacks of earache; after which, and also after a cold, the deafness is increased. Has had discharge from each ear on several occasions, and complains of a singing in them. When asleep he makes a loud snoring sound, and he always breathes through the nose. At times has had a cracking sound in the ears, which has been followed by a temporary improvement. On examination, the tonsils were found to be so greatly enlarged as nearly to touch the median line, while the mucous membrane of the fauces and of the nose was much thicker than natural. Right ear. —Hearing distance half an inch; membrana tympani concave; bright spot somewhat dull. Eustachian tube impervious. Left ear. —Hearing distance two inches; the bright spot of the membrana tympani subdivided. Eustachian tube obstructed. As the tonsils in this case were so much larger than natural, and as they apparently interfered with the respiration of the patient, and perhaps with his health, it was thought that the removal of a portion of one or both might be attended with benefit: but the patient's friends so strongly objected to the operation that it was not performed. The treatment consisted in the application of solid nitrate of silver to the fauces; in the use of an astringent gargle with counter-irritants over the ears and throat; in the administration of tonic medicines ; and in careful diet, with abundant exercise in the open air. On August 21st, a crack took place in the left ear, when he heard perfectly for a short time. After this date, a succession of cracks was heard in each ear, and at last the hearing power entirely returned and remained perfect, except during a cold, the effects of which, however, soon disappeared. 232 THE DISEASES OF THE EAR. Case IV. Obstruction from the mucous membrane of the fauces ; polypus in meatus externus; removal by operation; cure. —H. W., Esq., aged 19, was sent to me by Mr. White Cooper, in February, 1854, on account of a considerable diminution of the power of hearing, and of a discharge from the right ear. His health was not very good, and he was subject to enlarged cervical glands. The history of the case was, that about two years ago he found himself becoming gradually dull of hearing. After this dulness had remained some months, accompanied by a feeling of fulness in the ears, a discharge took place from the right ear, the quantity of which has lately considerably increased. On examination, the mucous membrane of the fauces was observed to be red and thick. Right ear. —The watch heard only when in contact; a raspberry polypus, the size of a small pea, was seen to fill the meatus, close to the membrana tympani. Left ear. —Hearing distance six inches; membrana tympani opaque, and calcareous in parts. Each Eustachian tube was impervious to air. The treatment consisted in the removal of the polypus by means of the lever-ring forceps. The membrana tympani was then observed to be white. Astringent and acid gargles were used; slight counter-irritation was kept up over the ears and the region of the fauces; tonics were administered; and daily sponging with cold water was enjoined. In the course of a week a crack took place in the right ear, followed by immediate great improvement of the hearing; this was succeeded by a crack in the left ear, and a perfect restoration. The discharge also wholly disappeared. On seeing this patient several months afterwards I found his hearing perfect, and there had been no return of the discharge. I have said that the use of the Eustachian catheter is rarely required, because the state of the mucous membrane generally so much improves by means of the other remedies. In the following case, however, where there was an additional cause of impediment besides the thickened mucous membrane, the catheter was used with advantage. Case V. Impervious condition of the tube from hypertrophy of the mucous membrane at the faucial orifice; fissure of the palate; catheter used with advantage. —Dr. P., a medical man, aged 43, consulted me in 1853, on account of deafness. History. —Several years previously he had a disease of the palate, which terminated in the loss of a considerable portion of the palatal 233 THE EUSTACHIAN TUBE. processes of the superior maxillary and palatal bones, and caused a large fissure. During the last two or three years he has suffered from attacks of deafness during a cold, which, after continuing for some weeks, have disappeared. On examination, the mucous membrane of the fauces was found to be red and much thicker than natural. Towards the posterior part of the palate was a large fissure, exposing the trumpet-shaped extremity of the Eustachian tube; the mucous membrane of which was much swollen. Each membrana tympani was of a leaden hue and very concave; and there was an appearance of redness beyond each, as if the mucous membrane were congested. The patient had to be spoken to distinctly within the distance of a yard. The Eustachian tubes were impervious. Treatment. —A solution of nitrate of silver (5ij @ 3j) was applied to the mucous membrane of the fauces and to the orifices of the tubes; an astringent gargle was ordered, and gentle counter-irritation over the throat. This treatment produced a slight improvement ; but as the deafness soon returned, as the patient was especially anxious to hear, and as it appeared probable that the muscles of the tube were partially disabled from performing their function, I passed the Eustachian catheter, and, by means of the explorer, blew air into the tympanic cavities. The good effect was instantaneous, and the patient heard well. The improvement, however, lasted for only about twelve hours, when the deafness gradually returned. At the desire of the patient I passed the catheter on several occasions, while other treatment was being followed. After each operation the hearing improved for about the same space of time; ultimately the condition of the mucous membrane was so much improved as to allow the muscles to open the tubes, and a cure resulted. In some cases after the Eustachian tube has been obstructed for a long time, the patient may almost wholly lose the power of hearing. These cases, as will be seen by the following instance, are by no means to be despaired of. Case VI. Obstruction by thickened mucous membrane of the faucial orifice; duration of many years; great and prolonged hardness of hearing; cure. —Miss J. A. O., aged 12, was brought to me from Manchester, on the 16th April, 1853. She was strong, but rather pale. The history of the deafness was, that during several years she had been dull of hearing during a cold; on the disappearance of which, the power of hearing partially returned, so that she could hear without much difficulty. For some months the deafness has been 234 THE DISEASES OF THE EAR. so much worse, that she cannot hear unless spoken to in a loud voice into the left ear, the right being useless. On examination, the mucous membrane of the fauces was found to be red, thick, and spongy, but the tonsils were not larger than natural. The mucous membrane of the nose was very thick and red; and respiration was usually carried on by means of the mouth. Right ear. —Watch heard on pressure but indistinctly; membrana tympani concave, surface uneven; and on that surface three irregular-shaped bright spots were seen. Eustachian tube impervious. Left ear. —Watch heard when pressed; membrana tympani and Eustachian tube the same as in the opposite ear. Treatment. —The solid nitrate of silver was directed to be applied to the mucous membrane of the fauces once a week; counter-irritation over the ears, and a leech or two at times over the region of the fauces; the one-thirtieth of a grain of the bichloride of mercury twice daily, and a warm bath once a week: occasionally an emetic was also given. She returned to Manchester, and on the 28th of May her father wrote to me, saying that she was " so much better that she can keep up a conversation across the table." The child had a relapse in the following January, but a repetition of the treatment again restored her to perfect hearing. It is not, however, only in long-standing cases of obstruction of the Eustachian tube that the deafness is very considerable; in weak persons almost total deafness may come on in a few hours. A wellmarked case of the kind has occurred to me while writing the present chapter. Case VII. Sudden obstruction of each Eustachian tube from congestion and thickening of the mucous membrane of the fauces, producing total deafness in a few hours / cure. —Dr. B., on the 24th January, 1855, called to ask me to see his wife, of whom he gave the following history. For several months she has been much out of health, and confined to her room; but has never suffered from any deafness or disease of the ear. On the night of the 20th instant she awoke, complaining of a loud singing in her ears; and when spoken to, it was found that she was so deaf as not to be able to comprehend what was said, although addressed very loudly. If possible, this deafness increased, so that on the 22d no sounds were heard, and all communication had to take place in writing. On examination, on the 24th, I found that the deafness was complete; each membrana tympani was very THE EUSTACHIAN TUBE. 235 concave and dull; the raucous membrane of the fauces was very red and thick, the tonsils and uvula much swollen. Bach Eustachian tube was impervious. Upon inquiry, I learnt that accidentally a part of the window had been left open during the night. The treatment recommended was the application of the solid nitrate of silver to the fauces and the orifices of the Eustachian tubes. This was done freely about eleven o'clock on the 26th. Dr. B. returned home about two hours after, and found the hearing so improved that he carried on a conversation with his wife in a loud voice. I might add to the above a large number of cases in which the treatment was quite successful, but will merely give the leading particulars of another. Case VIII.—H. L., Esq., aged 28, consulted me on June 25, 1853. Has suffered for several months from sore throat, consequent upon an attack of secondary syphilis: for two months has complained of deafness in both ears, so as not to hear any except a loud voice. The deafness is accompanied by constant singing, which is increased when the head is on the pillow, and it varies much. On one occasion, after gargling the throat, heard much better with the right ear for twelve hours. On examination of the right ear, the hearing distance was half an inch; the membrana tympani was opaque and of a leaden hue; the surface shone, but the bright spot was nearer the circumference of the membrane than natural. The Eustachian tube impervious. The left ear was in the same condition as the right. The treatment pursued was the use of the nitrate of silver to the fauces, and the administration of steel wine. On July 2d he told me that three or four days previously he heard quite well in the morning, and the improvement lasted for two days, since which he has been gradually getting deaf again. By perseverance in the treatment for a month he perfectly recovered. (b.) OBSTRUCTION OF THE EUSTACHIAN TUBE AT ITS FAUCIAL ORIFICE FROM RELAXED MUCOUS MEMBRANE. This affection is far from being so frequently met with as obstruction arising from thickened mucous membrane. In many symptoms the two affections greatly assimilate, but they also present certain decided differences. Obstruction from relaxed mucous membrane 236 THE DISEASES OF THE EAR. occurs less frequently in children or in persons subject to glandular enlargements, than in persons who have no thickening, but simply a relaxed state of the mucous membrane of the fauces. The physical cause of the obstruction appears to be a relaxed condition of the mucous membrane covering the faucial orifice of the tube, so that its muscles are unable to separate the lips sufficiently to admit the air. The predisposing cause is generally some debilitating influence, as over-work, keeping late hours, indigestion, &c. The exciting cause is often a cold. There is usually no history of any previous affection of the ears, the deafness coming on slowly, and gradually increasing until the patient is unable to hear ordinary conversation, and requires to be spoken to in a loud voice. Sometimes the patient improves for a short time, and then the deafness returns; but frequently the hearing is better when the head is placed in a recumbent position, or when the face is turned and looks backwards. There is often a feeling of weight in the ears, with a singing sound, and at times a sensation of confusion in the head. On examination, the patient generally looks pale and out of tone; the pulse is weak; the mucous membrane of the fauces is either relaxed and red, the bloodvessels being large and presenting long streaks; and the uvula is either hanging down, so as to touch the dorsum of the tongue, or it is of a much paler color than natural from being deprived of its due supply of blood. The membrana tympani is much more concave than natural, frequently of a leaden hue, its surface being glassy. Not unfrequently the long process of the incus is seen through it. Upon exploration with the otoscope, the Eustachian tube is found to be impervious. The treatment differs somewhat from that of cases of obstruction from thickened mucous membrane. Instead of nitrate of silver, stimulating gargles are to be used—one composed of whiskey is often very serviceable; tonic medicine and stimulants are to be administered, generous diet, rest from work, country air, and abundant out-door exercise should also be prescribed. Similar reasons to those which induce me not to use ordinarily the Eustachian catheter in cases of obstruction from thick mucous membrane, have prevented my resorting to it in the cases under consideration. Its use could not, of course, diminish' the cause of obstruction, or facilitate the progress of the treatment; and unless the patient, from some particular circumstances, was desirous to hear well 237 THE EUSTACHIAN TUBE. during a few hours, the introduction of this instrument should be avoided. A cure is always to be effected without it. Case I. Obstruction of the left tube from relaxed condition of the mucous membrane; constant beating sound. —J. R. H., Esq., a surgeon, aged 48, consulted me on December 15, 1823. The history was, that about six weeks previously he found himself deaf in the left ear; he felt no pain, but there was a constant sensation of beating in the ear, and a weight on that side of the head, which caused extreme discomfort. He is subject to a relaxed throat. On examination, the mucous membrane of the fauces was observed to be relaxed, though not thicker than natural; the meatus externus of the left ear was dry and smooth, and did not contain any cerumen; the membrana tympani was very concave and somewhat opaque. The processus brevis stood out very prominently; but the manubrium was so much drawn inwards that it could scarcely be seen. The otoscope showed the Eustachian tube to be impervious. The watch heard only in contact with the ear. The right ear perfectly natural. Treatment. —A whiskey gargle was ordered, and a mustard plaster to be placed on the region of the fauces; the outside of the throat to be rubbed with a coarse towel dipped in cold water; simple food, as much rest and as little " night-work" as possible. December 24th.—A crack took place in the ear, and the hearing became perfect for a few minutes, but again became gradually dull. The treatment was persevered in, and on the 7th January, 1854, the gentleman wrote, " I am quite well; the air passes into the ear perfectly well." All the unpleasant symptoms had subsided. Case II. Obstruction in each tube for ten days after an attach of bronchitis. —S. S., Esq., aged 51, an architect, was brought to me on June 24, 1853. History. —He has had a bad cough and bronchial affection for a month, which came on after having been considerably over-worked. Ten days ago deafness came on slowly in both ears, and has remained till now; so that he has to be spoken to in an elevated tone within a yard. He hears much better in the morning when reclining in bed. Has frequently tested his hearing by means of his watch, and the result is, that when lying down he can hear it at a distance of two feet with either ear; but after being in the erect posture for a minute or two the deafness returns, and he can hear the watch only at two inches from the ears. He has now and then 238 THE DISEASES OF THE EAR. had a slight crack in each ear, followed by somewhat improved hearing. On examination, the pulse was weak and slow, the face pale and flabby, and the mucous membrane of the fauces was seen to be relaxed, with enlarged streaky vessels ramifying in it. Right ear. —Watch heard only when in contact with the ear; the surface of the membrana tympani was dull, had a dark leaden hue, and the membrane was much more concave than natural, having two irregular-shaped bright spots in place of the single one; the long process of the incus was seen through the membrana tympani, and appeared to be in contact with its inner surface; the Eustachian tube was impervious. Left ear. —Similar to the right: hearing distance, a quarter of an inch. The treatment consisted in the administration of the citrate of iron, followed by decoction of bark and sulphuric acid; the use of a tannin gargle and gentle external counter-irritation. He was also advised to sleep in the country, to work as little as possible, and to live generously. On July 2d there was a slight improvement, but as yet no free passage for the ear through the tubes. On July 7th a sudden and great improvement took place in the right ear, after blowing the nose. Hearing distance, six inches in the right, and a quarter of an inch in the left ear. Cracks now occurred in both ears from time to time, and were followed by great amelioration in the hearing. At the end of July he had perfectly recovered. Case III. Obstruction at the faucial orifice from relaxed mucous membrane for two months after influenza. —Miss T., aged 16, was brought to me on June 7th, 1853. She was pale, with a weak pulse, and somewhat out of health, having had an attack of influenza for two months. Catamenia irregular. History. —When a child, was subject to dulness of hearing during a cold, but recovered as soon as the cold passed away. During the recent attack of influenza has been so dull of hearing as to require to be spoken to distinctly within the distance of a yard; general conversation is not heard. Sometimes during an entire day hears rather better. Complains of a ticking noise in the ears. Results of : right ear. —Watch only heard on pressure ; membrana tympani, surface dull, concave; Eustachian tube impervious. Left ear. —In the same state as the right. The mucous membrane of the fauces was relaxed. Treatment. —Considering that the relaxed condition of the faucial 239 THE EUSTACHIAN TUBE. mucous membrane was dependent upon the state of the health, steel was administered, and plans for invigorating the system were recommended : gentle counter-irritation over the region of the fauces was also enjoined. July 13th.—Has had a "rumbling" sound in the ears, since which she has been better. Hearing distance, two inches. July 20th.—Well. Eustachian tubes pervious. Several additional cases might be related, but the three I have mentioned will be sufficient to illustrate the nature of the affection. (c.) OBSTRUCTION OF THE EUSTACHIAN TUBE AT THE TYMPANIC ORIFICE FROM THICKENED MUCOUS MEMBRANE. Inasmuch as one of the most common affections of the ear is inflammation of the tympanic mucous membrane, it will be readily conceived that obstruction of the tympanic orifice of the Eustachian tube is likely to take place from the same cause. It is well known that the osseous portion of the Eustachian tube, which is about the size of an ordinary probe, is lined by an extremely thin mucous membrane, which, like that covering the osseous walls of the tympanum, adheres firmly to the surface of the bone, and appears to act in the twofold capacity of a periosteum and mucous membrane; one of the reasons for its extreme tenuity being the fact that the bony part of the Eustachian tube forms part of the cavity with resonant walls. The whole of the mucous membrane of the Eustachian tube, excepting at the two extremities, is so surrounded by muscles and bone as to be little liable to become the seat of disease. In making dissections, I have rarely found that it has been morbidly affected; indeed, in some cases of ulceration of the faucial mucous membrane in scarlet fever, accompanied by ulceration of the mucous membrane of the tympanum, the membrane lining the central portion of the tube has been found free from disease. It would thus appear that the commonly received opinion of the extension of the disease, by direct continuity, from the fauces to the tympanum, is not always correct; and from observation of what occurs in other cases, there is no difficulty in conceiving the affections of the two parts to originate at the same time without any relation of cause and effect. It cannot be doubted that it is very fortunate the mucous membrane of the central part of the tube is so little liable to become thickened, since it would of course be very difficult to act upon it effectually. 240 THE DISEASES OF THE EAR. The mucous membrane covering the bone which forms the tympanic aperture of the tube is, on the contrary, liable to congestion and hypertrophy, being, like the mucous membrane of the tympanum, exposed to the influence of the cold air entering the meatus externus. Symptoms arising from this cause are usually present in the cases under consideration; but there is generally in addition a great concavity of the membrana tympani, loud noises in the ears, and, upon examination, an impervious state of the Eustachian tube. The history of the two cases differs in the fact, that in cases of obstructed Eustachian tube, the deafness generally comes on rapidly, often disappears, and as rapidly reappears; whereas in those arising from disease in the mucous membrane, the progress is usually slow and regular. It must also be remembered, that in cases of obstruction of the Eustachian tube at the tympanic orifice, there is commonly a history of previous attacks of inflammation in the tympanic mucous membrane, which is not often the case in instances of obstruction at the faucial orifice: the membrana tympani also presents appearances indicative of inflammation having occurred in the tympanic cavity. The most simple cases of obstruction of the Eustachian tube at the tympanic orifice are those following an ordinary cold, in which a sense of fulness is felt in the ears, often attended with noises, and with dulness of hearing—symptoms which last for a few days, and then ordinarily disappear with a sensation of something bursting in the ear. In the treatment of these cases, all those measures should be resorted to which will be described as serviceable in hypertrophy of the mucous membrane of the tympanum. In addition, the operation of puncturing the membrana tympani is sometimes advisable. ON THE OPERATION OF PUNCTURING THE MEMBRANA TYMPANI. Since Sir Astley Cooper obtained a medal from the Eoyal Society, on account of the success which, in a few cases, followed the operation of puncturing the membrana tympani, this operation has been performed frequently, and in cases of deafness arising from every possible cause. Though, doubtless, in certain cases it may be of great service, it is an operation rarely required, and one which, if not judiciously performed, is liable to produce the most injurious consequences. In Sir Astley Cooper's successful cases, there was 241 THE EUSTACHIAN TUBE. simple obstruction of the Eustachian tube; and there is little doubt that the affection would have yielded to simple measures, having for their object the removal of the obstruction, while the cure instead of being temporary would have been permanent. In the great majority of cases where Sir Astley punctured the membrana tympani not the slightest benefit accrued, because the deafness was dependent upon other causes than obstruction of the Eustachian tube; and in some cases of deafness from debility of the auditory nerve, the shock of the operation greatly aggravated the symptoms. In what cases, then, should the operation be performed ? It will be observed that I have not recommended it in cases of obstruction of the faucial orifice of the Eustachian tube, because that obstruction can be otherwise removed; but should the faucial orifice be permanently closed by adhesion of its walls (a case never met with by me), there can be no question that it should be performed. It is also called for in cases of stricture of the osseous portions of the tube, in those of obstruction by fibrinous effusion, and where the thickened mucous membrane of the tympanic orifice will not yield to other treatment. Great and immediate improvement frequently follows the operation; but there is usually so much difficulty in keeping th*e aperture open, that the value of it is much diminished. The ordinary instrument for performing the operation is the sharp triangular end of a probe; and where only temporary effect is required, this is sufficient. Fabrizzi invented an instrument for drilling out a circular portion of the membrane; but the extreme sensitiveness of the outer surface of the membrana tympani renders it difficult of application. It consists of a silver tube, about four inches long, one end of which, about a line in diameter, is tipped with steel and made to cut; the opposite end is made to screw on the outer part of a trocar near its handle; while the trocar, consisting of a silver rod, has at its end a fine wire shaped like a corkscrew. When used, the trocar is passed through the canula, and the spiral wire which projects beyond it has its point passed through the membrana tympani, and then turned round so as to cause it to enter the tympanic cavity. When this has been effected, and a firm hold of the membrana tympani is secured, the canula is to be slightly unscrewed; an action by which its cutting extremity is pressed through the substance of the membrana tympani and removes a circular portion. This instrument may be used, however, in cases where the sensibility of the tympanic membrane has been impaired by disease. 16 242 THE DISEASES OF THE EAR. The usual method is, as stated, to puncture by the probe: and the part best adapted for this purpose is that between the handle of the malleus and the posterior margin. The plan adopted by me for keeping open an orifice in the membrana tympani, and the particulars of a case in which it was practised, will be found below: it consists in making a triangular flap, by means of a very small scalpel, the blade of which is not more than two lines in breadth. Case I. Obstruction by thickened mucous membrane at the tympanic orifice. —Miss K. J., aged 10, was brought to me on July 14, 1853. History. —Between five and six years ago, after a cold, suffered from an attack of earache, followed by dulness of hearing, so that she has been obliged to listen, in order to hear conversation. During attacks of cold, she has been so much worse as to require to be spoken to distinctly, within the distance of a yard or two. Is now subject to occasional attacks of earache, and has had a slight discharge from the right ear. On examination of the right ear, the dermoid layer of the membrana tympani was white and thick, and covered with a small quantity of discharge; the membrana itself was more concave than natural; and the Eustachian tube was obstructed. Left ear. —The surface of the meatus was covered with cerumen, having a natural appearance; the membrana tympani was white and concave; the Eustachian tube was obstructed; and the mucous membrane of the fauces was in a natural state. Treatment. —Leeches were applied below each ear, twice a week, followed by blisters; and the one-thirtieth of a grain of the bichloride of mercury was given twice daily; a course of treatment which was pursued for six weeks. At first, there was no improvement; after three weeks, however, a slight diminution of the deafness took place; and on the 1st of September, the hearing was quite restored, and the Eustachian tubes were pervious. Case II. Obstruction by thickened mucous membrane at the tympanic orifice, after influenza ; polypus in one ear, a collection of cerumen in the other; great improvement. —Master J. P. M., aged 14, in good health, was brought from Lincolnshire, July 27, 1853. History. —Four years ago he had an attack of influenza, followed by so conspicuous a hardness of hearing, that he required persons to speak to him in a loud voice. During a cold the deafness is much 243 THE EUSTACHIAN TUBE. increased; at times, after a feeling of cracking in the ear, has heard much better. This crack occurred once in the right ear, after bathing, and was followed by perfect hearing for a few hours. The right ear has discharged blood for several months, and been affected with earache. Previous treatment. —Glycerine has been dropped into both ears without any benefit; slight improvement followed the use of a blister behind each ear; tonics have been administered. On examination: right ear. —Hearing distance, half an inch; the meatus contained a discharge, and at its inner part, concealing the membrana tympani, was a red, globular polypus. Eustachian tube obstructed. Left ear. —Hearing distance, half an inch; the meatus contained a collection of cerumen; on removal of which, the membrana tympani was seen to be very concave and white: Eustachian tube obstructed. Treatment. —The polypus was extracted from the right ear by the lever-ring forceps; vesication was kept up over the mastoid processes ; small doses of the iodide of potassium were administered. In the course of three months the hearing returned, and he remained well. Case III. Obstruction of the tympanic orifice of the tube; polypus in the right ear; cured. —Miss M., aged 14, saw me on the 14th of February, 1854. Her health was good, but she complained of headache. History. —During the last seven years has been, at times, dull of hearing, and has had attacks of earache. During a cold is much worse. Has not had any discharge. Occasionally, after feeling as if something had burst in the right ear, had heard quite well for a short time. She now has to be loudly spoken to close to the right ear; the left is useless. On examination, the hearing distance of the right ear was found to be two inches; the membrana tympani was concave and white; the Eustachian tube obstructed. With the left ear, the crack of the nails was heard; the membrana tympani was thick; the Eustachian tube obstructed. Treatment. —Brown's vesicating paper was ordered to be applied behind both ears every night, and three grains of hydrargyrum cum creta were to be taken every night. March 7th. —The same: has not been pursuing the treatment with regularity: to take an emetic once a week, and the one-thirtieth of a grain of the bichloride of mercury, twice daily; the vesicating paper to be continued. 244 THE DISEASES OF THE EAR. April 6th.—Has heard well for a week, and hears better to-day than on March 7th. A small vascular polypus is seen in the right meatus near the membrana tympani. May 11th.—The right ear has greatly improved; hearing distance nine inches. Left ear: watch heard on pressure. June 14th.—Right ear cured: the polypus has disappeared. Case IV. Obstruction of the tympanic orifice of the tube; temporary relief by puncturing the membrana tympani; cured by removing the obstruction. —J. R., Esq., aged 53, strong, and in good health, was sent to me by Mr. Cock, on May 7th, 1853. History. —"When a boy, was deaf, and was taken to Sir Astley Cooper, who punctured the drum of each ear; which operation was followed by complete relief until eight years ago, when, after a violent cold, deafness gradually came on in both ears; and has remained till now, with the exception of a day or two's improvement, at times, after violent sneezing. At present, he has to be loudly spoken to within a foot of his head, in which there is a feeling of constriction and of pressure on the top part. On examination of right ear, the crack of the nails only is heard; the membrana tympani is very opaque, uneven, and concave; Eustachian tube obstructed. Left ear. —Watch heard on pressure. Membrana tympani and Eustachian tube in the same state as in the right ear. There was no doubt in my mind that the cause of the deafness was a thickened state of the mucous membrane at the tympanic orifice of the tube; and I prescribed the application of leeches below the ear, to be followed by blisters, while small doses of mercury were to be administered. The patient, however, implored me, if possible, to render him some immediate relief, as he was a candidate for a public appointment; for, although my assurance that he would recover might favorably influence the committee, before whom he was to appear the following day, still he greatly feared that, should he not hear what was said, he might be rejected. I, therefore, but unsuccessfully, attempted to pass air into the tympanum through the catheter. I then punctured each membrana tympani with an ordinary probe, which, as it passed, conveyed the feeling of the membrane being soft and flaccid. The result was an instantaneous return of the hearing power, and the total disappearance of the weight in the head: to use his own words, he "felt free again." The hearing distance of each ear was six inches." May 30th. —After the operation, continued to hear well until a THE EUSTACHIAN TUBE. 245 few days ago, when the deafness slowly returned, and he is now nearly as deaf as on the 14th. The orifice in each membrana tympani had closed. As he was unable to wait until the remedies for opening the tube could be tried, I made a triangular flap, about two lines long, and a line broad below, in each membrane, by means of a scalpel, the blade of which was about two lines in breadth: the apex of the flap was above, and it was turned down. The result was as instantaneously favorable as in the previous operation: and as it was considered probable that the aperture would close, active treatment for the purpose of opening the tube was at once carried out. The consequence was, that in a fortnight, although the orifice in each membrana tympani had closed, the air passed freely through the Eustachian tube, and the patient heard well. Closure of the tympanic orifice of the Eustachian tube by the effusion of fibrine will be spoken of when describing cases of the effusion of fibrine into the tympanic cavity. (d.) OBSTRUCTION OF THE MIDDLE PART OF THE EUSTACHIAN TUBE ; BY A COLLECTION OF MUCUS, BY A STRICTURE OF ITS CARTILAGINOUS OR OSSEOUS PORTIONS, OR BY BANDS OF ADHESION CONNECTING THE WALLS. In the tabular view giving the result of 1523 dissections, it will have been observed that in thirteen instances the Eustachian tube contained mucus. In my opinion, however, a collection of mucus rarely offers insuperable resistance to the action of the muscles of the tube, to the pressure of the air in the fauces during the act of deglutition, or to an attempt at a forcible respiration, with closed nostrils, &c. It is nevertheless possible that in some of the cases where the tympanic orifice of the tube is closed by thick mucous membrane, there may be also an accumulation of mucus; but as its presence would not require any alteration in the treatment, it is unnecessary to dilate upon the subject. Stricture of the osseous portion of the Eustachian tube is very rare. Only one case has fallen under my observation; but as I had the opportunity of seeing the patient during life, and afterwards of making a dissection of the ear, it is of sufficient interest to be detailed at length. Case I. Stricture of the osseous portion of the Eustachian tube; 246 THE DISEASES OF THE EAR. dissection, —C. J., aged 45, was visited by me in the month of November, 1849. He was dying from tubercular disease, so that I was precluded from making so minute an examination as would have been desirable. The history of the origin and progress of the deafness, as far as could be ascertained, was as follows: About twenty years ago the patient suffered from a violent inflammation in the right ear, followed by a discharge from the external meatus, which had continued almost without intermission up to the time he was seen by me. For a considerable period this ear had been unable to distinguish sounds, and the left ear had been gradually growing less and less sensitive to sonorous vibrations during the preceding six or seven years. No pain had been felt in it, however, and there had been no discharge from the external meatus. Upon inspection by means of a speculum and lamp, the membrana tympani of the right ear was observed to be absent, while the mucous membrane lining the tympanic cavity was very thick, and covered by a large quantity of purulent matter. In the left ear, the lining membrane of the external ear was slightly reddened, and the membrana tympani was as white as writing paper; while the handle of the malleus, usually so distinctly seen, could not be distinguished from the surrounding membrane. Towards its centre, the surface of the membrana tympani had lost the natural shining appearance; but a small portion of its surface, on each side of the handle of the malleus, although perfectly white, was so smooth as to reflect the light of the lamp. As the patient was in a state of great debility, the otoscope was not applied to either ear to test the condition of the Eustachian tube. The patient died a few days after the examination. Post-mortem inspection. Right ear. —The mucous membrane lining the tympanic cavity was thick and in parts ulcerated; while the bone forming the upper wall of the cavity, with which the ulcerated membrane was in contact, was carious. The Eustachian tube was healthy. Left ear. —The central portion of the membrana tympani was found to be white and thick; but those parts of it which lie anteriorly and posteriorly to the handle of the malleus, were soft and attenuated, and the white appearance was due to the presence of mucus in the tympanic cavity, in immediate contact with the inner surface of the membrana tympani. So softened was this portion of that membrane, that on applying the slightest pressure, the fibres THE EUSTACHIAN TUBE. 247 composing it gave way, and three small orifices were produced. The cavity of the tympanum and the mastoid cells were filled with thick, white mucus, and no air was discoverable. The mucous membrane lining the cavity was also thicker than natural. The Eustachian tube. —The internal portion for the length of half an inch was healthy ; but at about that distance from the cavity of the tympanum, there was a sudden constriction, and for the length of about a line and a half the tube was so contracted, that, even when its superior wall was removed, it was with difficulty that an ordinary sized bristle could be introduced into the opening. Fig. 81. Stricture of the Eustachian Tube. The black bristle is seen passing from the tympanic cavity through the strictured portion. This stricture resulted from the external and internal walls of the tube pressing against each other; the small space still permeable being at the upper part. The more remote cause of the stricture would appear, however, to have been an enlargement of portions of the bone constituting the external and internal osseous walls of the tube: the former being at this part twice its natural thickness, and somewhat rough, while the latter was forced outwards by the dilatation of the carotid canal, which, pressing thus upon the cartilaginous portion of the Eustachian tube with which it was in contact, produced a flattening of the natural concavity of the internal wall. The mucous membrane lining the Eustachian tube was in a natural state. Although three dissections are recorded of adhesion between the walls of the tube by means of membranous bands, I have not hitherto met with a case during life. In such an instance the treatment would consist in puncturing the membrana tympani, and establishing an orifice in it. CHAPTER XII. THE CAVITY OF THE TYMPANUM. ANATOMICAL OBSERVATIONS — PATHOLOGICAL OBSERVATIONS DISEASES OF THE MUCOUS MEMBRANE :— a, CONGESTION. b, ACUTE INFLAMMATION —AFFECTING THE PORTIO DURA NERVE—EXTENDING TO THE BRAIN—SCROFULOUS MATTER IN THE TYMPANIC CAVITY. C, CHRONIC INFLAMMATION. d, CHRONIC CATARRHAL INFLAMMATION, e, CHRONIC CATARRHAL INFLAMMATION EXTENDING TO THE BONE, DURA MATER, OR BRAIN. /, ULCERATION OF THE MUCOUS MEMBRANE. Anatomical Observations. —The tympanic cavity is lined throughout by a fine membrane, which forms the internal layer of the membrana tympani, and from which it can sometimes be detached without difficulty. Internally it covers the surface of the promontory and the nembrana propria of the fenestra rotunda; it is reflected from the promontory at the circumference of the fenestra ovalis upon the surface of the stapes, and it envelops the incus and malleus, by means of which it is continuous with the inner layer of the membrana tympani; above and below that membrane it covers the osseous walls of the tympanum, and is prolonged posteriorly into the mastoid cells, while anteriorly it is continuous with the lining membrane of the Eustachian tube. The mucous membrane of the tympanic cavity, in a healthy ear, is so extremely thin as to be quite transparent; and its presence upon the surface of the osseous walls and ossicles of the tympanum can often only be detected by the use of a magnifying-glass and by the touch. In a natural state the nervous filaments upon the surface of the promontory are very distinctly seen, the margin of the fenestra rotunda is defined and regular, and the membrana which occupies it is thin and transparent. The crura of the stapes, as well as their point of connection with the base, are clearly seen, and a distinct fissure is observable between the inferior surface of the crura and the promontory. The quantity of mucus covering THE CAVITY OF THE TYMPANUM. 249 this membrane in a healthy ear is so small as to be scarcely perceptible. The membrane itself is composed of extremely fine and delicate fibres, and it has a strong analogy with the serous membranes: first, in respect to its extreme tenuity and great smoothness; second, in the frequency with which membranous bands connect together various parts of the tympanic cavity. Over its surface extends a layer of very minute epithelial cells, some of which are ciliated. The supply of bloodvessels is abundant, though they are so minute as not to be discernible, except when distended with blood: this happens in disease, and then they are often very much dilated and surcharged. In young persons the membrane is highly vascular, and, when successfully injected, is found to be pervaded by plexiform ramifications. Beneath the mucous membrane lie the branches of the tympanic nerve from the glosso-pharyngeal. The upper wall of the tympanum is formed by a layer of bone which separates the tympanic cavity from that of the cerebrum, and which deserves special attention, inasmuch as the diseases of the tympanum, which affect the brain, usually advance through that bone. Its form is an elongated oval, and it measures about Fig. 82. An antero-posterior vertical section of the Temporal Bone through the Tympanic Cavity and Mastoid Cells. three-quarters of an inch long and from a quarter to half an inch in breadth. Its direction is obliquely inwards and forwards, like that of the petrous bone. Externally it is attached to the lower part of the squamous, and internally to the outer part of the petrous, bone: anteriorly it is continuous with the roof of the 250 THE DISEASES OF THE EAR. Eustachian tube, and posteriorly with the roof of the horizontal portion of the mastoid cells. This osseous lamina, forming the upper wall of the tympanum, varies much in thickness, being in some instances from half to an entire line thick, though more frequently it is very thin, presenting a mere shell of translucent bone. In many specimens this lamina is deficient in parts, and the mucous membrane of the tympanum is in contact with the dura mater covering the petrous bone. In some specimens in my possession, the head of the malleus projects through an orifice in this portion of the bone, and was directly covered by the dura mater. This defect in the upper wall of the tympanum is not usually the result of disease, but of the process of development. In the specimen, of which the following is a representation, the hori- Fig. 83. The upper Osseous Wall of the Tympanum defective zontal lamina alone is absent, while the vertical septa extend upwards, even above the surrounding surface. It has been thought desirable to be thus particular in the description of the relations of the tympanum, because frequent reference 251 THE CAVITY OF THE TYMPANUM. is made to the description in the pathological details subsequently entered into. Pathological observations. —The diseases of the tympanic cavity are numerous and important. Perhaps the most common affection to which the organ of hearing is subject, is a greater or less degree of thickening of the tympanic mucous membrane, with or without catarrh through the membrana tympani. Besides this affection, a simple accumulation of mucus in the tympanic cavity is of great frequency; and, finally, anchylosis of the stapes to the fenestra ovalis is a most common disease. The diseases of the tympanic cavity, as revealed by the dissection of 1013 diseased ears, are as follow:— CONTENTS. Mucus, 65 Blood 6 Blood and mucus 1 Blood, mucus, and lymph 1 Serum, .............. 10 Serum and mucus, 3 Serum and lymph, 1 Lymph 6 Epithelium, 2 Epithelium and oil, 1 Scrofulous matter, ........... 20 Calcareous matter, ........... 8 Cerumen, ............. 1 Cholesterine, ............ 1 Cholesterine and mucus, . 5 Cellular tissue, ............ 2 Oily matter, 1 Pus 17 STATE OF THE MUCOUS MEMBRANE. More vascular than natural, 75 Thicker than natural 211 Thick and very vascular, 16 So thick as to conceal the stapes 27 So thick as to fill the tympanic cavity, 6 Ulcerated 24 Pulpy 5 Containing black pigment cells, 2 Having serum beneath it, 1 MEMBRANOUS BANDS BETWEEN. Malleus and promontory, 6 Malleus, incus, and promontory 1 252 THE DISEASES OP THE EAR. Malleus and stapes, ........... 1 Malleus, stapes, and promontory, 6 Incus and promontory, ........... 5 Incus, stapes, and promontory 3 Incus and malleus, 1 Stapes and promontory, the mucous membrane being healthy, . . .79 Stapes and promontory, the mucous membrane being thick, . . .48 Stapes and promontory, the mucous membrane being vascular, ... 6 Stapes, promontory, and pyramid, 1 All the ossicles, ............ 30 All the ossicles and the promontory 9 Tensor tympani muscle (the tendon) and the stapes 3 Chorda tympani nerve, incus, stapes, and promontory, .... 2 Chorda tympani nerve and upper wall of tympanum, 1 MALLEUS. Adherent to the promontory, 1 Absent, apparently from caries or ulceration 4 Partly removed by caries, 1 Malleus and incus lying in the mastoid cells 1 Fixed by ligamentous anchylosis to the upper wall of the tympanum, . . 3 Fixed by osseous anchylosis to the upper wall of the tympanum, . . 2 The body anchylosed to the incus, 3 The long process detached from the membrana tympani, .... 3 The long process fractured, 1 The long process in contact with the promontory, ..... 3 The long process adherent to the incus, 1 The long process detached from the body, 1 The long process absent, 2 The long process carious, 3 The long process exostosed 1 INCUS. Absent, 4 Long process absent, 2 Partly removed by caries, 8 Disconnected from stapes, .......... 14 Disconnected from stapes and malleus, ........ 1 Fixed by membranous anchylosis to the orifice of the mastoid cells, . . 2 STAPES. The base anchylosed by bone to the fenestra ovalis 49 The base anchylosed by bone to the fenestra ovalis, the base being expanded, 6 The base anchylosed by membrane to the margin of the fenestra ovalis, . 36 The base anchylosed by membrane to the margin of the fenestra ovalis, the base being expanded 6 The base anchylosed by membrane to the margin of the fenestra ovalis, an exostosis surrounding the fenestra, 2 The base of the stapes attached to the fenestra ovalis more rigidly than natural, . 66 253 THE CAVITY OF THE TYMPANUM. The base projecting into the cavity of the vestibule, 5 The base expanded and more fixed than natural, 7 The base expanded and projecting into the vestibule 2 Detached from incus and attached to the membrana tympani, 1 Anchylosed to incus, 2 Detached from the fenestra ovalis and the incus, 2 Disconnected from the fenestra ovalis, 1 Partially absorbed, 1 Atrophied, 1 Absent, apparently from ulceration, 2 ALL THE OSSICLES. Less movable than natural 4 Absent, apparently from ulceration, 2 Disconnected from each other 1 Carious, 2 OSSEOUS WALLS. Thickened, 1 Carious, + . .6 Upper wall partly deficient, 54 Lower wall partly deficient, 25 Osseous lamina between mastoid cells and lateral sinus incomplete, . . 2 Osseous lamina between mastoid cells and cavitas cerebelli incomplete, . 1 Canal for portio dura nerve incomplete, 2 Carotid canal contracted, 7 Upon reference to Mr. Hinton's valuable paper on the Pathology of the Ear, published in the thirty-ninth volume of the "Medico- Chirurgical Transactions," it will be found that the results at which he has arrived agree with those quoted above. The plan I purpose to follow in investigating the subject will be to consider successively the affections of the mucous membranes, and those of the ossicles. (a.) CONGESTION OF THE MUCOUS MEMBKANE OF THE TYMPANUM. Congestion of the tympanic mucous membrane usually follows a cold, or an attack of influenza. The symptoms are a feeling of deadness in the ears, sounds like the ringing of bells, dulness of hearing, and not unfrequently slight pain. If neglected, this affection is liable to advance to acute inflammation. It frequently accompanies congestion of the mucous membrane of the fauces and of the Eustachian tubes. On examination, the surface of the membrana tympani is sometimes observed to be very shining, and in other cases opaque. 254 THE DISEASES OF THE EAR. The hearing power is but slightly diminished. The treatment consists in applying leeches below the ears, and using gentle counterirritation over the mastoid processes. The symptoms commonly yield in a few days. Case I. —Mrs. B., a3t. 40, was sent to me by a medical man in 1853. She enjoyed good health. History. —Has not suffered from any affection of the ears until a fortnight since, when, subsequently to an attack of cold, a feeling of numbness, and a sound as of the ringing of bells, supervened in both ears. There was also, at times, a shooting pain in the right ear. On examination, the mucous membrane of the fauces was observed to be red. Bight ear. —The membrana tympani was rather more opaque than natural; the hearing power natural; the Eustachian tube pervious. Left ear. —Membrana tympani opaque; hearing distance three inches; Eustachian tube pervious. Treatment. —Slight counter-irritation, by means of a stimulating liniment was kept up over and around each ear, and in the course of ten days the symptoms were wholly removed. Case II.—Mrs. P., set. 73, consulted me in July, 1853. History. —Six weeks previously had an attack of influenza, which was succeeded by considerable pain in the right ear, followed by a sensation of "pumping" in the ear, which has continued to the present time: recently deafness of that ear has been complained of, and the voice appears to come out of the ear. On examination, the membrana tympani and Eustachian tube appeared to be normal; but the hearing power was so diminished that the watch was heard only when pressed upon the ear. Treatment. —A leech was applied below the ear, and the symptoms abated; counter-irritation was then resorted to, and by degrees all unpleasant sensations vanished. (b.) ACUTE INFLAMMATION OF THE MUCOUS MEMBRANE OF THE TYMPANUM. I have not hitherto been enabled to distinguish between acute inflammation of the mucous membrane of the tympanum and that of its fibrous membrane, the periosteum, which is subjacent to it. When the delicacy of these membranes is taken into consideration, 255 THE CAVITY OF THE TYMPANUM. and their intimate union so as to form one membrane of such extreme tenuity that its presence in the healthy ear can only be detected by the closest examination, it would be a source of surprise if acute inflammation were to attack either of these structures without involving the other; although in many cases doubtless one of them is more specially implicated. In the description of acute inflammation of the mucous membrane of the tympanum, the periosteum will therefore be included by me, especially as the symptoms to be detailed appear to indicate that the view just advanced is correct. If the mucous membrane of the tympanum be examined during an attack of acute inflammation, an opportunity for which is sometimes afforded when a patient suffering from this affection dies of some other disease, the bloodvessels are so large and so numerous, that upon a cursory inspection the membrane seems as if it were covered by a layer of dark-colored blood. On more accurate inspection, however, it is observed that this blood is confined to the cavity of the vessels, and that the latter are completely distended in every part. The exciting cause is usually exposure to a draught of cold air, or sudden change of temperature. In its milder form this affection is met with in children, and known as earache; for although the paroxysms of pain are often very severe, the symptoms are generally confined to the ear, and do not produce much constitutional disturbance. In children it is evident that the mucous membrane is more affected than the periosteum; and perhaps one cause of the comparative mildness of the affection in the young, is, that the tympanic fibro-mucous membrane is laxer and more extensible than in the adult. In children attacks of acute inflammation of the mucous membrane of the tympanum are apt to be greatly neglected, and consequently they frequently recur in the same child; and even if they do not at the time produce a serious lesion of the membrana tympani or obstruction of the Eustachian tube, they probably lay the foundation of deafness in after life, by causing a permanent thickening and rigidity of the membrane: membranous anchylosis of the stapes seems also to originate in this manner. When called to see a child suffering from inflammation of this membrane, a medical man will generally find that the membrana tympani is very smooth and shining, and more or less red in color, according to the degree of distension with blood of the vessels of the mucous membrane 256 THE DISEASES OF THE EAR. forming its inner layer. Sometimes this latter membrane has become thickened, giving a sodden appearance to the membrana tympani; a condition liable to occur also when the tympanic cavity contains an accumulation of mucus. It commonly happens that in children the chief pain is felt at night, when the recumbent position and the heat of the pillow favor the congestion of the membrane. Although the child may not complain of pain in the daytime, and when seen by the surgeon may even be cheerful, still, should any appearance of congestion remain, or, tested by the watch, any dulness of hearing, it is important to apply one or two leeches below the ear, and to keep up a slight discharge behind it. In the adult, this affection is usually of a much more formidable nature, and it sometimes has a rheumatic or gouty character. The first symptom is a sense of uneasiness in the ear, which becomes pain during motion, pressure on the organ, the act of deglutition, or the use of the pocket-handkerchief. This uneasiness soon amounts to continuous pain, which, in severe cases, rapidly increases until it becomes so intense as to be scarcely endurable; and extends over the mastoid process, the whole of the affected side-of the head, down the neck, and into the fauces. The power of hearing rapidly diminishes, and a variety of the most horrible sounds are experienced; sometimes described as like the hissing and puffing of a steam-engine, varied by others like a series of explosions in the ear, or the ringing of bells. A symptom of this affection which adds greatly to the suffering of the patient, is the impairment of the functions of the brain; sometimes amounting only to a confusion of ideas, frequently accompanied by extreme fear and depression of the nervous system, causing the worst forebodings as to the result of the attack; in other cases delirium supervenes, and in the most formidable cases death takes place, from the inflammation extending to the membranes of the brain. Where only some of these symptoms, and those of a less violent character are present, the surgeon may doubt whether the affection is in the tympanic cavity or in the meatus. An examination of the ear with the speculum and lamp will decide the question ; for in the affection under consideration, there is no appearance of inflammation in the dermoid meatus or in the membrana tympani. The modes in which this affection terminates are the formation of lymph; the effusion of serum into the tympanic cavity, which escapes through the Eustachian tube into the fauces; or a copious secretion of pus or mucus, which distends the tympanum THE CAVITY OF THE TYMPANUM. 257 causes ulceration and perforation of all the laminae of the membrana tympani, and ends in abundant discharge. In some cases there is no indication of any secretion occurring in the tympanum, and the affection seems to terminate by resolution; in others, the dermoid meatus pours out a sympathetic discharge without the presence of any orifice in the membrana tympani. The prognosis in cases of this disease is favorable, and it is a great consolation to the patient to be assured, amidst the very distressing symptoms from which he suffers, that no permanent injury need be apprehended. It would appear that a single attack of inflammation of the fibro-mucous membrane of the tympanum, however violent it may be, does not leave behind it that rigidity and dulness of hearing which is a sequence of the attacks of a milder character occurring in children. When an orifice forms in the membrana tympani, it usually closes without difficulty; and the power of hearing is in two or three weeks completely restored. In some, but fortunately rare cases, the inflammation extends to the petrous bone, and thence to the membrane of the brain, causing death. It not unfrequently happens, however, that the inflammation extends to the portio dura nerve in the aqueduct of Fallopius, and partial or complete paralysis of that nerve is the result; which is removed as soon as the inflammation has wholly subsided. The treatment of this affection consists, in the first place, of the local abstraction of blood by leeches or cupping; the leeches being applied at the orifice or behind the ear, and the cupping practised directly below it. Leeches may also be applied to the nostrils. Vapor baths should frequently be applied to the ear, so as to allow the steam to penetrate as far as the membrana tympani. The throat should be repeatedly gargled with hot water. The patient is to be kept perfectly quiet, as the least excitement or exercise is apt to aggravate the symptoms materially; the room should also be darkened, and every sound excluded as much as possible. The use of mercury will be found very efficacious, especially when combined with full doses of opium or morphia. When the pain is very intense, it is desirable to keep the patient for several hours under the influence of opium. In the early stages of the affection tartar emetic proves advantageous. As soon as the discharge appears the meatus should be gently syringed with a copious supply of warm water thrice daily. In children the treatment may usually be less active; but it is 17 258 THE DISEASES OF THE EAR. important to try the application of leeches and counter-irritants, thoroughly to subdue the inflammation as rapidly as possible. Case I. Acute inflammation of the mucous membrane of the tympanum ; perforation of the membrana tympani. —C. C, aged 40, sent for me in November, 1852, on account of a severe attack of pain in the right ear. History. —Two days previously he had been exposed to a cold wind, which was followed towards night by pain in the ear. During the night the pain became much aggravated, and seemed not only to be in the ear, but to extend over the whole of the side of the head, and especially over the region of the mastoid process. There was also great constitutional disturbance, confusion in the head, and the most extraordinary noises. "At the same moment," said the patient, " I seemed to be standing at the side of a steam-engine, snorting, puffing, and hissing, and yet hearing the sound of a church bell tolling at a distance." On examining the ear, the membranous meatus was observed to be red, the membrana tympani dull and opaque. The patient was very excitable; pulse quick; skin hot. Leeches were ordered to be applied immediately below and at the back of the ear, to be followed by hot fomentations and poultices. Calomel and opium were administered. Under this treatment, with the addition of a blister to the nape of the neck, in three days the symptoms gradually subsided. At the end of the third day, while the head was on the pillow, a feeling as of something bursting in the ear was experienced. This was followed by a discharge from the ear, and a considerable additional relief to the pain. On further examination, a small orifice was detected in the lower part of the membrana tympani, through which viscid mucus escaped from the tympanum. There was also great dulness of hearing, which was the more distressing to the patient from his having lost the use of the other ear during childhood. The perforation was regarded by me as a favorable symptom, being likely to prevent the formation of membranous bands in the tympanic cavity. The inflammation slowly subsided; the aperture in the membrana tympani closed; and, in the course of ten days, the patient heard as well as before the attack. His hearing has since continued good. In some cases of acute inflammation of the mucous membrane of the tympanum, the pain in the ear is not so violent as in the case just detailed; but the symptoms of cerebral disturbance are more 259 THE CAVITY OF THE TYMPANUM. distressing and continuous. One reason for the cases of less active inflammation assuming the chronic form, seems to me to be, that a much smaller quantity of mucus being secreted, the membrana tympani does not give way. The consequence is, the mucus collects by degrees in the tympanic cavity, and thus keeps up a constant, though slight irritation. In these chronic cases the symptoms often disappear after a discharge from the ear; and careful inspection shows that there is no perforation of the membrana tympani, and that the discharge does not originate from the tympanic cavity, but has its source in the dermoid meatus; being the result simply of the irritation of the tympanic mucous membrane. The following case will illustrate the preceding remarks. Case II. Acute inflammation of the mucous membrane of the tympanum ; prolonged pain in the head; discharge from the meatus; relief. —M. A. K., aged 26, was admitted under my care in St. Mary's Hospital on October 6th, 1854. History. —About a month ago she complained of pain in the face and soreness of the throat, together with pain in the right side of the head. These symptoms were followed by deafness in the right ear. At the time of admission she complained of pain and throbbing in the right ear, extending inwards down the throat. On examination, the tongue was found slightly furred, the pulse 84 and small. The surface of the meatus was red, and the vessels of the dermoid layer of the membrana tympani were distended. The crack of the nail was heard when made close to the ear. Air passed into the tympanic cavity. Treatment. —Leeches were applied below the ear; and an evaporating lotion around it. October 12th.—Pain much the same. To repeat the leeches and take half a grain of the chloride of mercury, and a quarter of a grain of opium every night. October 16th.—Pain somewhat less, but still severely felt deep in the ear. October 20th.—To repeat the leeches. October 24th.—Much better; has had an abundant discharge from the ear, followed by immediate cessation of the pain. On inspection, it was seen that the discharge had issued from the surface of the meatus; and there was no perforation of the membrana tympani. October 28th.—The pain has totally disappeared. 260 THE DISEASES OF THE EAR. I. Acute inflammation affecting the portio dura nerve. —It is well known that the portio dura nerve passes through the aqueduct of Fallopius along the upper and posterior wall of the tympanum ; but Fig. 84. The Canal for the Portio Dura Nerve at the upper part of the tympanic cavity incomplete. A dark bristle is passed through the canal. it not unfrequently happens that the inner osseous wall of this canal is incomplete, and thus the mucous membrane of the tympanum is in contact with the outer surface of the nerve. In cases of acute inflammation of the tympanic mucous membrane, therefore, the nerve often becomes affected, either by the prolongation of the inflammation from the mucous membrane directly to the nerve, or through the wall of the canal. In some of these cases the membrana tympani ulcerates, and there is a copious discharge from the tympanic cavity; in others it remains intact. Case III. Acute inflammation of the mucous membrane of the tympanum; ulceration of the membrana tympani; paralysis of the portio dura nerve; cure. —E. I., aged 23, was admitted under my care at the St. George's and St. James's Dispensary, on February 28th, 1843. History. —He stated that three months previously he was suddenly seized with a violent attack of pain in the right ear, which extended over the side of the head. After the pain had lasted for about twenty-four hours, he experienced a sensation of something bursting in the ear, followed by an abundant thick and offensive-smelling discharge. During the attack of pain he had much giddiness, lost the use of the right side of the face, and could not shut his right eye, while the mouth was drawn to the left side. On examination, an orifice was observed in the right membrana tympani; the mucous membrane of the tympanum was red and thick, and poured out a mucous discharge. He was ordered to apply a blister behind the ear, and became better, having no return of the pain till March THE CAVITY OF THE TYMPANUM. 261 11th, when it suddenly reappeared in great violence, accompanied by a singing and by sensations of pumping and throbbing in the ear. These symptoms were much aggravated by coughing. The discharge was abundant, and the mucous membrane of the tympanum very red. Leeches were applied below the ear, which was often syringed with warm water; and after the pain was somewhat subdued, a blister was applied behind the ear. Calomel and opium were administered until the gums were rendered tender. The symptoms gradually subsided. April 11th.—Improved, and complains of but little pain. April 16th.—The discharge is much diminished; the orifice in the membrana tympani is smaller; and the singing noise not so loud. He cannot yet close the right eye or use the mouth freely, but the power over the muscles of the face is certainty greater. Ordered to rub the ointment of tartarized antimony behind the ear. From this time the patient gradually improved, and on the 3d of July the portio dura nerve had regained its power, and the quantity of discharge had much diminished. The following case of the same kind occurred in a younger person :— Case IV. Acute inflammation of the mucous membrane of the right tympanum; great pain in the head; temporary paralysis of the right portio dura nerve. —Master S., aged 5, pale and weakly, was brought to me on the 10th of February, 1850. History. —Three months previously, the right ear had been pulled rather violently. Fourteen days ago, he complained of pain deep in the right ear, which in two days was followed by discharge and relief. Lately he has so suffered from pain on the right side of the head, that he constantly presses it with his hand; and for a week he had paralysis of the right side of the face: but perfectly recovered. To-day he again complains of pain in the ear. On examination of the right ear, the surface of the meatus was observed to be red and swollen, denuded of epidermis, and covered by a thick white discharge; the membrana tympani, which was in the same state, bulged outwards. Leeches below the ear, the use of warm fomentations, and the administration of tonic medicines, speedily reduced the pain in the ear and head, and he was sent to the seaside. On March 7th, about a month after I had first seen him, I found that the matter had made its way through a small orifice in the lower part of the membrana tympani. 262 THE DISEASES OF THE EAR. In some cases, the portio dura nerve becomes affected while the patient is under treatment for secondary syphilis. Two instances of this kind have occurred to me. In one, the patient was a man of twenty-three, who stated, that six months previous to his consulting me, he had complained of pain in his left ear for two or three days, when he suddenly lost the use of the left side of the face, and found that he could not close the left eye. On examination, the left membrana tympani was rather opaque, although its surface was smooth. On swallowing with closed nostrils, and in forcing the air, it passed freely into the right tympanic cavity, but not so freely into the left. The patient was treated with small doses of iodide of potassium, and by the application of ointment of tartarized antimony behind the ear. After six weeks of this treatment, there was scarcely any trace of the paralysis of the muscles of the face, and the hissing sound had greatly diminished; but the deafness remained as before. 2. Acute inflammation extending to the brain. —In some cases, the inflammation advances from the tympanic cavity to the brain, and death is the consequence. The following illustrative case is taken, in an abridged form, from Itard. 1 Case V. Acute inflammation of the mucous membrane of the tympanum; inflammation of dura mater ; death. —J. B., aged 26, of a sanguine temperament and robust constitution, was received into the military hospital of Val de Grace, on account of an inflammation of the pleura. On the fifth day of the attack, he was seized with violent pain in both ears, but especially in the left, and the pain was accompanied by a rushing noise like that of a torrent. On the sixth day the pain increased so as to become intolerable, with throbbing in the ears; pain in the head violent, pulse hard and full. These symptoms increased, with great excitement, delirium, and stupor, and the patient died on the seventh day. On dissection of the right ear, the mucous membrane of the tympanum was red, swollen, velvety, and covered by puriform mucus, of which the cavity was full. The membrana tympani was entire, but its inner layer very thick and red. The mastoid cells were full of mucus. In the left ear, where the pain had been the most acute, the mucous membrane of the tympanum and mastoid cells was of a deep red color, but there was no secretion of mucus. The dura mater covering the anterior and posterior surfaces of the petrous bone was 1 TraitS des Maladies de 1'Oreille. Vol. i. p. 193, et seq. 263 THE CAVITY OF THE TYMPANUM. adherent to the adjacent cerebral substance; it was red and thick, and separated from the bone. Between the bone and the dura mater there was nearly half an ounce of a transparent gelatinous fluid. A case somewhat similar to the foregoing, I had an opportunity of inspecting, after death, with Dr. Blakely Brown. Case VI. Acute inflammation of the tympanic mucous membrane after whooping-cough; dura mater inflamed; effusion of serum between it and the petrous bone, and in the lateral ventricles. —The child was three years old, and shortly before the fatal seizure had gone through an attack-of whooping-cough. A year and a half previous to her death, she had a discharge from the left ear, at first unaccompanied with pain, but subsequently, at times, she suffered from acute attacks of pain in the ear and side of the head, previous to, and during which, the discharge subsided. A few days before her death, one of these attacks of intense pain in the ear and head came on, and resisted every remedial measure prescribed, until the child died in the greatest suffering. On inspection, it was found that the whole of the membrana tympani had been destroyed, with the exception of a small semilunar margin at the upper and posterior part. The mucous membrane lining the tympanic cavity was of a deep red color, from its bloodvessels being enlarged and distended with blood. The dura mater was much congested; serum was effused between it and the petrous bone, and its inner surface was adherent to the arachnoid. Serum was also effused beneath the arachnoid, and in the lateral ventricles. In cases of typhus fever, I have found the dura mater partaking of the inflammation of the tympanic mucous membrane. One case of this kind was that of a girl, aged 16, who died of typhus fever, after seven weeks' illness. She was, to a certain degree, dull of hearing from the commencement of the attack, but not previously. Dissection. Right ear. —The meatus externus contained a large quantity of thick matter, and the dermis and periosteum were so soft as to be easily detached from the bone. The membrana tympani had been removed by ulceration. The tympanic mucous membrane was thick and soft, and, although the ossicles were in their natural position, the long process of the malleus had been absorbed. The cavity contained thick mucus; and the dura mater was detached from the upper part of the tympanum. Left ear. —The meatus was full of pus; its lining membrane was 264 THE DISEASES OF THE EAR. soft, and a small strip only of the membrana tympani remained. The tympanum and mastoid cells were full of thick muco-purulent matter; the lining membrane being thick, soft, and disconnected from the bone. The dura mater adhered so slightly to the upper wall of the tympanum, that it was disengaged by the gentlest traction. In other cases of death from typhus fever, I found the dura mater inflamed, and separated from the upper surface of the petrous bone by serum. In one case, that of a patient aged 17, during the attack of fever, but not previous to it, there was great dulness of hearing for nine days, and discharge from the left ear four or five days prior to death. On dissection, the dura mater was found to partake of the inflammation of the mucous membrane; the bone was also very vascular, and it was separated from the dura mater by a small quantity of serum. The presence of scrofulous matter in the tympanic cavity sometimes gives origin to the most formidable cerebral symptoms, and, in some cases, without leaving any traces of inflammation of the brain after death. In the following case, which occurred under the care of Dr. Chambers, in St. Mary's Hospital, and which I had the opportunity of seeing during life, I think there is no doubt but that the cerebral symptoms arose from the affection of the ear. Case VII. Accumulation of scrofulous matter in the tympanum ; acute inflammation of the mucous membrane ; severe cerebral symptoms; death. —S. B., aged 10, was admitted into St. Mary's Hospital on the 21st April, 1854, with the following history: Vomiting, heat of skin, headache; occasional shrill screaming had commenced on the 18th, and continued to the time of admission. The bowels had not acted since the 19th. She had formerly a discharge from the right ear; but that had latterly ceased, though deafness remained. On examination, the pulse was rapid and regular; the skin hot and dry; the face flushed; the eyes heavy but shiny; the pupils naturally affected by light. There was a tendency to a sort of comatose sleep, but she was easily roused by speaking to her. April 21st.—Ten leeches to be applied to the head; also ice; one and a half grain of calomel every hour, and a purgative in the morning. 22d.—Urine albuminous, probably from the calomel. No more vomiting. Bowels opened several times. Complains of pain in the THE CAVITY" OF THE TYMPANUM. 265 cardiac region. Keeps boring her head into the pillow, and occasionally screaming. No pain in the head. Tongue white and furred; pulse 108, regular; one of the evacuations was mucous and bloody, the rest dark. Ordered the calomel every three hours, and a blister to the nape of the neck. 23d.—The same symptoms exaggerated, with violent delirium occasionally and screaming, alternating with a half-comatose state. This continued till her death, at two in the morning of the 25th, the face and lips remaining flushed till the time of decease. Post-mortem Inspection. —The tympanic cavity contained scrofulous matter. The mucous membrane lining the tympanic cavity was very red, and its bloodvessels very distended. The whole of the petrous bone and the dura mater covering it, was also of a deep red color, from the distension of the vessels. (c.) CHRONIC INFLAMMATION AND HYPERTROPHY OF THE TYMPANIC MUCOUS MEMBRANE. I am not sure that the above designation is perfectly correct, because it appears probable that hypertrophy of the mucous membrane sometimes takes place without the occurrence of any appreciable inflammatory symptoms; indeed, in children having a tendency to glandular enlargements, the mucous membrane appears to become thickened without the slightest sign of inflammation. In some cases, however, chronic inflammation undoubtedly precedes the hypertrophy. Pathological Observations. — The mucous membrane lining the tympanic cavity frequently undergoes the process of hypertrophy. This delicately thin mucous membrane, so fine in its natural state as often to require the aid of touch as well as sight to determine its presence, may nevertheless become so thickened as to fill the whole, or nearly the whole of the tympanic cavity. From being like a piece of the finest silver paper, it becomes more like velvet. Instead of throwing out just so much mucus as suffices to lubricate the surface of the membrane, it pours forth a thick and viscid secretion which often fills up the entire cavity unoccupied by the hypertrophied lining. In some cases where the Eustachian tube is partially or wholly closed by the hypertrophied membrane, the mucus presses upon the inner surface of the membrana tympani; gradually by its 266 THE DISEASES OF THE EAR. pressure causing absorption, and ultimately produces an orifice through which the mucus escapes into the meatus, giving rise to what was formerly called a case of otorrhcea. This discharge through an orifice in the membrana tympani, in the way just described, is one of the common results of scarlet fever; and though it does not appear probable that the mucous membrane should become hypertrophied in so short a space of time as that in which a case of scarlet fever is developed, yet it is still possible that it may be so. My belief, however, is, that in these cases of catarrh of the mucous membrane, hypertrophy has usually preceded the attack of fever; and that this condition of the tympanum and other organs are evidence of a weakened state of the system. Sometimes this condition of chronic inflammation of the mucous membrane extends upwards through the osseous wall, and affects the dura mater. The constant attacks of earache in some children are due to this affection. The predisposing cause is the most essential point to ascertain in respect to this affection, since it almost invariably occurs in those whose vital power has been lowered by disease, or some other debilitating influence. Improper food or clothing, insufficient ventilation or exercise, or some analogous cause, may almost always be detected; and when detected, should be at once removed, if possible, or at least diminished by the skill of the surgeon; after which, the next step is to assist in remedying the effects. It will usually be observed, On general examination, that the child is pale, flabby, deficient in bodily strength and spirit, with the submaxillary, or cervical glands, often hypertrophied, and the heart weak. On inspecting the ear, the dermis of the meatus is commonly thicker than natural, so that the calibre of the meatus is diminished, and there is some difficulty in obtaining a distinct view of the membrana tympani; but when the latter organ, or a portion of it, is seen, its surface is found to be less shiny than natural, and not unfrequently of a whitish color, resembling the appearance of parchment more or less sodden. Sometimes, while the long process of the malleus is unseen, the processus brevis stands out prominently. When the Eustachian tube is also obstructed, the membrana tympani is externally much more concave than natural. On exploring the tympanic cavity by the otoscope, air is not unfrequently heard most distinctly to enter the cavity, although the sounds developed by its entrance are abnormal. Instead of the normal crackling, a flap, as of air suddenly blown 267 THE CAVITY OF THE TYMPANUM. into a wet bladder, is heard. At times, daring the act of swallowing with closed nostrils, the air does not enter the tympanum, and a forcible expiration with closed nostrils is requisite to insure its admission ; but when the air is forced in, a sound similar to the last described is produced, but of a louder and more defined character. In certain cases there is an accumulation of mucus in the tympanic cavity, so that when air is forcibly injected a gurgling or bubbling sound is heard. Treatment. —As before stated, the first step is to discover what has been done or is doing in violation of nature's laws, and to insist, as far as possible, on a proper mode of living. This having been attended to, remedial medical measures may be hopefully applied. These are, gentle counter-irritation over the mastoid processes by means of vesicating plaster or solution ; and, where there is much congestion, with frequent attacks of pain, a leech or two may be applied beneath each ear; a stimulating gargle may be prescribed, and cold water freely used outside the throat. The tonsils, often much enlarged, may be washed with a solution of nitrate of silver (twenty grains to an ounce), and tonics administered. In very advanced cases, where the health is much deranged, the child anaemic, and its physical powers greatly depressed, it may be requisite at once to insist upon sea air, or at least change of air. The prognosis in these cases is usually favorable; by careful management, the mucous membrane is gradually restored to a more natural state; the mucus disappears from the tympanic cavity, and the patient regains his hearing in a month or two. Cases of a less favorable character occasionally occur, where the earache has been violent, the inflammation acute, and rigid bands of adhesion have formed in the tympanic cavity, or the membranes of the articulations of the ossicles have become rigid: these, of course, demand longer perseverance and greater attention, but are usually eventually cured. (d.) CHRONIC CATARRHAL INFLAMMATION OF THE MUCOUS MEMBRANE LINING THE TYMPANIC CAVITY. This affection differs from the last in the circumstance that mucus has collected in so large a quantity as to distend the tympanic cavity, and press upon the inner surface of the membrana tympani, so that this structure, becoming gradually atrophied and yielding to 268 THE DISEASES OF THE EAR. the pressure of the mucus within, has given way, and the discharge issues through the orifice thus made. The treatment of this class of cases differs from that of the preceding in the use of the syringe and warm water twice, or oftener, daily, to effect a complete removal of the secretion. The great desire of the friends to stop the discharge must be earnestly contended against, since that discharge is simply an effect and not a cause; and it is the latter which requires to be removed. Among the causes to which attention is frequently called, is the admission of cold air to the delicate mucous membrane of the tympanum through the external meatus. In these cases, the artificial membrana tympani is to be used where the age of the child will permit it, and reference must be made to the chapter where it is described, together with its mode of application. (e.) CHRONIC CATARRHAL INFLAMMATION OF THE TYMPANIC MUCOUS MEMBRANE AFFECTING THE BONE, DURA MATER, OR BRAIN. The first effect upon the tympanic mucous membrane produced by scarlet fever and other predisposing diseases, is usually a simple catarrhal inflammation, i. e., the ciliated mucous membrane, which is naturally extremely thin, and pours out a very small quantity of thin mucus, becomes hypertrophied, and secretes copiously a viscid matter, which, being too abundant and thick to escape through the natural excretory passage,—the Eustachian tube, —gradually fills the tympanic cavity, and presses against the inner surface of the membrana tympani, causing the partial or entire destruction of that organ; the mucus then freely escapes into the meatus, and forms one of the class of cases usually comprised under the term otorrhoea, it being in reality a case of simple catarrh of the mucous membrane of the tympanum. So long as there is a free exit for the discharge, I believe that the disease rarely extends to the cerebrum ; and fortunately, in a large proportion of cases where the ear is injured by scarlet fever or other diseases, so large a section of the membrana tympani is removed, that the viscid mucus secreted has free egress from the tympanum. But, as stated, the membrana tympani sometimes remains entire, or has only a small aperture, or a part falls inwards and becomes attached to the promontory, thus making a septum, shutting off the tympanic cavity from the meatus. Sometimes 269 THE CAVITY OF THE TYMPANUM. membranous bands stretch across the tympanum, or scrofulous deposits accumulate. By one or other of the above circumstances, the secretion of the tympanic mucous membrane is prevented passing outwards; and it gradually distends the tympanic cavity till it affects the osseous walls; and thus disease of the membranes of the brain, or of the brain itself, is originated. Although, as just stated, simple chronic catarrh of the tympanic mucous membrane when there is free egress for the discharge, rarely extends to the brain, the dura mater may, nevertheless, become diseased. In chronic catarrhal inflammation the tympanic mucous membrane becomes much hypertrophied and its vessels enlarged; and as r these vessels are, through the medium of the bone, directly continuous with those of the dura mater, it is not surprising that the latter membrane should be affected, and we find it accordingly undergoing slight changes. One of these is hypertrophy; another is detachment from the petrous bone; and the third is atrophy and extremely firm adhesion to the bone. The bone is also liable to-be slightly affected. The following case illustrates the effects of simple catarrh of the tympanic mucous membrane, with free egress for the secretion. Case I. Catarrh of the tympanic mucous membrane; bone soft. — A woman who had been deaf in both ears during many years, died of apoplexy at the age of 64. On dissection of the right ear, nearly the whole of the membrana tympani was found to have been destroyed ; the small portion which remains is thick and soft, and is in contact with the promontory. The malleus has disappeared, but the incus remains, and is attached to the stapes; the latter bone being wholly concealed by the thick mucous membrane. The upper osseous wall is soft. Chronic catarrhal inflammation of the mucous membrane of the tympanum, where the membrana tympani is entire, and where there has been but slight catarrh from the mucous membrane, may also produce disease in the dura mater; but so far as my experience extends, no cases have occurred in which the disease has advanced to the injury of the brain, so long as there is not more discharge than can pass away through the Eustachian tube. Cases of this class have come before me when making dissections of the ears of patients who have died of other diseases; and the following brief notices indicate the state of incipient disease that may be present; and further consideration will show that it is likely to assume a very 270 THE DISEASES OF THE EAR. serious character, when, under the influence of exciting causes, the quantity of the secretion is much increased. Dissection. Mucous membrane of the tympanum thick; membrana tympani entire; bone carious; dura mater ulcerated; the arachnoid in contact with the tympanic mucous membrane. —A man who had been many years deaf, died of consumption at the age of 50. Right ear. —The membrana tympani is white, concave, and very thick, and the whole of its inner surface adheres to the inner wall of the tympanum, while the ossicula are firmly bound together by bands. The membrane lining the mastoid cells is thick, and the cells contain a viscid fluid. Left ear. —In much the same state as the right, but there was a carious orifice in the upper wall of the tympanuin. The dura mater was thin in some parts, and ulcerated in others, so that the outer surface of the visceral arachnoid was in contact with the 1 mucous membrane of the tympanum. Dissection. Mucous membrane of the tympanum thick ; membrana tympani entire; bone carious; dura mater atrophied, ulcerated. — A woman, aged 65, died of paralysis. Many years previous to her death, deafness slowly came on in the right ear, after repeated attacks of earache. Dissection of right ear. —Membrana tympani white and thick, and a large membranous band connects the incus with the inner wall of the tympanum, so as nearly to conceal the stapes. The tympanic mucous membrane is four or five times its natural thickness, and adheres firmly to the bone. The upper osseous wall of the tympanum is cribriform, so that at various points the thickened mucous membrane is in contact with the outer surface of the dura mater. The dura mater is very thin, and presents two or three small orifices. In another woman, aged 70, who died of apoplexy, and who had been many years deaf, the following was the condition of the left ear. The membrana tympani was thick and opaque, more especially at its posterior part; and its inner surface firmly adhered to the inner wall of the tympanum and to the stapes, which bone is concealed by bands of adhesion. The upper osseous wall of the tympanum is carious, and presents several large orifices, which allow the dura mater to be in contact with the thickened mucous membrane. Treatment.— Chronic catarrhal inflammation of the mucous membrane lining the tympanum is usually attended by so extensive a destruction of the membrana tympani, that fortunately the discharge finds a free outlet, however viscid it may be. The effects, therefore, THE CAVITY OF THE TYMPANUM. 271 are confined to a certain amount of congestion of the dura mater covering the petrous bone. In cases of this simple kind, it is therefore not uncommon to meet with symptoms of slight cerebral irritation, which gradually yield to treatment by local depletion and gentle counter-irritation. The majority of these cases result from an attack of scarlet fever. The following is an instance: — Case II. Catarrh from the tympanic mucous membrane after scarlet fever; destruction of each membrana tympani; attacks of giddiness. —Miss A. H., aged 15, consulted me in November, 1845, on account of a discharge from each ear, accompanied by dulness of hearing and frequent giddiness. She stated that seven years previously she had an attack of scarlet fever, for which she was confined to her bed. During the fever a copious discharge issued from each ear, and the hearing was greatly diminished. For the last three years there has been so much less discharge, that it has not reached the orifice of the ear for two or three weeks at a time; but with this diminution of the discharge the deafness has been aggravated. She now complains of frequent attacks of giddiness. Upon examination, each membrana tympani was discovered to be entirely absent, and the mucous membrane, which was thick and red, was the source of the secretion. Watch heard at one inch from the right ear, and at two inches from the left. The treatment consisted in the application of leeches below the ears; the use of a very weak solution of the diacetate of lead as an injection after tepid water ; and the administration of the twentieth of a grain of the bichloride of mercury twice daily. Under this treatment the congestion of the mucous membrane of the tympanum greatly diminished, the discharge gradually decreased in quantity, and the giddiness disappeared. Other casefe might be cited in which catarrhal inflammation of the tympanic mucous membrane had been accompanied by symptoms of giddiness; some resulted, as in the last case, from scarlet fever; others from measles. The treatment in each case was very similar; and although in some instances the pain extended over a, great part- of the head, and was even accompanied at times by vomiting, all ultimately recovered. In the case above cited the entire membrana tympani was absent, so that the whole of the discharge could be removed by syringing. In those which follow, part only of the membrana tympani was destroyed, and the remainder prevented the egress of the matter; 272 THE DISEASES OF THE EAR. additional care had therefore to be exercised to insure the complete removal of the discharge. Case III. Catarrh from the mucous membrane of the left tympanum ; perforation of the membrana tympani; pain in the left side of the head. —F. H., an architect, aged 44, consulted me in 1852, respecting a discharge from the left ear, accompanied by pain and tenderness over the left side of the head. He stated that since childhood he had been subject to a discharge from the left ear, which had never ceased for more than a few days. During the last five or six years he has also complained of pain in the left side of the head, extending in front as far as the temple, and behind over the region of the mastoid process. Slight excitement or fatigue produces considerable aggravation of the symptoms. At times, the pain in the ear comes on suddenly, and is followed by very abundant secretion. About a month ago, during a cold, he had an attack of pain in the ear, attended by a loud whizzing sound and great additional tenderness over the left side of the head. On examination, an ulcerated orifice, about two lines in diameter, was observed in the posterior part of the left membrana tympani, through which oozed a large quantity of thick tenacious discharge, having an offensive odor. On removing this, the mucous membrane of the tympanum was seen to be red and much thicker than natural, so as to project towards the orifice in the membrana tympani, and in some degree prevent the free passage of the secretion through the orifice. The treatment in this case consisted in keeping up a discharge from the mastoid process, and in administering small doses of the bichloride of mercury in conjunction with sarsaparilla. The ear was also syringed twice daily with warm water, care being taken that the stream was directed to the orifice in the membrana tympani, so that the water might be made to enter the tympanic cavity, and, by mixing with the mucous secretion, so soften it as to facilitate its discharge through the orifice of the membrane. This treatment was very successful, for the pain around the ear diminished greatly by degrees, and the attacks of pain within the ear became less frequent. The quantity of the discharge, however, remained much the same until a weak solution of the diacetate of lead was injected. This treatment was pursued for four months, at the end of which time the patient no longer complained of any pain in the ear or head, and the quantity of discharge had greatly decreased. 273 THE CAVITY OF THE TYMPANUM. Cases similar to the above being frequently met with in practice, the following brief particulars of a very similar instance are subjoined. Case IV. Catarrhal inflammation of the tympanic mucous membrane ; perforation of the membrana tympani ; pain in the head, and giddiness; irritation of the portio dura nerve. —Miss M. S., aged 30, says, that since childhood, with exception of an interval of two years' duration, she has had a discharge from the right ear, following an eruption on the head. For eight or nine years has complained of pain at the top of the head, with heat and a sense of weight. This pain sometimes suddenly shoots across the head from the right ear. She suffers at times from giddiness, and for the last few months has had a feeling of confusion in the head; six months ago had twitchings of the muscles on the right side of the face. On examination, the membrana tympani of the right ear was seen to be perforated at its upper and interior part, the aperture measuring about a line and a half in diameter. Mucus oozed through the aperture, and having been removed, the mucous membrane of the tympanum was observed to be thick and red. The treatment was the same as in the last case, except that leeches were applied below the ears once a week. After three months all the symptoms were much diminished, and the patient was ordered to continue the counter-irritation and the injection with warm water. From the situation of the orifice in the membrana tympani in the above case, it will be observed that in the usual position of the head during the day, a portion of the mucus must have been confined to that part of the tympanic cavity which was beneath the orifice; there was, however, a free escape of the mucus during the recumbent position, as there was then an opportunity for the complete evacuation of the contents of the tympanic cavity; and as the symptoms were not very urgent, it appeared advisable to try the effect of counter-irritation, instead of enlarging the orifice in the membrana tympani. In treating the class of cases now under consideration, it is of great importance to be able to decide when the membrana tympani should be perforated by artificial means, or when an orifice in it should be enlarged. To the perforation of the membrana tympani, much objection exists on account of the difficulty of keeping the aperture open. It is seldom that a punctured aperture, even of large size, does not close in the course of two or three days. I have 18 274 THE DISEASES OF THE EAR. found, even after making a triangular flap and turning it down, that the orifice thus produced sometimes closed in a few days by the effusion of fibrin. It is, however, not always possible to make a triangular aperture of this kind, either on account of the small calibre of the meatus, or the extreme sensibility of the surface of the membrana tympani. The only sure way of keeping open an aperture in this membrana with which I am acquainted, consists in applying to it the point of a fine stick of potassa cum calce. Such a proceeding appears, at first sight, to be attended with danger to the adjacent parts; but, in reality, the action of this substance is wholly under control; for the injection of warm water at once entirely stops its escharotic properties. During and after the application of this remedy, to which I have resorted in the destruction of polypoid growths, I have never known any inflammation to arise. At the same time there is no doubt, that in cases such as we are now considering, when there are symptoms of cerebral irritation, extreme caution should be used, and every other possible measure adopted before having recourse to this, or indeed any other operative proceeding; and as remedial measures of a different kind are generally sufficient to alleviate or cure the disease, the operation of perforating the membrane is rarely required. The potassa cum calce has been used by me in only one case. In those cases of catarrhal inflammation where the quantity of discharge from the tympanic mucous membrane has not been sufficient to cause ulceration of the membrana tympani, but where the superabundant quantity has passed away through the Eustachian tube, it seems to me that, as a general rule, unless the disease has made great progress and threatens the life of the patient, the ordinary remedial measures already adverted to will be found sufficient to arrest its progress and produce considerable improvement. The following cases will illustrate this branch of the subject, and it will be seen that they differ from those last quoted in the circumstance of the membrana tympani being still entire. Case V. Chronic inflammation of the mucous membrane of the tympanum, without perforation of the membrana tympani; giddiness, c&c.—M. C, aged 27, consulted me on the 15th of February, 1857. She said that for four months she has had at times a sensation of pricking in the right ear, accompanied by a humming noise, deafness, giddiness, a sensation of swimming in the head, and pain over the right side. During the last few days has complained of a 275 THE CAVITY OF THE TYMPANUM. throbbing in the ear, attended with great pain, and followed by discharge: has also been "light-headed at night." Every time she draws in breath through the nose, she states there is a rattling sound in the ear, and for a minute or two she hears better. The hearing is also better after a copious discharge. On inspection, the surface of the meatus was found to be red, denuded of epidermis, and secreting a muco-purulent fluid. The membrana tympani was opaque, especially at its lower part; the Eustachian tube pervious, and the power of hearing much diminished. Considering the case to be one of chronic inflammation of the mucous membrane of the tympanum, with a collection of mucus in the lower part of the tympanic cavity, and that the irritation of the meatus was only a symptom of this inflammation, the treatment adopted consisted in the application of leeches below the ear, and of blisters behind it; under this treatment the head-symptoms greatly diminished, while the hearing was much improved. On the 12th of May, the patient was again seized with violent pain in the right ear, extending across the head and towards the forehead. On the 17th she became much worse, and was insensible for some hours. Blisters were applied to the nape of the neck, and a constant discharge was kept up through them for some weeks; small doses of calomel were also administered until the gums became tender. The acute symptoms were soon abated, but counter-irritation was kept up for a long period, and iodide of potassium and sarsaparilla were afterwards administered. Treated in this way the symptoms of cerebral irritation wholly subsided, and the power of hearing greatly improved. Although it is difficult to determine positively whether there is a collection of mucus in the tympanic cavity, the history and symptoms of the case, and the peculiar sodden condition of the membrana tympani, such as was presented in this case, especially at the lower part, left little doubt in my mind that mucus had collected; and the second attack was probably the result of a collection of this fluid, causing irritation and pressure on the labyrinth. It is possible that more speedy relief might have been effected, by allowing an escape of the mucus through an orifice in the membrana tympani; but I was quite aware, from previous operations, of the great difficulty of keeping open the aperture, even if the means employed did not cause a serious increase of the inflammation. The important rule to bear in mind, is to keep up counter-irritation 276 THE DISEASES OF THE EAR. long enough to cause absorption of the fluid, and the arrest of the inflammatory action which produces the secretion. As stated, there is some difficulty in ascertaining positively whether there is a collection of mucus in the tympanic cavity. Sometimes the opacity and sodden appearance of the membrana tympani is the chief indication; but often the gurgling sound, produced by the entrance of air into the tympanum, or the peculiar flap, resulting from the air striking against a soft flaccid membrane, shows, at least, that there is a considerable quantity of mucus in the cavity. The following case will further elucidate the subject:— Case VI. Chronic catarrh of the mucous membrane of the tympanum ; giddiness, and symptoms of cerebral irritation. —E. Middleton, aged 14, was admitted under my care, at the St. George's and St. James's Dispensary, in December, 1849. She had an attack of measles at four years of age; since which she has complained of much pain in both ears and in the front of the head, attended by throbbing and frequent attacks of giddiness, especially when walking quickly. At times, also, she has been delirious and very violent. The head-symptoms have much increased in severity since the cessation of the discharge, which took place nine months previous to her consulting me. On examination, the membrana tympani of the right ear was seen to be very white, and parts of it had fallen in. Hearing distance, with watch, half an inch. Left ear. —The membrana tympani is milky white: hearing distance same as right ear. Air passes into each tympanum during an expiration with closed nostrils, producing a gurgling sound. The treatment consisted in the use of a blistering ointment to the nape of the neck, by which a constant discharge was kept up for more than a month, and in giving tonic medicines. By slow degrees the head-symptoms abated; she was free from giddiness for days, and the occasional attacks were in a mitigated form, and for short intervals only. At the end of two months, she had so far improved as to be able to enter service as a housemaid. Although the general cause of this kind of inflammation is most usually an attack of scarlet fever, measles, or common cold, this affection may follow a blow on the ear or head; and it is probable that in the following case a blow was the primary cause of the disease. J. S., aged 35, was admitted under my care, in the Hospital, on May 1st, 1853, complaining of pain in the right ear and down the THE CAVITY OF THE TYMPANUM. 277 back, accompanied by faintness when the nose was blown, or the ear was pressed. She stated that when she was ten years old, she received a blow on the right ear, since which that ear has been deaf. Two years ago, discharge took place from the right ear, and has continued. On examination, the membrana tympani was observed to have fallen in, and there was a valvular opening at the lower part, through which discharge was forced upon blowing the nose. Regarding the case as one of long standing disease of the tympanic mucous membrane, causing irritation of the brain, I at once ordered a seton to be placed in the back of the neck, the effect of which was slowly, but entirely, to remove pain from the ears, the head, and the spine. The general opinion respecting the mode in which disease progresses from the ear to the brain, appears to be that the bone becomes carious, the dura mater ulcerates, the arachnoid and the pia mater, and ultimately the substance of the brain, participate in the disease, as the result of direct extension from the ear. A careful examination of the post-mortem appearances found in some of the fatal cases, shows that the disease does not always advance from the ear to the brain as the result of continuity; indeed, in some instances, an abscess is developed in the brain without ulceration of the mucous membrane of the tympanum, or caries of the bone. It would appear that constant irritation in the tympanic cavity, produced by chronic inflammation of the mucous membrane, with the absence of a free outlet for the matter, is sufficient to produce an abscess in the substance of the cerebrum. Dr. Abercrombie states: There is reason to believe that extensive suppuration within the cavity of the tympanum is capable of producing symptoms of great urgency, especially if there should be any difficulty of finding "an outlet;" but the evidence derived from dissection shows that these symptoms of great urgency are associated with disease of the cerebral substance, without the existence of caries of the petrous bone. Thus in a case published by Dr. Joseph Williams, 1 of which the following is an abstract, there was no caries of the petrous bone. Case VII. Ulceration of the tympanic mucous membrane; abscess in the substance of the brain; petrous bone not carious. —E. B., aged 23, not strong, but her health, till about a fortnight before her death, had been uniformly good : she was then suddenly seized with violent headache, and most severe pain in the right ear; chilliness 1 Treatise on the Ear. London, 1840. 278 THE DISEASES OF THE EAR. next came on, which in a short time amounted to actual rigors. The pain in the ear now increased, and for several hours there was an oozing of blood from the meatus. The next day the discharge became thin and ichorous; the febrile symptoms rapidly increased; she fell into a state of semi-stupor, and the discharge became thick, fetid, and purulent. She died on the third day after the appearance of the acute symptoms. Autopsy.— The dura mater was softened, and easily broken down over the petrous bone. In the substance of the middle cerebral lobe was an abscess containing an ounce of pus, which had a fetid odor, was of a dark yellow appearance, and was mixed with serum. The abscess itself appeared to be about the size of a five-shilling piece. It had penetrated deeply into the substance of the brain, and its contents were mixed with blood. The portion of the brain surrounding the abscess was soft and very vascular. The surface of the petrous bone was of a somewhat dark color, and on sawing into it, the inner portion of the petrous bone was found increased in vascularity, and even in some parts ulcerated; the secretion was fetid and puriform, and the mucous membrane completely destroyed. The membrana tympani was ulcerated nearly through, and some of the bones of the external ear were destroyed. Dr. Williams adds: " Dr. Alison has communicated to me a case where abscess was found in the brain, consequent upon disease attended with discharge. The petrous bone was sound, consequently there was no communication between the matter of the ear and that of the brain." In other considerable portion of healthy brain is found to exist between the abscess and the petrous bone. For the particulars of the following case, and for the opportunity of making the dissection, I am indebted to Dr. Merriman. Case VIII. Catarrh of the mucous membrane of the tympanum, since measles ; attack of arachnitis ; death ; petrous bone not carious ; abscess in the substance of the brain; adjacent cerebral matter healthy. —M. K., a widow, aged 26, of a scrofulous diathesis, and much confined to the house as a maker of military caps, came under the care of Dr. Merriman, at the Westminster General Dispensary, for a cough, on the 7th January, 1846. On the 26th, she complained of earache on the right side, and then said that she had been subject to a discharge from the right ear since an attack of measles when a child: the discharge was at times very offensive. Previous to the present attack, no pain had ever been felt; but she is said, for 279 THE CAVITY OF THE TYMPANUM. twelve or sixteen months to have suffered much from headaches, being at times forgetful and very giddy. She has also fallen away very much. At first, only fomentations were ordered, which were followed by leeches; but without any benefit. The pain greatly increased, and was described as if, at times, a knife were being thrust into the ear; and then, as if there was a sawing outside the ear at its edge. During paroxysms of pain the patient screamed out suddenly, and then could not open her mouth. On two occasions a small quantity of discharge was observed, but its appearance afforded no relief. When the pain at all relaxed she lay in a partial sleep. On the 17th of February she became insensible, but put out her tongue when loudly told to do so, and then relapsed into a comatose state. She died on the evening of the 17th, twenty-three days after the attack of pain had commenced. Autopsy. —When the skull was sawn through, pus flowed from within the dura mater; and upon examination it was found to come from an abscess which occupied the whole of the upper part of the right cerebral hemisphere. The substance of the surrounding brain was healthy. The dura mater above the part cut off by the saw presented a patch of coagulable lymph, about the size of a fourpenny piece; lymph was also effused on the surface of the dura mater, covering the petrous bone, and a portion of it was detached from the bone. Upon dissection of the ear, the membrana tympani was absent; the tympanic mucous membrane, and that of the mastoid cells, was thick and soft, and covered by a large quantity of caseous, scrofulous matter. The upper tympanic wall was of a dark color, extremely thin, and perforated by numerous bloodvessels. The dura mater covering the upper part of the petrous bone, and that lining the squamous bone, was very thick and detached from the bone, and a large quantity of purulent matter was deposited between the dura mater and the arachnoid. The arachnoid membrane was highly congested. In some parts the purulent matter had passed through the dura mater, and was in contact with the bone. The outer surface of the dura mater, forming the lateral sinus, was rough where in contact with the inflamed bone; and the internal surface of the sinus had portions of fibrin adhering to it. The presence of a portion of healthy brain between the abscess and the petrous bone, has induced some observers to conclude that abscess in the cerebrum is the primary disease, and affection of the 280 THE DISEASES OF THE EAR. ear the result. The objections to this opinion are: Firstly, that the cases of abscess in the cerebrum are usually preceded by a long standing affection of the ear. Secondly, that the portion of bone which becomes carious is far from being the most dependent part of the cerebral fossa. And, thirdly, that although the abscess may be very large, the walls of the tympanum only are the real seat ot disease in the bone. The very insidious progress of the disease in its course towards the brain has been already adverted to. In some cases no symptom indicates to the patient that the brain has become affected until the sudden appearance of the acute stage; the presence of a discharge from the ear and a certain amount of deafness are, as they assure the medical man, the only unpleasant symptoms. Nevertheless, it does seem to me that, by a careful professional examination of the patient, the early stages of the disease might be detected; for in cases where my suspicions have been aroused by the condition of the ear, and the inward progress of the disease, I have not unfrequently found an unnatural sensibility of the brain upon percussing the suspected side of the head. In some cases the discharge may take place for a month or two, and then disappear for a similar period; where this cessation occurs, however, there is usually tenderness in or about the ear. The simple fact of discharge occasionally issuing from the ear should induce the medical man to make a careful investigation. The exciting causes of the acute cerebral symptoms are various: a blow upon the head, violent exercise, a cold, stimulating applications, or any depressing influence, may bring them on. Sometimes no exciting cause can be detected beyond the progress of the chronic affection of the ear. One of the first symptoms of the disease assuming an acute form is the cessation of the discharge; this is the result of inflammatory action, and it is so commonly associated with the origin of acute symptoms, that the stoppage of the discharge has been considered as the cause instead of the effect of acute inflammation; and medical men have been afraid to stop a discharge from the ear, lest inflammation of the brain should be induced. If this fear were confined to the exclusion of all irritating astringents in these cases, it would be salutary; but when it gives rise to a belief that it is injudicious to interfere in any way with a disease of the ear which is slowly progressing, and which, if neglected, would probably terminate in THE CAVITY OF THE TYMPANUM. 281 the death of the patient, it may act very prejudicially. Mr. Wilde, in his work on " Aural Surgery," before alluded to, has some interesting observations on this subject. Two cases of abscess in the substance of the cerebrum, arising from catarrhal inflammation of the mucous membrane of the tympanum, have been already described. In that which follows, the -post-mortem examination was attended by me with the late Mr. Farish. Death took place from arachnitis, and an abscess was found in the middle cerebral lobe; but the cause of the irritation appeared to be the presence of scrofulous matters in the tympanum. Case IX. Scrofulous matter in the tympanic cavity; caries of the upper wall of the tympanum; arachnitis; abscess in the middle cerebral lobe. —Miss H. G., aged 9h, fair and delicate, but not unhealthy, had measles when quite a child, though not severely; since the measles, has had an offensive discharge from the left ear, attended by occasional attacks of pain. On the 5th May, 1845, she was seized with symptoms of active fever. She did not complain of headache, but when questioned, said there was some uneasiness about the vertex. The discharge had ceased. There was constant vomiting. Calomel and opening medicines were administered, followed by effervescent salines. On the 7th she seemed well; every unpleasant symptom had vanished; her pulse was natural, her tongue clean, food was relished, and there was no pain. On the 8th, the bad symptoms reappeared. On the 10th, she complained of pain in the left ear, which, by degrees, became excruciating to the last degree; she, however, retained her faculties till from twelve to twenty hours previous to her death. The only symptoms of derangement of the nervous system were, some vomiting and a slight degree of paralysis of the muscles on the left side of the face. The remedial means employed were leeches, calomel, James's powder, and a little opium; and these were employed freely from the 11th. In spite of all efforts, she gradually became comatose; but even then frequently shrieked out from pain on the left side of the head. She died at midnight on the 15th, twelve days after the occurrence of the first symptoms. Autopsy. —Upon removing the calvaria, the dura mater was observed to be red, and its bloodvessels distended. The cavity of the arachnoid on the left side contained nearly half an ounce of yellow purulent matter; lymph was deposited upon the inferior surface of the posterior lobe of the left hemisphere. The arachnoid 282 THE DISEASES OF THE EAR. and pia mater covering the inferior surface of the middle lobe on the left side, were thick and dark colored over a superficies about the size of a sixpence. This thickened portion corresponded with an orifice in the dura mater covering the upper surface of the petrous bone. In the interior of the left middle cerebral lobe, there was an abscess as large as a small hen's egg, in which a quantity of dark-colored fetid matter, of a watery consistence, was contained. There was no communication between the abscess and the cavity of the arachnoid. The dura mater covering the upper surface of the petrous bone was three or four times its usual thickness, and its inner surface darker colored than natural and rough; being in some parts firmly adherent to the bone, and in others detached from it. About the centre of the upper surface of the petrous bone, the dura mater presented an orifice about a line in diameter, directly beneath which was another and smaller one in the petrous bone, measuring about a quarter of a line in diameter. The latter orifice, and several smaller ones about the size of pinholes, were filled by concrete scrofulous matter, which projected from the tympanic cavity. The superior wall of the cerebellar corner of the tympanum presented two carious orifices. The tympanic cavity and mastoid cells were completely full of scrofulous matter, having the consistence of soft cheese, by which the mastoid cells appeared to be much dilated; the mucous membrane of the tympanum was but slightly thicker than natural, and, where orifices existed, they appeared to have been produced by atrophy, resulting from the pressure of the scrofulous matter rather than from the process of ulceration. The greater part of the substance of the membrana tympani had been destroyed, and the remaining fibres were adherent to the inner wall of the tympanum. (/.) ULCERATION OF THE MUCOUS MEMBRANE OF THE TYMPANUM. This disease is rarely met with, and its treatment is the same as that of chronic catarrhal inflammation. The following case, belonging to this class, was supplied to me by Mr. together with the preparation. Case I. Scrofulous ulceration of the tympanic mucous membrane; destruction of the upper wall of tympanum; purulent degeneration of the middle cerebral lobe. —A young lady, aged 18, of scrofulous 283 THE CAVITY OF THE TYMPANUM. diathesis, and who was treated by a medical friend, was attacked, on November 20th, 1846, with fever and hysterical symptoms, unaccompanied by any pain. The following day symptoms of pleuritis appeared, accompanied by severe pain in the right side of the head. It was now ascertained that she had been deaf in the right ear for two years, and that the deafness was preceded by a fetid discharge. Notwithstanding the most active treatment, the symptoms of cerebral irritation grew worse daily, and death occurred on the ninth day of the attack. The patient's memory and intellect were perfect up to the hour of her death, which was preceded by epileptic fits. There was a very fetid odor about the ear, but no discharge. On dissection, the periosteum was found detached from the exterior, and the dura mater from the interior, of the squamous bone, and separated by dark-colored pus. The dura mater on the right side of the head was gangrenous over a large surface; and the middle Fig. 85 The internal surfaoe of the Temporal Bone, showing the Tympanic Cavity in a state of disease; the entire upper osseous wall of the Tympanum having been destroyed by caries. lobe of the right hemisphere was in a state of suppuration, being principally composed of pus. On careful inspection of the petrous bone, the whole of the upper wall of the tympanum was found to have been destroyed by caries; and the tympanic cavity communi- 284 THE DISEASES OF THE EAR. cated with that of the cerebrum by an aperture, measuring threequarters of an inch in length, and a third of an inch in breadth. It thus appears that in some cases the disease of the ear, instead of an abscess, produces purulent degeneration of the substance of the brain. Case II. Ulceration of the mucous membrane of the tympanum; caries of the bone; partial destruction of the portio dura nerve, and softening of the dura mater. —John Cochrane, a laborer, aged 44, was admitted under the care of Dr. Kingston, at the Westminster Hospital, for consumption, in October, 1849. His history is, that twenty-four years previously, discharge took place from the right ear, and has continued ever since. He has long been deaf in that ear, but has not complained of any head-symptoms. On examining the ear the membrana tympani was absent, and the tympanic mucous membrane was covered by an opaque discharge like cream. When that was removed, the mucous membrane was seen to be thick and its surface rugose. The patient died of consumption about a month after his admission into the hospital. Some days previous to his death, there was a paralytic condition of the muscles of the right side of the face; but there was a partial recovery of their action a short time previous to death. On dissection, the mucous membrane lining the tympanic cavity was found very thick and dark colored, excepting at the anterior part, where it had been destroyed by ulceration. The stapes was absent. At the upper part of the tympanum the bone was carious; the aqueduct of Fallopius was exposed for a space of more than a line and a quarter in length, and the portio dura nerve, in a soft and ulcerated state, protruded from it. The part of the nerve towards the tympanum was gelatiniform in its consistence, and extended downwards so as to cover the fenestra ovalis. The posterior half of the nerve was healthy. The dura mater covering the petrous bone was thicker than natural; and a small circular portion, about a line and a quarter in diameter, was of a dark brown color, and of a pulpy consistence. It was slightly raised above the surface of the surrounding membrane, and on being touched broke up, and exposed a carious orifice in the bone below it. The bone around the orifice was very thin. The brain was not diseased. In this case there appeared no obstacle to the free escape of the discharge, excepting its tenacity and its concretion in the tympanic cavity; and it is worthy of observation in a practical point of view, 285 THE CAVITY OF THE TYMPANUM. that unless the syringe with warm water be frequently used, the matter secreted by the mucous membrane of the tympanum is apt to accumulate and solidify, and so cause a certain degree of irritation in the adjacent parts. In the following, which is the last case I shall cite in reference to this class of diseases of the tympanum, the disease was evidently of a scrofulous character. The mucous membrane of the tympanum had ulcerated, and its place was occupied by scrofulous matter. The substance of the brain had also undergone scrofulous degeneration. Case III. Ulceration of the mucous membrane of the left tympanum ; softening and tubercular deposit in the corresponding cerebral lobe. —Wm. K., aged 4, was admitted under my care, at the St. George's and St. James's Dispensary, in March, 1849. He was described as never having had good health, his bowels having always been irregular, and his abdomen tumid. In earliest infancy discharge of offensive matter took place from the left ear, and has never disappeared for more than a few days at a time. The ear appeared tender to the touch, although no pain had been complained of. Has suffered from pain in the forehead and eyes for some months. Three days before my seeing him, he fell down at school in what appeared to be a fit, and remained insensible for some minutes. Upon his recovery he was found to have lost the use of the muscles of the right side of the face and body. When seen by me he was in a state of extreme exhaustion, speechless, and hemiplegic. On the following day he complained of great pain in the left ear and the left side of the head, and there was an abundant, creamy, offensive discharge from the ear. On examination the whole of the membrana tympani was found to have been destroyed, the tympanic mucous membrane had disappeared, and the cavity contained thick, caseous, scrofulous matter. The pain in the head and the convulsive fits increased in intensity; he often remained insensible for hours together; his strength gradually declined; and, in spite of the most active treatment with leeches and mercury, he died on the 21st of May. Autopsy, sixteen hours after death. —The dura mater covering the upper surface of the cerebral hemispheres was healthy; but in the substance of the left cerebral hemisphere, above the middle cerebral lobe, was a space measuring three inches from behind forwards, an 286 THE DISEASES OF THE EAR. inch and a half from without inwards, and an inch from above downwards, which was much harder than natural and studded with tubercles ; and between this mass and the lateral ventricle the brain was pulpy. In the left lateral ventricles was a small quantity of turbid serum. The dura mater covering the upper surface of the petrous bone was more vascular than natural, and on its free surface was a patch of blood. The upper wall of the tympanum was dark-colored, Fig. 86. The lower osseous wall of the Tympanum incomplete, so as to allow of a communication between the Tympanic Cavity and the Fossa Jugularis. and the thick mucous membrane was seen beneath it. The tympanic mucous membrane was very thick, and of a dark purple color, its vessels being distended. The upper part of the tympanum was so filled by this thick membrane, that the scrofulous matter and pus were retained by it. The scrofulous matter itself was composed of fine granules of epithelial cells, and of very fine crystals, which latter were stated by Dr. Garrod to consist of phosphate of ammonia and magnesia. The stapes was disarticulated from the incus, and the ossicles were concealed by the thick mucous membrane. The lower Fig. 87. The orifice seen from the Jugular Fossa. osseous wall also was thin and of a red color, and presented an orifice which allowed of a communication between the tympanum and the fossa jugularis. 287 THE CAVITY OF THE TYMPANUM. This case is especially interesting, from the fact that the disease had extended downwards to the lower osseous wall, as well as upwards. The lower wall of the tympanum is frequently formed by a thin layer of bone, which separates it from the fossa jugularis. In many instances this osseous lamina is deficient in parts, and the outer surface of the mucous membrane of the tympanum is in contact with the jugular vein. Disease may thus be propagated from the tympanic cavity to the jugular vein. CHAPTER XIII. THE CAVITY OF THE TYMPANUM {concluded). a. RIGIDITY OF THE MUCOUS MEMBRANE —CAUSE OF DEAFNESS IN ADVANCING YEARS TREATMENT —CASES. b. THE FORMATION OF BANDS OF ADHESION. C. ANCHYLOSIS OF THE STAPES TO THE FENESTRA OVALIS —PATHOLOGICAL OBSERVATIONS—TREATMENT —CASES. d. DISCONNECTION OF THE INCUS AND STAPES —PHYSIOLOGICAL OBSERVATION —PATHOLOGICAL OBSERVATIONS —CASES. The mucous membrane of the tympanum may be subject to chronic inflammation, complicated or not with rheumatism, at any period of life, and, if neglected, this is liable to terminate in a rigid state of the membrane; so that the ossicles become bound together more firmly than is natural. In advanced years this rigid condition seems to take place without any symptom of inflammation. The membrana tympani also partakes of this rigid condition, and, what is of far greater importance, the base of the stapes may become much more firmly fixed to the border of the fenestra ovalis than is natural. As a consequence, the membrane of the fenestra rotunda and the fluid of the labyrinth participate in this fixed condition. This affection is less prevalent in the young than in the adult, in whom it is liable to occur after repeated attacks of cold, whether with pain or not. It is, however, most frequent in persons advancing in life, and may, in fact, be considered as the disease which causes deafness in advancing years. The generally received opinion that in this kind of deafness the nervous system is at fault, is manifestly incorrect, as proved by the symptoms, and by the mode of relief found beneficial. The diagnosis of this affection is far from being difficult; although, as will be seen, it offers very little to guide the medical man, except the history of the case. Thus, there is very often little or no opacity, or even dulness, of the membrana tympani; the Eustachian tube too is pervious, and the air enters naturally. Not unfrequently, THE CAVITY OF THE TYMPANUM. 289 however, the membrana tympani shows signs of chronic inflammation, in hypertrophy and a greater concavity than natural; while the air, when forced into the tympanum, enters it with a dull flapping sound instead of the normal crackling. Sometimes on forcing the air into the cavity very suddenly, a greatly louder crackling than is natural is heard; and the patient occasionally hears better for a short time subsequent to the operation. A symptom of considerable importance in forming a diagnosis, is the peculiar character of the deafness. Many patients will most distinctly hear a single voice, although low, but are puzzled to hear anything distinctly when two or more persons are speaking; others hear the voice, but cannot discriminate the words; others again can hear slow conversation, but cannot follow it when rapid. These symptoms indicate that the adapting power of the ear, dependent, as already shown, upon the ossicles and their muscles, is at fault. But the history of the case, showing it to be one of slow hardening of the tympanic mucous membrane, together with the absence of all those symptoms which render it liable to be confounded with other diseases, as nervous deafness, obstruction of the Eustachian tube, &c, are usually sufficient to enable an attentive observer to form a correct diagnosis. Treatment. —It is highly important to inquire whether any remedial measures can be suggested which will tend to diminish a rigid state of the mucous membrane, and consequently improve the power of hearing. Practical experience induces me to believe that not only may the thick membrana tympani be relieved, but the thickened mucous membrane be so reduced as to offer but little impediment to the function of hearing. The most suitable application for this purpose which has been tried by me, is that of a solution of nitrate of silver, of a strength varying from half a drachm to a drachm of the salt to an ounce of distilled water. Proceeding from the exterior orifice of the meatus externus, the passage may be touched to an extent varying from one-half to two-thirds of its length every third or fourth day. In some cases the membrana tympani also may be washed with a solution of this salt of six grains to the ounce. When the noises are loud, and the symptoms indicate much congestion in the ear, leeches should be applied immediately below, not behind the ears; and where there is irritation of the external tube, an ointment, composed of half a drachm of pulvis cantharidis added to an ounce of simple 19 290 THE DISEASES OF THE EAR. ointment, and applied behind the ear, either daily or every other day, will be found beneficial. The administration of alterative doses of pilula hydrargyria hydrargyrum cum creta, or the hydrargyri bichloridum, is very useful; but it should always be recollected that these doses ought to be so proportioned as not to produce debility or any other unpleasant symptom; in other words, so gentle should be the alterative that no sensation should suggest to the patients that they are under a course of medicine. In addition to the medicines described, patients should be cautioned to avoid warm rooms and sitting very near the fire; daily exercise, and, where possible, on foot, should be taken in the open air, together with a warm bath every week or ten days. This course of treatment has been productive of the greatest advantage in several cases of deafness of a most unpromising character. Some of the cases about to be cited are those of patients who attributed their failure of hearing to old age. The treatment pursued by continental surgeons in cases of rigidity of the tympanic mucous membrane, has been the injection of air by means of the Eustachian catheter. There can be no doubt that temporary benefit in these cases sometimes follows the use of the airdouche, as well as the act of forcing the air into the tympanic cavity, by the patient holding the nose while he attempts a forcible expiration. But the very temporary character of this benefit, and its occurrence in only a few cases does not induce me to recommend the performance of an operation; in fact, a forcible expiration by the patient usually answers equally well. On this subject I may quote the following judicious remarks from the article on the Diseases of the Ear, in the Cyclopaedia of Surgery, by Mr. Wharton Jones —an article characterized, as are all his works, by the most careful observation and patient research. He writes: "According to Kramer's ' Tabular Yiew of the Frequency and Curability of Diseases of the Ear,' out of three hundred cases of diseases of the ear of all kinds, two hundred, in round numbers, required the airdouche to assist the diagnosis, but about thirty only were improvable or curable by it. Of the remaining one hundred and seventy about thirty are put down as cured, and about fifty as relieved, by the injection of vapors of acetic ether; this treatment having been continued for months. Of the remainder, eighty were considered incurable from the first, and not treated further than was necessary THE CAVITY OF THE TYMPANUM. 291 for exploration, I suppose; the rest remained rebellious to treatment. Dr. Kramer does not tell us how permanent his cases were. It will be seen from the above statement of the results of Itard's experience, and also from what I have related of my own, that the advantage gained is seldom permanent." Case I. Rigidity of the tympanic mucous membrane. —The Rev. M. M., set. 70, consulted me in 1855, on account of an increasing dulness of hearing, which caused him much inconvenience, as he could not hear general conversation. It had come on very gradually, without pain, noises, or any unpleasant sensation, beyond that of a feeling of heaviness in the ears. The deafness is increased by a cold, but not by fatigue. On examination, each membrana tympani was seen to be less translucent than natural; and though the Eustachian tube was natural, the air entered the tympanic cavity in a puff instead of producing a faint crepitation. The treatment consisted in keeping up a slight irritation by means of a vesicating plaster behind each ear, and in giving the bichloride of mercury in doses of one-thirtieth of a grain, using also a stimulating gargle. This treatment was continued, with intermission of the mercury, for a week at the end of each fortnight, for four months. At the expiration of that time, the hearing power was greatly improved, and the patient wrote to me as follows: " I have not recovered the quick hearing of early life, which a man in his 70th year has no right to have; but I hear comfortably, and I am freed from that dunny sensation as if sounds came through a damp cloth. Case XL —R. B., Esq., aged 80, in tolerable health, consulted me on 29th of March, 1844, on account of deafness in both ears. He stated, that three years before, the power of hearing began gradually to decline in the right ear, and had continued to do so up to the time of consulting me; that about six months previously the left ear had been similarly affected; and that his deafness had so much increased as to disable him from hearing the voice without the aid of a speaking-trumpet. He was unable to assign any cause for the deafness. On examination, the membrana tympani in each ear was observed to be dull and opalescent: and although by aid of the otoscope the air was heard to pass into the tympanic cavities, yet it did so with the bubbling, crackling sound, indicating obstruction. Two grains of pilula hydrargyri were ordered to be taken every night, and a stimulating liniment to be applied around and below the ears. This plan having been persevered in for about three 292 THE DISEASES OF THE EAR. weeks, and some slight improvement experienced, the patient was directed to take one grain of hydrargyrum cum creta daily. At the end of two months this gentleman recovered his hearing, and gave up the use of the speaking-trumpet. Case III.—J. P., Esq., aged 64, consulted me in July, 1845. During the last four or five years the right ear had been growing deaf, and the deafness has now so far advanced as to render the ear useless to him. Has been suffering from a cold for a few days* during which there has been a sensation of singing and of vibration in the head and ears, accompanied with deafness. In each ear there was a large collection of wax, on the removal of which the symptoms somewhat abated. The membrana tympani of both ears was white. Air passed freely into the tympanic cavities. The fifteenth of a grain of hydrargyri bichloridum thrice a day was prescribed, and counter-irritation around the ears. In the course of six weeks the patient had perfectly recovered. Case IV.—Lady R., aged 62, consulted me in December, 1848, for a deafness which had come on during the preceding month, and gradually increased, till, by the time I saw her, it was requisite to speak loud and close to the ears. The deafness had first been perceived after a cold, and was accelerated by an attack of influenza. The feeling in the right ear was that of a veil hanging over it. In each ear the membrani tympani was white, and air passed freely into the tympanic cavities. The treatment pursued consisted in the application of a solution of argenti nitras to the outer half of the external meatus; beginning with the strength of half a drachm of the salt to an ounce of distilled water, afterwards increasing it to double that strength. This course of proceeding, coupled with the administration of alterative doses of pilula hydrargyri, effected so great an improvement, that in two months this lady had no difficulty in hearing in ordinary society. Case V.—Mrs. A. T., aged 67, consulted me in April, 1845. She stated that when eight years pi age she fell down on the left ear, and had been deaf of that ear ever since. About four years ago loud internal noises disturbed the right ear, and increased to so distressing a degree, that this lady felt as if she were continually travelling in a carriage over gravel; and at times a loud explosion would be heard, succeeded by acute pain. She can scarcely hear her own voice, and is obliged to use a trumpet in society. The ears seem to her stopped up with pegs. She attributes this deafness to THE CAVITY OF THE TYMPANUM. 293 a close attendance in the sick-room of her husband during a long illness. Bight ear. —Membrana tympani concave, and evidently nearer to the promontory than natural; and the membrane is so white that the malleus is not distinguishable. Left ear. —Membrana tympani has been entirely removed by ulceration. Treatment. —In the first instance leeches were placed immediately below the ear; tincture of iodine was applied to the external meatus of the right ear; and three grains of pilula hydrargyri were given every night. June 3d.—Feels much better; has less confusion in the head and more confidence in herself. June 15th.—The noises are so much diminished that she is no longer troubled by them; is feeling stronger and better, and the hearing improves. Case VI.—J. C, Esq., aged 64, consulted me in November, 1844. His father became deaf at the age of fifty, and he has a sister deaf. About a year ago he found that he was deaf in the left ear; might have been deaf a longer time; but at the period mentioned, singing commenced in the left ear, which has continued without intermission ever since. Occasionally it is much diminished. The noise and deafness are much worse during a cold. The right ear is not so bad as the left. When he closes the right ear, he cannot hear any sound naturally. Bight ear. —Membrana tympani opaque, and the handle of the malleus only just discernible. When air is forced into the tympanum it can be heard by the otoscope entering it in a series of small puffs. After the air has been forced into the tympanum, a crackling sensation is experienced. Hearing distance two inches. Left ear. —Membrana tympani white; handle of malleus indiscernible ; air enters the tympanum in a short puff. Hearing distance absolute contact. For this gentleman two grains of the pilula hydrargyri were prescribed, to be taken every night; and tincture of iodine was applied behind the ears. In the course of three months I saw him again, and found the hearing decidedly improved; the noises also had diminished. Case VII.—Mrs. R. N., aged 64, consulted me August 2d, 1844. For the preceding four or five months deafness had been coming on, and had lately so much increased that she finds it difficult to hear 294 THE DISEASES OF THE EAR. any conversation. Has for several years been subject to occasional dulness of hearing. The present deafness was apparently produced by an attack of cold, which left a sensation of fulness in both ears. The membrana tympani of each ear is quite white. Treatment. —One-twentieth of a grain of hydrargyri bichloridum, in conjunction with vinum ferri, was administered thrice a day. The dose of bichloride was subsequently increased to one-sixteenth of a grain, and a solution of argenti nitras, half a drachm of the salt to an ounce of distilled water, was applied to the outer half of the external meatus. In the course of three months this patient recovered her hearing, and has remained quite well ever since. (b.) MEMBRANOUS BANDS IN THE TYMPANIC CAVITY. Membranous bands are formed in every part of the tympanic cavity, connecting together the ossicles, and attaching them to the walls of the tympanum and to the membrana tympani. In cases where these bands are lax, it is probable that the movements of the ossicles are not impaired, and that there is no diminution of the power of hearing. In the majority of instances, however, these membranous bands are so firm and unyielding as to cripple the movements of the bones to which they are affixed. On reference to the table it will be seen that these membranous bands most usually connect the stapes with the promontory, and thus produce one species of anchylosis of that bone. These adhesions originate either from the effusion of fibrin from the surface of the membrane, and its conversion into a firm and vascular membrane, or from the circumstance that when the mucous membrane is much hypertrophied there is an adhesion of the portions of it which are in contact, and the neighboring parts are drawn into bands, when the membrane subsides to its normal condition. Care should be taken to distinguish between bands formed of organized membrane, and those which are produced by dried mucus, as pointed out by Mr. Hinton in the paper before alluded to. Let me now relate the results of some dissections of cases in which these bands were found. Case I. Considerable hardness of hearing for six years; bands of adhesion in the cavity of the tympanum. —Mrs. L. died in December, 1848, at the age of 87, from a gradual decline of the vital powers. 295 THE CAVITY OF THE TYMPANUM. Until the age of 50, she had no symptoms of derangement of the function of hearing; but about that period she was in the habit of taking "cephalic snuff," which she thought produced a buzzing sensation in her ears, a symptom which disappeared as soon as the use of the snuff was discontinued. At that period there was no sign of deafness; but about the age of 81, she perceived that the sense of hearing was becoming blunted. From that time deafness gradually and very slowly increased, attended now and then with noises in the ears. The deafness would be temporarily increased by a cold, but, as that vanished, the usual amount of hearing returned. During the last year of her life the disease made but little progress, though the deceased was obliged to use a speakingtrumpet for the purpose of conversation. It was observed that the sense of hearing became much more acute during the last few days of her life. This lady took very little exercise during the ten years preceding her death, but kept within doors, and sat in a warm room the greater part of every day. She was troubled with a chronic inflammation of the mucous membrane of the eyelids, lachrymal sacs, and nasal ducts. It is worthy of notice that this lady had two sisters, one of whom died at the age of 90. She was a very active person nearly up to the period of her death, and was but slightly deaf. The other sister, at the age of 89, is extremely deaf, and has been confined to her room for years. Dissection. Right ear. — The external meatus was dry and deprived of cerumen. The membrana tympani has its fibrous layer slightly thickened and white, and is more concave than natural. Tympanic cavity. —The mucous membrane appears to be healthy, Fig. 88. Membranous Bands connecting the Ossicles and not thicker than natural, but there are bands of adhesion by which the ossicula are connected together and with the walls of the tympanum. These bands of adhesion may be divided into two dis- 296 THE DISEASES OF THE EAR. tinct sets; one placed between the incus and the inner wall of the tympanum and stapes, and the other connecting the head of the malleus and the body of the incus with the external wall of the tympanum. The first-named set consists of two portions, of which the one, measuring half a line from above downwards, and threequarters of a line from without inwards, connects the anterior part of the long process of the incus with that part of the wall of the tympanum which is posterior to the fenestra ovalis. This band is connected by several smaller ones to the superior surface of the stapes, and also to a fine membrane which connects the two crura of the latter bone. These small bands are so firm and so tightly stretched between the stapes and the larger band, and between the incus and the inner wall of the tympanum, as to keep the stapes more fixed than natural. There are also adhesions between the upper surface of the crura of the stapes and the margin of the fossa fenestras ovalis. The outer portion of this band extends from the posterior part of the long process of the incus to the inner wall of the tympanum, posterior to that just described; this band is also firm and tense. The second set of adhesions passes from the head of the malleus and the body of the incus directly outwards, connecting them with the osseous walls of the tympanum, superior and posterior to the attachment of the membrana tympani. It is interesting to consider what effect these bands must have had upon the ossicula and membrana tympani during life. Those which surround the stapes and connect it with the fossa fenestras ovalis, must have impeded the movements of the stapes; and those which connect the long process of the incus with the inner wall of the Fig. 89 Membranous Bands connecting the Ossicles of the Promontory. (Magnified.) tympanum, by pulling that process inwards, would probably have been the means of pressing the stapes towards the vestibular cavity. The effect of the adhesions between the bodies of the malleus and THE CAVITY OF THE TYMPANUM. 297 incus, and the outer wall of the tympanum, would seem to have been to draw those parts outwards, and, in consequence, their inferior extremes inwards. This action upon the malleus is apparent and may account for the greater concavity of the membrana tympani externally; it having been carried inwards with the long process of the malleus and being very tense. The bones of the stapes is also fixed more firmly than is natural to the margin of the fenestra ovalis. The membrane of the fenestra rotunda appears to be in a normal state. The membranous labyrinth is healthy; and except that there is rather more black pigment than usual in the cochlea of the left ear, it is in a similar condition to the right ear, and presents adhesions connecting the ossicula. Case II. Membrana tympani very concave externally; bands of adhesions connecting the ossicula together and to the tympanic walls. — Mrs. F. O., died of gangrena senilis, at the age of 62. She had been deaf for a considerable period previous to her death, especially in the left ear. Dissection. Bight ear. —The membrana tympani is unusually concave externally, and the central part of its internal surface is not more than a quarter of a line from the promontory; it is also rather opaque in parts, especially at its circumference; and its internal layer is white, and slightly hypertrophied. The mucous membrane of the tympanic cavity is rather thicker and more vascular than natural, and is very tough. A firm band of adhesion connects the cervix of the malleus with the long process of the incus, and another membranous band of adhesion connects the anterior surface of the long process of the incus with the promontory and with the stapes, which latter bone it completely envelops. The tensor tympani muscle is smaller than natural. Left ear. —Although the surface of the membrana tympani is smooth, it is white around the line of attachment of the malleus; the bloodvessels are enlarged and much distended with blood. The membrana tympani is more concave externally than natural. The cavitas tympani is three parts filled with a thick, tenacious, white mucus, which is partly the cause of the white appearance of the membrana tympani, though the inner layer of the membrana tympani being opaque and white, aids in producing this effect. The mucous membrane lining the tympanum is thick and very vascular. It is not possible to distinguish, during life,'between the cases of rigidity of the tympanic mucous membrane, and those of adhesions 298 THE DISEASES OF THE EAR. in the tympanic cavity; but as the treatment in both cases is the same, the distinction is not of much importance. (c.) ANCHYLOSIS OF THE STAPES TO THE FENESTRA OVALIS. In the published catalogue of the preparations contained in my museum, I have described one hundred and thirty-six specimens of anchylosis of the base of the stapes to the fenestra ovalis; and these specimens form the basis from which the pathology of this articulation has been studied. In a tabular view of the morbid appearances found in 1149 diseased ears, published originally in the Transactions of the Royal Medical and Ohirurgical Society, and afterwards as an appendix to the catalogue of my museum, fifty-three specimens of membranous anchylosis are described, specimens in which the stapes was attached more firmly than natural to the circumference of the fenestra ovalis; that is to say, upon the stapes being pressed by a fine probe, more than usual resistance was offered before the stapes moved. Now, in these cases, no expansion of the base of the stapes, or of the articular surface of the fenestra ovalis, was observed; and the only inference that could be drawn was, that these were cases of partial anchylosis of the stapedio-vestibular articulation, resulting from rigidity of its capsular ligaments; and I am disposed to think, that this rigidity of the fibrous tissue is one of the earlier and more remediable stages of anchylosis of this and other articulations, which, if allowed to proceed, ends in the formidable pathological conditions known under the name of rheumatic arthritis, and which are about to be more particularly described. The second morbid change found in this articulation is a simple expansion of the articular surfaces, while the structure of the bone itself remains, as far as can be ascertained, in a natural state. This morbid condition of the articular surfaces was found in forty-nine out of the one hundred and thirty-six cases of anchylosis; and was distinguishable from membranous anchylosis by the greater degree of firmness with which the stapes adhered to the fenestra ovalis, and by the presence of a distinct tumefaction of one or other articular surface, but generally of the stapedial. The third pathological condition is that in which the whole of the base of the stapes has become hypertrophied, and assumed a calca- THE CAVITY OF THE TYMPANUM. 299 reous whiteness; the border being so much enlarged as to be impacted within the fenestra ovalis with that degree of firmness, that the crura are often broken from the base in the attempt to withdraw Fig. 90. The whole of the Circumference of the base of the Stapes anchylosed to the Fenestra Ovalis, the Crura being detached, and seen below, a, the base of the Stapes; i, the Crura (magnified two diameters). the latter from the fenestra ovalis. In some instances, this expansion of the base of the stapes is accompanied by its protrusion into Fig. 91. Base of the Stapes expanded, and osseous matter thrown out around it and the Crura a, the Stapes; b, the cavity of the Vestibule (magnified two diameters). the cavity of the vestibule; still there appears, even in these cases, to be nothing more than hypertrophy and condensation of the nor- 300 THE DISEASES OF THE EAR. mal osseous structure. This morbid condition shows itself in twenty-nine specimens. Fig. 92. Expansion of the base of the Stapes, and its protrusion into the cavity of the Vestibule (Magnified.) The fourth pathological condition is that in which the base of the stapes is greatly expanded, and new osseous matter is thrown out Fig. 93. Expansion of the Vestibular Surface of the Articulation. "(Magnified two diameters.) a, The Upper Margin of the Stapes free ; b, the Lower Margin of the Stapes anchylosed. beyond the natural limit of the bone, so as to connect the stapes with the adjacent parts of the fenestra ovalis; a morbid condition which is seen in twenty-five specimens. 301 THE CAVITY OF THE TYMPANUM. The fifth pathological condition is that in which the structure of the base of the stapes undergoes little or no alteration; but where ossific matter is thrown out at its circumference, and the base is thus partially or wholly anchylosed to the fenestra ovalis. This morbid condition is shown in twenty-one specimens, in eight of which the lower border only was anchylosed; there being a distinct space between the upper margin of the base and the fenestra ovalis; while in thirteen others, the whole circumference of the base is firmly anchylosed to the fenestra ovalis. The sixth pathological condition consists in the expansion of the vestibular surface of the articulation, and the effusion of bone around the fenestra ovalis, the stapes remaining perfectly healthy ; an abnormal condition which occurred in twelve instances. The five morbid conditions last described, comprised in 136 specimens, may be summarily stated in this form:— 1. Simple expansion of the articulating border of the base of the stapes, . 49 2. Expansion of the articulating border of the base of the stapes with calcareous whiteness of the whole base, ........ 29 3. Expansion of the whole of the base and effused bone connecting the two articulating surfaces, .......... 25 4. Osseous matter effused between the stapes and fenestra ovalis connecting the two articulating surfaces, ......... 21 5. Osseous matter effused around the fenestra ovalis, 12 136 DIAGNOSIS AND PROGNOSIS. The diagnosis of this affection is, in the majority of cases, attended with little difficulty, if the origin and progress of the affection be carefully investigated, and the organ be examined with sufficient accuracy. The symptoms, in fact, of this class of disease are very similar to those occurring in cases of rigidity of the mucous membrane, already described. After a certain duration of these symptoms, sometimes for many months, the patient is found to be growing gradually deafer and deafer, frequently without any other marked symptom, though often there is a feeling of fulness or pressure in the ears, or a buzzing sound when laying the head upon the pillow. The progress of the affection is at first usually slow j at intervals of two, three, four, or more months, the patient observes the deafness to be decidedly on the increase, though mitigated tem- 302 THE DISEASES OF THE EAR. porarily perhaps by his resorting to very violent exercise, or by taking spare diet or aperient medicines. If the progress of this affection be left unchecked, total deafness results, and may take place at an early period of life, as between the ages of twenty and thirty, though commonly it does not happen till a much later period. Sometimes the affection advances so far as to produce a certain degree of deafness only, as where the patient has to be addressed in a loud voice within a yard or two of his ear, and then, from some constitutional change, no further progress takes place. An interesting symptom frequently met with in cases of this disease is the momentary improvement of the hearing produced by the acts of yawning widely, or pulling the outer ear, or pressing the tragus hard and quickly against the orifice of the meatus; each of which actions is followed by a temporary relaxation of the membrana tympani and chain of ossicles. In the case of yawning, I am disposed to believe that this relaxation is produced by the mechanical action of the chorda tympani nerve, which, being drawn tight, slightly pulls out the chain of ossicles. Another and peculiar symptom is the effect produced by very loud and sudden sounds, as in two of the appended cases. In one of these, where, doubtless, the stapes was fixed by the expansion of its border, a loud scream in the ear at once restored the hearing by, as it would seem, suddenly releasing the bone; a restoration which lasted for several days, until, in fact, the two again became fixed; in the other, a very loud sound of bagpipes in the patient's hall, where he was sitting, so increased his deafness that his friends were obliged temporarily to use a slate and pencil to communicate with him. This increase of deafness also disappeared, and the patient recovered his previous amount of hearing. A third interesting and very common symptom of the early stages of anchylosis of the stapes, is the loss of what I am in the habit of calling the adapting power of the organ. Thus the patient will hear perfectly a single distinct voice, but a second voice intermingling, completely disables him from hearing either; he having lost the power of rapidly adjusting his ear to suit the sound of the voice of the person immediately addressing him to the exclusion of that of the other. Yet another striking symptom of the early stages of the affection, is the necessity of exercising an act of sustained volition, in order to catch the sound of a voice, which ceases to be perceptible as soon as the effect is relaxed. It has, indeed, happened to me to receive patients whose complaint consisted not in being dull of hear- THE CAVITY OF THE TYMPANUM. 303 ing, since they could hear everything said in a room, but in not being able to do this without a prolonged effort of attention, the fatigue of which soon became intolerable. This latter condition is, of course, perfectly explicable, from the more or less rigidity of the chain of bones in this disease, and the muscular effort consequently required to move it and keep it in constant motion. Another symptom, and one certainly characteristic of the later stages of this affection, but which it is not in my power to deny may not also be present in another disease of the ear, is the immense improvement to the hearing which attends the patient's travelling in a carriage over a hard road, by which considerable vibration is communicated to his body—a vibration that'doubtless in a degree shakes the chain of bones, and imparts to them a kind of vibratory movement, which permits the muscles, while it lasts, so to act on these bones as to restore more or less of their proper functions in adjusting the pressure on the labyrinth. On examining the patient, there is usually abundant evidence of the rheumatic or gouty diathesis having been or being present, such as congestion or tumefaction of the nasal and faucial mucous membranes, and, in addition, hypertrophy of the tonsils in young persons. On inspecting advanced cases, there is usually an absence of cerumen from the external meatus, the result of the congestion of this part of the organ, of which the membranous meatus presents most characteristic symptoms, in being red and so swollen as generally to have lost its oval form and to have become, in parts, constricted. Thus the upper half of the tube may retain its normal size and shape, while the lower may be reduced to a narrow fissure only one-half or one-third of its proper dimensions. Sometimes this diminution of the calibre of the meatus arises from a bulging of the bone forming the walls, so as to become a convex protuberance; in other instances, these osseous protuberances are so prominent as to gain the name of tumors, and as such they have been described in treating of the meatus. The dermis covering this bone is usually of a deep red color; indeed, as a rule, the dermoid meatus is highly congested in cases of gouty and rheumatic affections of the ear. The condition of the membrana tympani does not afford much aid in forming a diagnosis, though as a general rule, to which there are many exceptions, it is somewhat more opaque, and its surface duller than natural. Often it is very opaque, and white as parchment, and not unfrequently it 304 THE DISEASES OF THE EAR. exhibits patches of opacity in different parts. Occasionally the membrane is more concave externally than is natural. In advanced cases, like those where the base of the stapes has become fixed, the membrana tympani is rigid. The presence of this rigidity is, however, difficult to ascertain by simple pressure on the surface; but its existence may be proved by the use of the otoscope, while the patient either swallows with closed nostrils, or forces the air into the tympanic cavity by blowing the nose forcibly, the nose and mouth being at the same time closed. In each of these acts the air is heard to enter the tympanic cavity, for the Eustachian tube in these instances is usually open; but in place of the fine crackling sound elicited by these operations, when performed on a healthy ear, a flapping, or coarse crackling, is heard, produced by the air striking against the inner surface of the unyielding or tense drum. A yet further symptom of this disease is, that the patient commonly hears better in proportion to the loudness of the speaker's voice; whereas, in cases of debility of the nervous apparatus of the ear, it is not the loud voice, but that which is peculiarly modulated which is heard the best, occasionally even when as low as a whisper. In addition to the foregoing symptoms, the existence of anchylosis of the stapes may be diagnosed by a careful attention to the causes producing it, and to the stages of its progress, which offers so marked a contrast to cases of debility of the nervous apparatus, with which cases of anchylosis of the stapes may, doubtless, otherwise be confounded. With regard to the "prognosis, it may be laid down as a general rule, that so long as the affection depends upon rigidity of the ligaments, or upon a slight expansion of the bases of the stapes (and the surgeon can judge of the existence of these conditions during life by the symptoms being but little advanced), then there is every prospect that considerable amelioration may be effected, and the patient, in fact, be enabled to hear without any inconvenience, for experience has taught me that a rigid ligament may be relaxed, and an expanded bone be reduced in size. I may even venture on the further statement, that, judging from the visible diminution of the bony tumors in the external meatus under the influence of remedial measures, and taking into account also the decided improvement which at times takes place in cases where, from the symptoms, there was every reason to believe that the stapes or vestibule had become similarly expanded, there can be but little doubt that, even in the more advanced stages of anchylosis by expansion, some benefit can be ob- THE CAVITY OF THE TYMPANUM. 305 tained by the use of remedies which shall cause the effused matter to be absorbed. The more hopeless cases are those in which the opposing articular surfaces of the stapes and vestibule are united by ossific matter; and at present I am unaware of any means by which they can be diagnosed and discriminated from cases of anchylosis by expansion of the articular surfaces. Treatment. —The treatment in these cases differs in no essential respect from that recommended for cases of rigidity of the fibromucous membrane. Case I.—Mr. W., aged 47, consulted me, in the year 1848, on account of the state of his health, which was greatly impaired by attacks of rheumatic gout and congestion of the liver. When I saw him, he was so deaf that he required to be loudly spoken to, within the distance of a yard from his head. His habits were far from being temperate, as he indulged freely in alcoholic drinks. The history of his deafness was, that many years previously he had gradually become dull of hearing, and that this dulness had increased slowly up to the period of my seeing him. The only occasion upon which he had been temporarily benefited was on the removal of a large mass of cerumen from the meatus. I did not examine the ears, as I was not consulted on account of the deafness; but this omission is supplied by the particulars of the post-mortem inspection. After having known him for a few years, he died from an attack of inflammation of the lungs. Dissection. Bight ear. —The meatus externus was somewhat contracted, the lower part being rough, and the surface irregular. The membrana tympani was thicker, and more opaque and rigid than natural; the chain of ossicles formed so solid a bridge between the membrana tympani and the vestibule, that considerable pressure on the handle of the malleus at the outer extremity of this bridge was requisite to produce the slightest movement of the chain. In the lower part of the tympanic cavity, a white deposit adhered to the surface of the bone, and was so closely incorporated with the fibromucous membrane, as to render it difficult to pronounce whether it was in the substance of, or below the membrane. The base of the stapes was somewhat expanded, and its circumference was perfectly anchylosed to the fenestra ovalis. This anchylosis was partly effected by the expansion of the bone of the stapes, and partly by the effusion or prolongation from it, especially at the posterior part,, of hard white matter. 20 306 THE DISEASES OF THE EAR. Left ear. —The meatus externus was contracted, presenting at its posterior part a bulging of bone, and at its inferior part being very narrow. The membrana tympani was opaque, and the chain of bones as rigid as in the right ear. The head of the malleus presented small nodosities, similar to those on the heads of other bones affected with rheumatic gout. The stapes was perfectly anchylosed to the fenestra ovalis by the expansion of its base, and by the presence of a large quantity of hard white matter which surrounded it. The cavity of the vestibule contained also a great deal of white matter, similar to that in the right tympanic cavity. In another case, somewhat analogous in its morbid condition to the foregoing, and in which the deafness and anchylosis were equally complete, the patient died with consumption under the care of Dr. Sibson, in St. Mary's Hospital, at the early age of 20, clearly showing that this affection is not necessarily an accompaniment of advancing years. Case II.—Mr. L. J., aged 90, in good health, except that he suffered from attacks of gout, often complicated with rheumatism. About the age of 40, he found a dulness of hearing gradually coming on, which as gradually increased, until, at the time I saw him, he could only hear the voice when loudly spoken to close to the head. This gentleman had no desire for any treatment to be pursued, and I merely diagnosed the affection from the history of the case, —its slow, insidious progress, the absence of all symptoms of nervous debility, and the attacks of gout with which the patient was troubled. My opinion, thus formed, was that the cause of the deafness was anchylosis of the stapes; an opinion that I expressed to his medical and other friends. He died, some years after my first seeing him, of gouty inflammation of the bladder, and the opportunity was afforded me of carefully dissecting both petrous bones. Bight ear. —Meatus externus. At the posterior and upper part there was a distinct, smooth, and rounded projection of the bone, which extends obliquely from without and below, inwards and upwards, and is continuous with the rough scabrous portion of bone which forms the lower part of the meatus externus at its orifice, and is quite distinct from the mastoid portion of the bone. This projection measures about three lines from above downwards. At the upper part of the meatus the bone is rough and hypertrophied. The membrana tympani was more concave externally, and much thicker and more opaque than natural. It was so rigid that pressure THE CAVITY QF THE TYMPANUM. 307 upon the outer surface of the malleus by means of a fine probe was not followed by any movement of the chain of bones. Upon laying open the tympanic cavity and pressing upon the stapes, this bone was found to be so compactly attached to the inner wall of the tympanum, that upon pressure there was not the slightest degree of movement. A broad membranous quadrilateral band entirely filled the space between the long process of the incus, the internal wall, the stapes, and the posterior wall of the tympanum. On laying open the vestibule, the base of the stapes was observed to be of a white calcareous aspect, and perfectly united to the circumference of the fenestra ovalis by calcareous matter. The membrane of the fenestra rotunda appeared to be healthy, except that it was, if anything, slightly thicker than natural. Left ear. —The meatus externus presented a bulging similar in shape and direction to that in the right ear, though somewhat larger. The membrana tympani was thicker and more rigid than natural, but not more concave externally than usual. The difference in the degree of concavity of this membrane in the two ears was so decided, that the inner surface of its central part, in the right ear, was onethird nearer to the inner wall of the tympanum than it was in the left ear. The stapes was firmly fixed, and its base, when the vestibule was opened, was found to be expanded and completely anchylosed to the fenestra ovalis. Case III.—Mr. T. L. J., aged 50, of a gouty diathesis, the son of the above patient, consulted me, in 1852, on account of gradually increasing deafness. When I saw him, he had to be loudly spoken to within the distance of a yard of the head. He stated that the deafness had come on very gradually without any pain or uneasy feeling in the ears, and that no relief was ever experienced except from taking long walks, and perspiring very copiously. On examination, the membrana tympani in each ear was somewhat opaque, and the Eustachian tube pervious; the air entering in a loud puff. The history of the case, and its similarity to that of the father, made me sure that the cause of deafness was anchylosis of the stapes. I laid down certain rules to be carried out, but on account of the sedentary nature of the patient's occupation, they could not be observed; attacks of gout became more frequent, and total deafness ensued. Case IV. —Mr. N. C, aged 60, a man of intemperate habits, gradually became deaf at the age of 24. The deafness slowly 308 THE DISEASES OF THE EAR. increased to the day of his death, which took place at the age of 60, from an attack of bronchitis. There was hereditary deafness in this gentleman's family, several sisters and brothers becoming slowly deaf about the same age as did this patient. For some time previous to his death, the patient's right ear was useless, but, by means of a trumpet, he could manage to hear loud conversation addressed to him in the left. Dissection of right ear. —(This dissection was made by Mr. A. Nopper, who kindly forwarded to me the specimen and his notes.) Membrana tympani more opaque than natural. Numerous transparent, membranous bands traverse the tympanic cavity. The ossicles were in a healthy state, with exception of the stapes, the crura of which had disappeared. 1 The fenestra ovalis was closed by the base of the stapes, which projected slightly into the cavity of the vestibule. In the vestibular cavity surrounding the fenestra ovalis, was a white mass of bone, which formed an annular protuberance around the interior two-thirds of the fenestra ovalis. Case V. Partial anchylosis of the stapes temporarily cured by the effect of a loud shout in the ear. —The Rev. L. D., aged between 50 and 60, saw me in the year 1856, but not on account of his deafness, for which he did not seek advice; I, however, was able to glean the following interesting details of his case. The general health of this gentleman was good, with the exception of attacks of indigestion and rheumatism, which caused him great inconvenience. In a letter to me, he says, "I have had rheumatism in the shoulder-joint, which I always walked off, the pain becoming much aggravated as I got warmer, but being always at last driven out. I suffered for some weeks, three winters ago, from extreme weakness in both anklejoints, so that I could scarcely go about my parish work. My friends assured me that it was the beginning of creeping paralysis, but I was sure that the stomach was the enemy. My work must be done, and I gradually walked my legs back into use." Deafness in the right ear appeared to have come on suddenly a few years before my seeing the patient, when the left ear was puzzled to know the direction of sounds. " I had no conception," he writes, " whence sounds came, until by degrees the left ear learnt to put sounds into their right places, or rather to settle the place of the cause of 1 It is probable that the crura of the stapes had been accidentally disconnected from the base in the act of dissecting the ear. THE CAVITY OF THE TYMPANUM. 309 sound." No treatment was adopted, and the patient for some years remained in the same condition, the left ear being useless, or nearly so, and the right remaining tolerably perfect. In the year 1856, while this gentleman was superintending his Sunday-school, he was called upon to seize a boy who was endeavoring to bite his teacher, when, to use the clergyman's own words, "he (the boy) sent such a yell into my right ear, that I heard not only the yell, but for some days I heard all other sounds most distinctly, when it, the hearing, again relapsed, and my left ear had again to learn its duties." From the history and examination of this case, I have no doubt that the affection consisted of rheumatic disease of the stapedio-vestibular articulation, and that the morbid condition was no other than that peculiar expansion of the base of the stapes so frequently adverted to. The effect of the loud scream was doubtless to release the stapes for a time, so as to allow of its movement by its muscles. It may here be added, that in another patient who was under my care for some time for deafness produced by rheumatism of the ears, an exactly opposite effect, viz., complete deafness, was temporarily produced by a sudden loud sound. This gentleman was quite deaf in one ear, but with the other heard a loud voice, when distinctly spoken at a short distance from him. In this condition he was subjected to the sudden shrill sound of bagpipes played in the hall where he sat, by which he was at once rendered too deaf to hear the human voice, and all communications to him were obliged to be in writing. This increased deafness lasted for several days, and then the ear recovered the hearing power it possessed previous to the accident. There appears to be great probability that in the latter case the cause of the increased deafness was, that the stapes were driven inwards and held tight by the fenestra ovalis, and that the return of the hearing power was due to the release of the stapes. (d.) DISCONNECTION OF THE INCUS AND STAPES. An affection of the ear directly opposite to rigidity of the chain of bones sometimes takes place, and this consists in the disconnection of the incus and stapes. I will preface my account of this affection by making some physiological observations bearing on the subject. Physiological Observations. —The opinion usually entertained is, 310 THE DISEASES OF THE EAR. that two channels are requisite for the transmission of sonorous undulations to the labyrinth from the membrana tympani; one channel being the air in the tympanic cavity, which conducts the undulations to the membrane of the fenestra rotunda and the cochlea; the other channel being the chain of ossicles, which conducts the undulations to the vestibule. That this opinion is not universally received is apparent from the following quotation from an authority highly deserving of attention, Mr. Wharton Jones. He says: "Some physiologists assert that the sonorous undulations are communicated from the membrana tympani to the ossicles, and through them conducted to the vestibular fenestra; others suppose the undulations to be propagated merely through the air in the cavity of the tympanum, to the membrane of the fenestra rotunda; the ossicles and their muscles serving the purpose of regulating the tension of the membrana tympani, the membrane of the vestibular fenestra, together with the membranous labyrinth. A combination of the two views is most generally received. However well founded the view may be that sound is propagated through the chain of small bones, the circumstance that some degree of hearing may persist along with loss partial or complete of the membrana tympani, and of the malleus and incus, is a conclusive proof that sound may be conveyed through the fenestra to the labyrinth, by the vibrations of the air in the tympanum alone. It would appear, also, that the integrity of one fenestra may suffice for the exercise of hearing." 1 Mr. Brooke, whose views on questions of experimental science are worthy of the fullest consideration, has published his reasons for believing that it is not possible for the sonorous undulations to be conducted to the labyrinth by the chain of bones. He says: "The transmission of sound cannot take place through the ossicula, as it was formerly supposed, inasmuch as the plane in which the crura of the stapes lie, is exactly perpendicular to the plane passing through the manubrium of the malleus and long leg of the incus; and consequently, the vibrations passing through them would be almost entirely intercepted by the stapes. And, moreover, it appears essential that the transmission of vibrations through the chain of ossicula should be prevented; for as the velocity with which sound is transmitted through solids, such as bone, so very far ex- 1 Cyclopsedia of Surgery. Article, "Diseases of Ear and Hearing," p. 23. THE CAVITY OF THE TYMPANUM. 311 ceeds the velocity in air, if the same undulations reach the labyrinth through this channel, and through the channel previously described (the air in the tympanum), they would reach in different times, and constant interference would be produced." 1 Although Mr. Brooke has thus confidently expressed his opinion that " the transmission of sound cannot take place through the ossicula," his statement, unsupported by experiments and observations, does not seem to have induced writers on the physiology of the ear to adopt his conclusions. Thus Dr. Carpenter, in the latest edition of his Human Physiology, having referred to Mr. Brooke's paper, says:—"From what has been stated it is evident that sonorous undulations in the air will be propagated to the fluid contained in the labyrinth through the tympanum, the chain of bones, and the membrane of the fenestra ovalis to which the stapes is attached without any loss, but rather an increase of intensity." 2 Indeed, with a consciousness of the wonderful accuracy of M. Savart's experiments in acoustics, it appears impossible, without further experiment, to disbelieve the assertion he made in the following quotation from his writings:—"Les vibrations de la membrane se communiquent sans alteration au labyrinthe par le moyen des osselets, comme les vibrations de la table superieure d'un instrument communiquent h la table infdrieure par le moyen de l'ame." 3 But supposing with Savart, that under ordinary circumstances sonorous undulations are conducted to the labyrinth by the chain of ossicles, is it also possible, under certain conditions, for the function of hearing to be carried on without the aid of these bones ? Mr. "Wharton Jones has answered this question in the affirmative, as he says, that " the integrity of one fenestra may suffice for the exercise of hearing;" and Sir J. Herschel inclines to the same opinion. He says: " These bones form a kind of chain, and no doubt vibrations excited in the tympanum by vibrating air, as in the experiments above detailed, are somehow or other propagated forward through these; but they are so far from being essential to hearing, that when the tympanum is destroyed, and the chain in consequence hangs loose, deafness does not follow." 4 1 Report of a Lecture delivered at the Royal Institution ; Lancet, 1843, p. 380. 2 Page 733. „ 3 Recherches sur les Usages de la Membrane du Tympan, et de 1'Oreille externe. Journal de Physiologie. Par F. Majendie. Tome iv. p. 219. * Encyclopaedia Metropolitana. Article, "Sound," p. 810. 312 THE DISEASES OF THE EAR. My object at present is to attempt to ascertain, — Firstly, whether sonorous undulations from the external meatus can reach the labyrinth without the agency of the ossicles; and, Secondly, whether the chain of ossicles can conduct sonorous undulations to the labyrinth. Firstly. Can sonorous undulations reach the labyrinth from the external meatus without the agency of the ossicles f There can, I think, be no doubt but that the malleus and incus, and even the crura of the stapes, can be removed without the production of any very serious detriment to the hearing, but there is no well-authenticated case in which the base of the stapes has been removed in which total deafness did not ensue, but this deafness must doubtless be attributed to the removal of the fluid of the labyrinth at the time the stapes was withdrawn. But what is the effect of a fixed condition of the base of the stapes ? Now it happens that bony anchylosis of the base of the stapes to the margin of the fenestra ovalis is by no means a rare morbid condition, and I have had several opportunities of seeing patients with this affection during life, watching their symptoms, and subsequently dissecting the organ. The result of my observations is to demonstrate that simple bony coalescence of the base of the stapes to the wall of the vestibule is productive of so high a degree of deafness, that the sonorous undulations could reach the nerve only by passing through the walls of the cranium; and this statement accords with that of Dr. Pappenheim, who found merely " some degree of hearing" in a similar case. It may possibly be argued that the deafness occurring in cases of anchylosis of the stapes to the fenestra ovalis, maybe accounted for by the fixed condition of the membrana fenestras rotundas which necessarily results* but I think it is palpable that the mere incapacity of this membrane to alter its state of tension would not be sufficient to account for the high degree of deafness to sounds (acute equally with the bass) which characterized the whole of the cases that have fallen under my observation. It may however be asked, is it not possible for sonorous undulations to reach the labyrinth without the aid of the stapes, since the function of hearing is but slightly impeded by the removal of the incus, and when consequently no vibrations can reach the stapes, except through the air in the tympanum? It seems indeed to have been assumed, that when the stapes is thus detached from the incus, it cannot receive vibrations from the air externally 313 THE CAVITY OF THE TYMPANUM. and conduct them to the vestibule; what grounds there exist for this conclusion will be seen from the following experiments. That solid bodies are capable of being thrown into a state of vibration by the agency of sonorous vibrations existing in, and communicated by, the air, is a fact too well known to require demonstration ; but the following experiments show how far the solid stapes, when isolated from the incus, may possibly receive vibrations from the air and conduct them to the labyrinth. Experiment. —The ears having been closed, a piece of wood, five inches long and half an inch in diameter, was held between the teeth, and a vibrating tuning-fork, C, having been brought within the eighth of an inch of its free extremity, was distinctly heard, and it continued to be heard for between five and six seconds. Experiment. —One end of the piece of wood used in the previous experiment being pressed gently against the outer surface of the tragus, so as just to close the meatus, a vibrating tuning-fork C, placed within a quarter of an inch from the free extremity, was heard very distinctly at first, and it did not cease to be heard for fifteen seconds. Experiment. —Three portions of wood, having the same length and thickness as those used in the above experiments, were glued together so as to form a triangle having somewhat the shape of the stapes. The base of this triangle being placed against the outer surface of the tragus so as to close the meatus, the tuning-fork, C, vibrating within a quarter of an inch from the free apex, was heard for twelve seconds. From the above observations and experiments, I think it may be reasonably inferred that the stapes, even when detached from the ossicles, if free to move in the fenestra ovalis, will receive sonorous undulations from the air in the tympanic cavity, and will conduct them to the labyrinth? and that there is no evidence that sonorous undulations can reach the labyrinth from the external meatus without the agency of at least one of the ossicles, viz., the stapes. I shall proceed to inquire, in the second place, whether the chain of ossicles can conduct sonorous undulations to the labyrinth. In this second part of the inquiry, I shall endeavor to determine, 1 The result of these experiments accords with the fact I have observed, viz., that an amount of hearing so efficient that the patient was not supposed to be deaf, or to have deficiency of hearing power, has been found to coexist with isolation, apparently congenital,, of the stapes from the incus. 314 THE DISEASES OF THE EAR. a. How far the sonorous undulations excited in the membrana tympani are intercepted in the chain of ossicles by the " plane in which the crura of the stapes lie, being exactly perpendicular to the plane passing through the manubrium of the malleus and the long leg of the incus;" and b. To what extent the articulations of the chain of bones impede the passage of these undulations. (a.) To what extent are these vibrations, excited in the membrana tympani, arrested by the variation in the plane of the chain of ossicles. After M. Savart's conclusive experiments, repeated and verified by so many subsequent observers, it is needless for me to point out how freely sonorous undulations excited in the air. are communicated to a membrane like that forming the membrana tympani; nor how fully they are conducted from a stretched membrane, like the membrana tympani, to a solid attached to this membrane like the malleus, and free to oscillate. Assuming, therefore, that the vibrations reach the malleus, I will proceed to examine how far they are conducted through it and the other ossicles. Experiment. —Three pieces of wood, each five inches in length and half an inch thick, were glued together so as to represent the planes of the three bones of the ear; while three other portions were glued together end to end, forming a straight rod. A watch was placed at one end of the straight rod, while the other end was applied against the tragus of the ear, which it pressed firmly inwards so as to close the meatus completely and to exclude sounds from entering the ear by it. The result was, that the watch was heard nearly as distinctly as when it was placed in contact with the ear. When a similar experiment was performed with the angular piece of wood representing the chain of bones, the watch was still heard, but less distinctly. Experiment. —A tuning-fork, C, being made to vibrate, was placed in contact with one extremity of the angular piece of wood, the other being placed against the tragus of the ear; and when the straight portion was similarly used, it was found, as in the former experiment, that the sound was decidedly less loud when heard through the angular than through the straight portion; and after the sound had altogether ceased to be heard through the angular portion, the same tuning-fork was heard for about three seconds, when the straight piece was substituted. Finding that there existed some little difficulty in exercising the 315 THE CAVITY OF THE TYMPANUM. same amount of pressure on the tragus of the ear in each experiment, and considering that a variation in the amount of pressure might cause the air in the meatus to assume different degrees of density, I had recourse to the teeth as a medium for the transmission of the sound. I found that a solid placed in contact with the teeth of the lower jaw conducted vibrations with rather greater facility than when in contact with those of the upper jaw, and I therefore adopted the plan of holding the conducting body between the teeth. Experiment. —A tuning-fork, C, was placed at one extremity of the angular piece of wood, the other extremity being held between the teeth; the fork was at first heard very distinctly, and when this sound could no longer be distinguished, the straight piece was substituted, and it was again heard for the space of two seconds. Experiment. —Instead of the horizontal portion of wood representing the stapes, three portions of the same size were made into a triangle, and this was glued to the anterior surface of the inferior extremity of the piece representing the incus; the last experiment was repeated, with the substitution of this apparatus for the angular portion, and with very nearly the same result, viz., the fork was heard through the straight piece about three seconds after it had ceased to be heard by the apparatus representing the chain of bones. Experiment. —A piece of iron wire eighteen inches long and about two lines in diameter, was bent so as to represent the different planes of the chain of ossicles of the human ear; the tuning-fork, Q r , was placed at one extremity, while the other was held between the teeth. The sound was heard very distinctly at first, and when it ceased to be heard, a straight portion of the same length was substituted, through which the tuning-fork was heard for three seconds. Experiments. —A piece of very thin paper was gummed over one end of a glass tube three inches in diameter. To the outer surface of this paper a model of the ossicula, similar to the one used in a previous experiment, was glued. A vibrating tuning-fork, C, being placed in the interior of the tube and within a quarter of an inch of the paper, the end of the chain representing the base of the stapes was placed between the teeth; the sound was heard distinctly, and it continued to be heard for ten seconds. The sound of the tuning-fork, was heard for twenty seconds. The results of these experiments appear to indicate that the passage of sonorous undulations is somewhat, but only slightly, impeded by the variation of the plane in which the ossicles are placed. 316 THE DISEASES OF THE EAR. I proceed, secondly, to consider the effect of the articulations between the ossicles, upon the passage of sonorous undulations through them. The articulating surfaces of the small bones of the ear are usually described as being incrusted by cartilage, which is covered with synovial membrane. Professor Kolliker, speaking of these bones, says, "Their articulations and ligaments resemble in miniature those of other similar organs in all respects, even down to the cartilaginous layer, consisting of scarcely more than a single stratum." 1 Before proceeding with the inquiry concerning the passage of sonorous undulations through the chain of bones, it is desirable to consider carefully the structure of their articulations. They may be considered as four in number, viz.:— 1. The malleo-incudal. 2. The inco-orbicular. 3. The orbiculo-stapedial. 4. The stapedio-vestibular. (1.) The malleo-incudal articulation. The convex surface on the lower and posterior part of the head of the malleus is received into the concavity on the anterior part of the body of the incus; when applied together, as they are retained by their ligaments in a natural state, the surfaces of these two bones appear to be in close contact. Upon examining the articulating surfaces of the malleus and incus in a recent specimen, by means of a lens magnifying five or six diameters, no appearance of cartilage can be detected; and when touched with a fine probe, the surface is felt to be hard, as if no membrane were present. If, however, these articulating surfaces be scraped with a small scalpel, fine pieces of transparent membrane are removed. Examined by the microscope, this membrane, in some parts, is seen to be homogeneous, having no appearance either of fibres or cells; in other portions, delicate fibres can be detected, while here and there a single layer of cartilage cells can be distinctly recognized. As a general rule, more cartilage cells are to be found in the membrane removed from the incus than in that from the malleus. 1 Manual of Human Histology. By Busk and Huxley. Vol. ii. p. 404. 317 THE CAVITY OF THE TYMPANUM. (2.) The inco-orbicular articulation. The orbicular bone is sometimes described as a process of the incus. Careful examination of recent specimens shows, however, that the orbicular bone is connected to the incus by firm fibrous tissue. (3.) TJie orbiculo-stapedial articulation. The orbicular bone, on its surface towards the stapes, presents a slightly convex head, which is received into the superficial concavity on the head of the stapes. This convex surface of the orbicular bone is covered by a membrane, in which I have not been able to detect any cartilage cells. The outer extremity of the stapes is covered by a saucer-shaped cushion, soft to the touch; and upon examination by the microscope, it is seen to be a disk of fibro-cartilage, being a representation in miniature of those existing between the bodies of the vertebrae, the circumference being composed of fibres arranged concentrically around cartilage cells which occupy the central position. (4.) Tlxe stapedio-vestibular articulation is formed by the circumference of the base of the stapes, which is applied against the inner surface of the fenestra ovalis; the stapes, as I have shown, being moved by muscles to and fro in the fenestra ovalis, as a piston moves in a cylinder. I have not been able to detect any cartilage on the surface of either the base of the stapes or of the fenestra ovalis, a very fine membrane alone being discernible. The articulating surfaces forming the several articulations are connected together by very delicate capsular ligaments., The next step of my inquiry was to ascertain by experiment how far these articulations tend to impede the passage of sonorous undulations through the chain of ossicles. As in the former experiments, these tympanic ossicles were represented by portions of wood; while the cartilage and synovial membrane were represented by layers of vulcanized india-rubber. 318 THE DISEASES OF THE EAR. Experiment. —Three pieces of wood, each about five inches long and half an inch in thickness, were separated from each other by a piece of vulcanized india-rubber about as thick as ordinary writingpaper; they were held together by means of elastic bands, and so as to assume the angular form possessed by the chain. The tuningfork placed at the distal extremity of the chain, the other end being placed in the mouth, it was found that the sound was heard as distinctly, and for the same length of time, as when it passed through the chain formed of the three portions glued together. Experiment. —A similar result took place when two layers of india-rubber were placed between each piece of wood. Experiment. —When eight layers of the india-rubber were placed between each piece of wood, there was still very little difference in the intensity of the sound when it passed through these, and when it passed through the portions glued together. Experiment. —One, two, or three fingers being placed between the first and second pieces of wood, and eight layers of india-rubber between the second and third, a very slight diminution in the intensity and duration of the sound was observed as compared with its passage through the pieces glued together, it being requisite that the fingers be pressed tolerably firm against the wood. Experiment. —If the back of the hand be placed against the teeth, and the end of the vibrating tuning-fork be pressed against the palm, the sound is heard very distinctly for several seconds; and when it has ceased to be heard, if a piece of solid wood three inches long be substituted for the hand, faint vibrations are again heard, but for about four seconds only. Considering the extreme tenuity of the layers of cartilage and synovial membrane which are interposed between the ossicula auditus, and the very slight influence in arresting the passage of the sonorous undulations produced by layers of india-rubber, the inference is that the articulations between the bones forming the chain in the human ear, impede very slightly, if at all, the passage of vibrations from the membrana tympani to the labyrinth. The experiments and observations detailed above lead to the following conclusions:— First. —That the commonly-received opinion in favor of the sonorous undulations passing to the labyrinth through the chain of ossicles in the human ear is correct. Second. —That the stapes, when disconnected from the incus, can THE CAVITY OF THE TYMPANUM. 319 conduct sonorous undulations from the tympanic cavity to the vestibule. Third.—So far as our present experience extends, it appears that in the human ear sound always travels to the labyrinth through two media, viz., the air in the tympanic cavity to the cochlea, and one or more of the ossicles to the vestibule. After a detail of the above results, it will readily be assumed that a simple disconnection of the incus from the stapes is not productive of any large amount of dulness of hearing. In the course of my dissections I have met with eight cases in which the incus was disconnected from the stapes, and in no instance could I trace deafness specially to this cause. Some of the patients from whom the dissections were taken were undoubtedly deaf, but their deafness could be assigned to other causes than the existence of the solution of continuity in the chain of bones. One of the patients in whom it occurred was not detected by the surgeon to be deaf; but this might arise from the fact that the lesion existed in one ear only. From some researches I have made on the subject, it appears probable that the cause of this peculiar lesion is hypertrophy of the mucous membrane of the tympanum; in cases of this disease, the supply of blood to the substance of the incus being interfered with. It is important to recognize the existence of this disease, and to do all that is possible to avert it by subduing any thickening of the tympanic mucous membrane, but it remains for future investigations to decide to what extent this lesion interferes with the hearing power. Case I.—A man, set. 19 ; deaf in the left ear; died of apoplexy. In this ear the membrana tympani contained calcareous matter. The mucous membrane of the tympanum was very thick. The extremity of both long and short process of the incus had disappeared, and the surface of the adjacent bone was rough. Case II.—A man, set. 67. Bight ear. —The inferior extremity of the long process of the incus has been absorbed, and the os orbiculare is attached to the stapes. On the inner surface of the head and long process of the incus are numerous orifices which lead into the interior of the bone, giving it a worm-eaten appearance. Case III.—A boy, set. 5; died from scarlatina, and was not known to be deaf. Right ear in a normal state. Left ear. —The os orbiculare is separated from the incus, and is attached to the stapes; the stapes is fixed to the fenestra ovalis more firmly than natural. 320 THE DISEASES OF THE EAR. The tympanic cavity contained mucus; lymph was also effused, and bands of adhesion between the membrana tympani and the inner wall of the tympanum were in process of formation. The whole of the inner surface of the long process of the incus presented a wormeaten appearance, and its lower extremity has disappeared, apparently from absorption. The os orbiculare is attached to the neck of the stapes, the part usually attached to the incus being free and rough, and projecting somewhat from the neck of the stapes. Case IY. A boy, set. 3J years; died from dysentery; he was not ascertained to be deaf. Right ear. —The incus on the inner surface of its long process presented numerous foramina, and the orbicular process was partly absorbed, only a small rough portion of it remaining attached to the incus—the inner surface of the extremity of the process being hollowed out, and having sharp margins. Left ear. —The incus is in the same state as that of the right ear, and the larger part of the orbicular process is attached to the stapes. CHAPTER XIV. THE MASTOID CELLS. ANATOMICAL OBSERVATIONS ! a, DISEASES OF THE MASTOID CELLS IN CHILDHOOD — CASES OF THE DISEASE ADVANCING TO THE BONE AND THE CEREBRUM. b, DISEASES OF THE MASTOID CELLS IN THE ADULT —ACUTE INFLAMMATION OF THE MUCOUS MEMBRAN —CHRONIC INFLAMMATION OF THE MUCOUS MEMBRANE —PURULENT INFECTION —SYMPTOMS OF REMITTENT FEVER—CARIES OF THE LATERAL SULCUS —ABSCESS IN THE CEREBELLUM. C, NECROSIS OF THE MASTOID PROCESS —PARALYSIS OF THE PORTIO DURA NERVE—TREATMENT —OPINION RESPECTING LIFE-INSURANCE IN CASES OF DISCHARGE FROM THE EAR. As regards their functions, the mastoid cells may be considered merely in the light of an appendage to the tympanic cavity; but their peculiar conformation and intimate relations with the lateral sinus render a special study of their diseases necessary, previous to entering on which it is, however, important thoroughly to understand their anatomical relations. Anatomical Observations. —Like the mastoid process, the mastoid cells vary much in size in different individuals. In some persons they occupy the whole of the interior of the bone behind the meatus externus for the distance of an inch and a half; their vertical diameter is two inches, and they extend inwards as far as the fossa jugularis; in other cases the mastoid process is almost solid, and the cells communicating with it are small and few in number. The mastoid cells may be considered as consisting of two portions; one contained in the mastoid process, where the cells have more or less of a vertical arrangement, the other situated between the mastoid process and the tympanic cavity: this latter portion is generally horizontal and frequently presents a concavity at its floor, in which mucus or other secretions are apt to lodge. On the inner surface of the mastoid process is the sulcus lateralis, which is occupied by the lateral sinus. Numerous orifices exist in this sulcus for the passage of veins from the mastoid cells to the lateral sinus, which is generally 21 322 THE DISEASES OF THE EAR. the part first affected in disease of the mastoid cells occurring in the adult. These cells are bounded anteriorly by part of the posterior wall of the meatus. At birth and during early life, the mastoid process is in a rudimentary state, and the only representative of the mastoid cells is the horizontal portion which is adjacent to the tympanic cavity; the extension of which backwards and downwards, in later periods, forms the cavity of the mastoid process. It is essential that the relations of this horizontal portion of the mastoid cells in the earlier periods of life should be well understood, since disease occurring in it then produces entirely different results from those of a later period. If a vertical section be made so as to pass through this horizontal portion in the temporal bone of a child about two years of age, these mastoid cells will be observed to be bounded externally by a part of the squamous bone, which is superior and Fig. 94. The External Surface of the Temporal Bone of a child. The outer wall of the horizontal portion of the cells has been removed, and the cavity of this portion of the cells above the Mastoid Process is exposed. slightly posterior to the meatus externus; and it is this particular part which becomes affected in cases of disease of the mastoid cells in early life. The upper wall of the horizontal portion of the mastoid cells is formed by a layer of bone, continuous with that of the upper wall of the tympanum. This lamina partakes of the disease of the cavity, and thus the dura mater and cerebellum become liable to'be affected when, in early life, disease occurs in the mastoid cells. Before the second year this cellular cavity is comparatively much larger than at a later period. THE MASTOID CELLS. 323 The diseases of the mastoid cells in the child will be first described, and afterwards those in the adult. Fig. 95. A Vertical Section of the Temporal Bone of a child through the horizontal portion of the Mastoid Cells. It is seen to be bounded externally by the layer of bone, which has been removed in the preceding cut, and which usually becomes carious in cases of disease in the horizontal portion of the cells in early life. (a.) DISEASES OF THE MASTOID CELLS IN CHILDHOOD. The most frequent causes of disease in the mastoid cells, as in the tympanum, at this period, are scarlet fever, measles, small-pox, and scrofulous affections. In the three former of these affections; the mucous membrane is usually the subject of chronic catarrh, becomes hypertrophied, and mucus collects in the cells. In the undeveloped state of the mastoid process in childhood, the mucus collects in the horizontal portion, bounded externally, as already described, by the squamous bone, and above by the continuation of the lamina forming the upper tympanic wall. Hence it is evident that the portions of bone liable to be affected by disease in the mastoid cells of the child, are the squamous bone immediately above and behind the external meatus, and the posterior part of the upper wall of the tympanum. Dissection shows also that these two parts are in fact those which do become affected, and that in cases of disease attacking the mastoid cells in early life, the cerebrum is the 324 THE DISEASES OF THE EAR. part of the brain which suffers, while, as we shall see in later periods of life, the cerebellum becomes affected. In disease of this part the discharge from the affected ear often dates from birth, and is generally at first unaccompanied by any pain; so that too often (especially among working people) no notice whatever is taken of it. In its earlier stages the discharge appears to be purely sympathetic, and, as in many other cases of irritation of the tympanic mucous membrane, it proceeds from the meatus and the outer surface of the membrana tympani. As the disease progresses, the tympanum becomes filled by mucus or scrofulous matter, and the membrana tympani yields to the pressure on its inner surface ; and no doubt in some cases, if a thorough outlet be thus made for the discharge from the mastoid cells, while the health of the patient at the same time improves, no further mischief accrues; but unfortunately the peculiar conformation of this part of the mastoid cells usually prevents the free escape of the matter; part of it, at least, remains lodged in its concavity, or the whole is barred from exit by the closure of the tympanic cavity through the hypertrophy of the lining mucous membrane. In all fatal cases the discharge has been deprived of a free egress. One of the peculiar features of the disease is, that it sometimes causes death, by producing general cerebral irritation 'rather than inflammation. In the first two cases' which follow, there was no appearance of disease in the brain, pia mater, or arachnoid; in the third case these parts were but slightly affected in comparison with the large amount of disease in the ear. Case I. Scrofulous disease of the horizontal portion of the mastoid cells before the first year of life; caries of the squamous bone ; disease of the dura mater. —J. R, aged thirteen months, was admitted under my care as an out-patient, at St. Mary's Hospital, on the 12th February, 1852. Although she had a good color and was not thin, her mother stated, that since her birth she had never been strong, and that she had been brought up by hand, on account of herself (the mother) having an abscess in one breast. The history was, that at six y_ears_old a discharge was observed to flow from the right ear, which had continued to the present time with but short intermission's. Three weeks ago an abscess formed at the back of the ear and discharged into the meatus. On inspection, the surface of 1 A somewhat analogous case has been cited as having occurred to Dr. Chambers. THE MASTOID CELLS. 325 the meatus was seen to be red, and its substance so much tumefied as to prevent its being ascertained whether the membrana tympani was or was not present. The discharge consisted of pus and mucus. The abscess behind the ear communicated with the meatus by an aperture at its posterior part. The ear was ordered to be syringed with warm water. February 19th.—Symptoms much the same, but the discharge more offensive. Until the 1st of April the symptoms gradually subsided, the discharge diminished, and the child appeared stronger. On the 2d, however, the discharge grew more offensive, and less in quantity. On the 8th the child cried, as if in pain, and started in her sleep. April 15th.—Leeches afforded some relief, and were ordered to be continued. 19th.—Has had shivering fits to-day. From this date the headsymptoms gradually increased; the respiration became difficult, and the child died in convulsions on the 29th. Autopsy. —The part of the sterno-mastoid muscle attached to the mastoid process was discolored. The membranous meatus was much thickened, and of a dark purple color. The posterior part of the osseous meatus was carious; and the bone continuous with and above it, for a space the size of a sixpenny-piece, was also carious; this being the portion of bone which bounds externally the horizontal mastoid space. The periosteum covering this carious bone is thick and soft in some parts, and ulcerated in others. There is also internally a portion of necrosed bone about one-half the size of that externally; and upon a section the inner surface is found to be part of the necrosed portion of bone which is seen externally, where it covers the tympanic cavity and extends above it. The outer surface of the dura mater which is in contact with the dead bone, is soft, spongy, and of a dark color, and partly filled the superficial cavity formed by the necrosed bone: in immediate contact with that bone, however, was a soft pulpy tissue. The membrana tympani was absent, the mucous membrane of the tympanum ulcerated, and the ossicles carious. The lungs were tuberculous, the mesenteric glands large, containing also scrofulous matter. The following case is very analogous to the one just reported. Case II. Scrofulous disease in the horizontal portion of the mastoid cells in the first year of life; caries of squamous hone and disease of dura mater. —E. B., aged sixteen months, subject to scro- 326 THE DISEASES OF THE EAR. fulous glands, was admitted under my care at the St. George's and St. James's Dispensary, in November, 1849. When seen, there was a large abscess behind the left ear and discharge from the Fig. 96 The External Surface of the Temporal Bone, showing the irregular-shaped carious portion of Bone above the Meatus. meatus. The membrana tympani was absent, the mucous membrane of the tympanum thick and red. At the bottom of an abscess behind the ear, dead bone could be felt. Her mother stated that there was discharge from the right ear at the age of three months, which lasted six or seven weeks, and then disappeared. When five months old, discharge took place from the left ear, and after continuing for a month, a swelling appeared at the back of the ear, which was opened and continued discharging, as well as the meatus, to the time I saw the patient. Soon after seeing her, the symptoms of cerebral irritation, which had shown themselves at times in the form of great pain in the left side of the head, rapidly increased; and in face of all the remedial measures employed, death ensued in a few days. Autopsy. —On slitting open the abscess at the back of the ear, the bone above and posterior to the meatus externus, over the space of a sixpence, was denuded, and was rough, black, and soft: the external table had been removed. On making a vertical section of the bone through the horizontal portion of the cells, the walls of the latter were observed in a state of disease, and the cavity contained purulent matter. The outer wall of this portion of the cells 327 THE MASTOID CELLS. was carious throughout. The membranus meatus was softer than natural. The membrana tympani had been entirely removed by ulceration, as also parts of the,tympanic mucous membrane; the Fig. 97. A Vertical Section of the Diseased Bone. The walls of the horizontal mastoid cavity are diseased ; the upper wall forming part of the cerebral cavity, and continuous with the external wall, is carious ; the entire substance of the external wall is dead. small portions remaining being thick, soft, and of a livid color. The long process of the malleus had disappeared, and the remnant was partially disconnected from the incus, as was the incus from the stapes. The inner surface of the carious bone is of a dark color, and is itself carious, presenting numerous small depressions. The thick, soft, and red dura mater was separated from the carious bone by a transparent fluid. On examining the right ear, the same disease appeared, but in an incipient state; the meatus was soft and red; the membrana tympani thick, white, and concave; the mucous membrane lining the tympanum and mastoid cells was thick and red; and there was a collection of mucus. Another case, which occurred under the care of Mr. H. J. Johnson, when assistant-surgeon to St. George's Hospital, is as nearly as possible a counterpart of the one just cited; and the specimen for which I am indebted to that gentleman, is almost a fac-simile of the preceding one. Disease sometimes extends upwards and outwards, and destroys nearly the whole of the squamous portion. A case of this kind was brought under my notice by Mr. Willing, of Hampstead. The following are the particulars furnished by him. 328 THE DISEASES OF THE EAR. Case III. Scrofulous disease in the horizontal portion of the mastoid cells before the first year; destruction of a large part of the squamous bone by caries; disease of the dura mater; a small abscess in the cerebrum. —M. A. W., aged 11 months, the youngest of three children; the other two were healthy. The parents are in bad circumstances; the mother very emaciated, having during her pregnancy had very insufficient food, owing to her husband, a bricklayer's laborer, being out of work for a long time. The child was first seen by Mr. Willing in June, 1850, and was then three months old, small and much atrophied. The mother said it was small when born; and as she had no milk, she endeavored to bring it up by hand. There had been, she added, a discharge from the right ear since birth. On examination, a redness and tumefaction both of the meatus and ear were observed, with evident tenderness on pressure of the mastoid process, and the cervical glands were enlarged. The child suffered under diarrhoea, and was extremely weak. Codliver oil was administered, and emollients applied to the ear, which was syringed daily with warm water. Under this treatment, the child somewhat improved until October, when paralysis occurred on the left side of the face. The discharge grew more abundant, the soft parts around the ear became sloughy, and the mastoid process offered no resistance to pressure. These symptoms lasted till the death of the child in February. Autopsy, thirty-two hours after death. —The body was so much emaciated as to be scarcely larger than at birth. The dura mater was very thin, and the surface of the brain greatly congested, with patches of dark-colored blood scattered over its hemispheres, especially on the right side, where, in one or two places, they extended to the depth of three or four lines into the substance of the brain. The cerebral veins were distended by coagula. At the surface of the posterior part of the middle lobe, on the right side, was a small abscess, the size of a pea. The ventricles contained about three ounces of thick, turbid serum. The middle cerebral arteries were distended by firm fibrin, and there were about four ounces of fluid at the base of the brain. The dura mater covering the petrous portion of the right temporal bone was separated from it by pus, and very much thickened. On examining the temporal bone, which Mr. Willing presented to me, I found that the part of the squamous portion between the root of the zygomatic process and the mastoid process had been entirely 329 THE MASTOID CELLS. destroyed; and that the larger part of the mastoid process had also disappeared, causing an aperture an inch in length, and threequarters of an inch in depth. The petrous bone was detached, and both its superior and posterior surfaces were carious. The small remaining portion of the mastoid cells contained scrofulous matter. In other cases the disease may advance to a very considerable extent, and then, supposing the health to improve, reparative efforts may be made. A highly interesting case of this kind was brought under my notice through the kindness of Mr. French, to whom I am indebted for the opportunity of making a careful dissection of the ear. The case derives additional interest from the fact that it was the subject of judicial proceedings, the exciting cause of the fatal symptoms being a blow on the head. Case IV. Catarrh of the mucous membrane of the horizontal portion of the mastoid cells in childhood; caries of the bdne ; partial reparation by deposit of new bone. Death following a blow on the head; abscess in cerebrum. —B. C, aged 12, previously in good health, was seen on the 3d of July, 1850, on account of violent pain in the head, chiefly in the left temporal region, accompanied by severe febrile symptoms. The day before she had received a violent blow on the head, during a scuffle; she was thrown down, her head struck against the door, and subsequently against the wall: a similar, but less severe assault, was repeated a few minutes afterwards. On examination, there was a fulness of outline, and a pufnness of the temporal muscle. The symptoms of cerebral irritation and fever rapidly increased; a large abscess formed beneath the temporal muscle; discharge issued from the ear; coma ensued; and death occurred twenty-two days after the injury. It could not be ascertained whether there was a history of discharge from the ear in earlier childhood. Autopsy. —The pericranium was found separated from the squamous bone by purulent matter; the dura mater lining the squamous bone, and covering the upper wall of the tympanum, was thicker than natural, and but slightly adherent to the bone; the arachnoid and a portion of cerebral matter were attached to this part of the dura mater. In the cavity of the middle cerebral lobe was an abscess containing four ounces of pus. The petrous bone was diseased. The membranous meatus was thicker than natural, and its free surface was smooth, presenting no signs of ulceration. The superior and posterior walls of the osseous meatus were rough, and 330 THE DISEASES OF THE EAE. this roughness was produced by a deposit of new bone, which was also found to extend on the outer surface of the squamous bone, above the meatus, for a space measuring half an inch in its vertical, and an inch in its antero-posterior diameter. The posterior twothirds of the membrana tympani were absent; the mucous membrane of the tympanum was healthy; but in the passage to the mastoid cells there was a collection of pus and scrofulous matter, which had not been freely discharged on account of the small size of the aperture leading into the tympanum, contracted as it was by the thick mucous membrane. The upper wall of the tympanum was in a diseased state; the surface next to the dura mater being composed of a very fine scale of dead bone, about six inches long by four broad, which was perforated by small orifices, and eaten away posteriorly in parts. Beneath this dead bone was a layer of new bone, which formed the upper wall of the tympanum, and was continued upwards and outwards on the inner surface of the squamous bone to its upper margin. The old bone underneath and adjacent to the new bone was worm-eaten, and had been the seat of the disease; it was about half an inch in breadth. There can be no doubt, from the examination of the specimen, that disease in the horizontal portion of the mastoid cells had commenced in early childhood; that, as in the cases previously cited, the squamous bone became diseased, the dura mater and the cerebrum being also affected, but not to such a degree as to endanger life. It would further appear, that as the bone was developed, new bone was deposited on each side of the diseased squamous bone, and extended into the meatus, which, it will be remembered, forms in the first few years of life part of the squamous bone; and it is possible that, in spite of the disease of the brain and dura mater, the patient might have lived many years, if no very active exciting cause had been brought into operation. At the same time, it is most probable that the blow on the head would not have caused death had there not been pre-existing disease; and in this view the Grand Jury concurred. The peculiar anatomical relations of the mastoid cells in childhood have now been pointed out: it has been shown, that in the first year of life the mastoid process is not developed, and consists merely of the horizontal portion, which is intimately connected with the cerebral cavity, to which, in childhood, disease is usually propagated rather than to the cavity of the cerebellum. Those cases of disease THE MASTOID CELLS. 331 in early life which have been hitherto described, must be, therefore, considered as exceptions to the rule previously laid down by me, — that affections of the mastoid cells produce disease in the cerebellum. (6.) DISEASES OF THE MASTOID CELLS IN THE ADULT. Subsequent to the second or third year of life, when the mastoid process is somewhat developed, it will be found that the layer of bone bounding the horizontal portion externally, attains to a thickness of three or four lines, and becomes extremely dense. Hence, after the first or second year of life, disease is scarcely ever observed to extend from the horizontal portion to the outer surface of the squamous bone; but as the cells are developed posteriorly, and contract intimate relations with the lateral sinus and the cerebellum, it is to these two parts that disease is communicated. Cases of disease in the mastoid cells may be divided into acute and chronic. I. Acute inflammation of the mucous membrane lining the mastoid cells. —This affection is somewhat rare, and when it does occur, is usually subdued before it progresses to the bone or dura mater. Cases, however, are occasionally met with in which acute inflammation of the mucous membrane lining the mastoid cells ends in suppuration, the lateral sinus becomes inflamed, and abscesses occur in the brain. The following is a case of the kind which occurred to Dr. Brinton, at the Eoyal Free Hospital, to whom I am indebted for the notes of the case, and for the opportunity of making the dissection. Case I. Acute inflammation of the mucous membrane lining the mastoid cells ; suppuration; disease of the lateral sinus; abscess in the cerebellum.—A girl, aged 21, was admitted into the hospital, three weeks subsequent to an attack of scarlet fever. The history was, that since the fever, she has had a constant and abundant discharge from the left ear. On admission, this discharge was observed to be copious; she was drowsy,-and at times almost comatose, with a rapid feeble pulse, a cold body and limbs, and a hot face and head. In spite of all the remedies employed, the coma gradually grew more intense, and she died ten days after her admission. Autopsy. —An abscess was found in the left lobe of the cerebellum, of the size of a walnut. It extended to the surface, and thus came 332 THE DISEASES OF THE EAR. in contact with a large quantity of pus, bounded by the diseased and distended walls of the lateral sinus, which latter contained pus and blood. There was an opening through the membrana tympani of a regular shape, and of a size one-third the whole diameter of the membrane. The upper wall of the tympanum was healthy, and not even discolored. The portion of the mastoid cells posterior to the incus contained some pus and blood mixed together; this extended down as far as the mastoid process. The portion of the lateral sulcus, about an inch long by half an inch broad, which forms the exterior boundary of this part of the mastoid cells, was of a dark leaden color. The canals in this portion of the bone were also distended with black matter. It seems to me, there can be no doubt that, in this case, the purulent matter from the mastoid cells was the cause of the disease in the lateral sinus, for the bloodvessels between the two parts were distended with dark pus and blood. II. Chronic inflammation of the mucous membrane lining the mastoid cells. —Cases of chronic disease of the mastoid cells usually take their origin before the adult period of life, although the more serious symptoms may not be developed until after that period. As in disease of the tympanum, the cases now under consideration commonly originate in chronic inflammation of the mucous membrane. Whatever may be the cause of this inflammation, —whether scarlet fever, measles, or an ordinary cold, —the result is the secretion of a larger quantity of mucus than is natural, which in the milder forms of the affection is afterwards absorbed, or else discharged through the tympanic cavity and Eustachian tube, into the cavity of the fauces; but in the more severe, to which attention has now to be directed, the mucous secretion is too abundant to escape from the cells, and the bone becomes affected. The effects of chronic disease in the mastoid cells upon the lateral sinus and cerebellum are:— 1st. Suppuration in the lateral sinus with or without secondary purulent deposits. 2d. Inflammation of the dura mater and arachnoid, and the formation of pus on the surface of the cerebellum. 3d. Abscess in the cerebellum. The history of cases of chronic disease in the mastoid cells bears some analogy to that of those occurring in the tympanic cavity, although, as a general rule, there is more irritation from the outset of THE MASTOID CELLS. 333 the affection, and consequently attention is attracted to the case in its early stages; and this is the reason, as will be seen when the treatment is spoken of, why the disease is more amenable to remedial measures than when it attacks the tympanum. The following may be taken as the ordinary history of a case of disease advancing from the mastoid process to the lateral sinus or cerebellum. The patient, who has often a tendency to glandular enlargements, has suffered when a child from pain in the ear, followed by discharge. During childhood, and perhaps up to adult age, there have occurred attacks of pain and discharge at intervals of some months. Between the attacks there is often a sensation of pain in the region of the mastoid process and back of the head, and giddiness sometimes comes on. These symptoms are aggravated by fatigue or any other depressing influence. Upon examination, the surface of the meatus is seen to be red, and to be the source of the discharge. No perforation exists in the membrana tympani, which, however, is white and thickened, so that the discharge is purely sympathetic. The surgeon is more commonly called, however, to cases where the symptoms have become much more urgent, and where, indeed, the disease has advanced so far that the brain or its membranes have become so greatly disorganized as to defy all remedial measures. Cases of disease in the mastoid cells terminate fatally from two different causes. 1st. From purulent infection, arising from the introduction of pus into the circulation through the lateral sinus. 2d. From disease of the cerebellum or its membranes. Cases of purulent infection have not been met with when the disease occurs in the tympanic cavity. On account of the proximity of the jugular vein to the lower wall of the tympanum, it is, however, quite possible for disease to extend to the venous system. Dr. Abercrombie published an interesting case of purulent infection from disease of the ear; but the subject has been more thoroughly investigated by Dr. Watson, who, although deprived of the opportunity of making post-mortem inspections of the highly important cases he has so fully described, had no doubt in his mind, and leaves no doubt in the minds of his readers, that the cause of death was the introduction of pus into the system from the mastoid cells. Dr. Bruce has since published some valuable cases bearing upon the subject; Mr. Wilde gives the details of a case in his work on the ear; and more recently still, Dr. Gull, in the Guy's Hospital 334 THE DISEASES OF THE EAR. Reports, has thrown much light on the subject. The facts brought forward by these gentlemen, coupled with those which are now to be related as the result of my own experience, will, I trust, lead to a thorough comprehension of the nature and progress of the disease. Dr. Abercrombie's case is the following:— Disease of the mastoid cells; deposit in the lateral sinus; secondary deposit in the pleura. —A young lady, aged 15, had been liable for six or seven years to attacks of pain in the right ear, followed by discharge of matter; but she had been free from any of these attacks for some time previous to the abscess which forms the subject of the following history. On the 25th April, 1822, she complained of cold shivering through the day, and in the evening had headache with pain in the right ear, symptoms which continued on the following day. On the 28th she was seen by Mr. Brown, who found her with quick pulse and foul tongue, severe pain in the ear, and slight headache. On the 29th some discharge took place from the ear, but without relieving the pain which continued with violence until the next day. On the 1st of May, the pain had somewhat abated in the ear, but had extended over the right side of the head; pulse frequent. General and local bloodletting were employed with partial relief. I saw her on the 3d; the headache was then rather abated; the pulse was frequent and weak; she had a pale, unhealthy aspect, and a look of oppression bordering upon coma. The pain was chiefly referred to the parts above and behind the right ear, where the integuments were painful on pressure, and, at one spot near the mastoid process, felt soft and elevated. A puncture was made at this place with a lancet, but nothing was discharged. Topical bleeding, blistering, &c, were recommended. 4th.—Pulse in the morning 148; in the course of the day it fell to 84; looking very languid and exhausted. 5th.—Dark-colored matter of intolerable fetor began to be discharged from the puncture which had been made behind the ear. The opening here was enlarged, and a probe being introduced, the bone was felt bare and rough over a considerable space; headache much relieved; pulse natural. 6th.—Great discharge from the opening, headache much relieved; pulse 112; complained of some pain in the left side of thorax, and there was considerable diarrhoea. 7th.—No headache; there was much discharge of fetid matter from the opening near the mastoid process, and a probe introduced 335 THE MASTOID CELLS. by it passed downwards and backwards, under the integuments, as far as the spine. 8th.—Pain in the thorax continued, and was now so urgent that a small bleeding was employed with partial relief; it could not be carried further on account of increasing weakness; pulse 140. 9th.—Said she felt better, and made no complaint of pain; pulse very rapid, and strength sinking. Died on the 10th. Autopsy. —Every part of the brain was in the most healthy state, except a small portion on the right side, near the ear, which was of a dark leaden color; the tinge, however, was entirely superficial. The right temporal bone externally was bare, through a great part of its extent; internally, it was in many places rough and darkcolored ; and there was some dark-colored matter betwixt it and the dura mater. The dura mater at this place was, for a considerable space, thickened, spongy, and irregular; the coats of the right lateral sinus were greatly thickened through its whole extent, and the capacity of the sinus was very much diminished by a disposition similar to that which occurs in the cavity of an aneurism. The internal ear contained dark-colored matter; the left cavity of the pleura contained fully a pound of puriform fluid; the left lung was collapsed, dense, dark-colored, and covered by a coating of coagulable lymph. From the examination made by me of deposits in the cavity of the lateral sinus, I have no doubt that the matter alluded to in the above case, consisted of coagulated blood mixed with pus. The following is one of Dr. Watson's cases: "A boy, 11 years old, had had a discharge of offensive, purulent matter from his ear since the time when, four years before, he had gone through an attack of scarlet fever. In August, 1833, he went for a walk into Kensington Gardens, and there lay down and slept upon the damp grass. The next day he was attacked with headache, shivering, and fever; strong rigors, followed by heat and perspiration, occurred very regularly for two or three days in succession, suggesting the suspicion that his complaint might be ague; but then pain and swelling of some of the joints came on, and were at first considered rheumatic. However, the true and alarming nature of the complaint soon became apparent; abscesses formed in and about the affected joints, and one of these fluctuating swellings was opened, and a considerable quantity of foul, grumous, dark-colored matter 336 THE DISEASES OF THE EAR. let out. After about a fortnight, the child sank under the continued irritation of the disease. The hip-joint presented a frightful specimen of disorganization; it was full of unhealthy sanious pus; the ligamentum teres was destroyed, the articular cartilages were gone; and matter had burrowed extensively among the surrounding muscles. The knee and ankle-joints of the same limb were in a similar condition. Unfortunately the head was not examined, but that the fatal disorder had penetrated from the ear to the dura mater, I entertain no doubt; in all probability the inflammation had involved the veins or sinuses of the head." Having given another case of a similar nature, Dr. "Watson says:— " I much lament that, in these instances, the direct link of connection between the disease of the ear and the disorganization of the joints was not demonstrated, for seeing (they say) is believing. Yet the pain of the ear, the discharge of pus from the external meatus, the subsequent pain in the head, coming on with fever and rigors, and followed, after a short interval, by destructive suppuration in several distant parts, and, in the latter case, the actual femoral phlebitis—these circumstances form a chain of presumptive evidence amounting, in my judgment, to moral certainty, that the fatal mischief, in each case, found entrance through the porches of the ear, and that the dura mater underwent inflammation. The same evidence is scarcely less affirmative of the complication of cerebral phlebitis. Perhaps the veins of the diploe, which, in the cranial bones, are of considerable magnitude, were involved in the inflammatory mischief; perhaps the large sinuses of the brain. The close proximity of the lateral sinus to the diseased bone, and its formation by a duplicature of the dura mater, would seem to render such a complication highly probable." The direct link of connection between the disease in the ear and that of the circulating system was pointed out by Dr. Bruce, and also in the case cited by Mr. Wilde. In the latter, " The membranous walls of the right lateral sinus, throughout the whole of the mastoid portion of its course, were much thickened, and their lining presented a sloughy appearance, being covered with lymph of a greenish hue, and smeared with unhealthy purulent matter. This condition of the lining membrane extended along the jugular vein and superior vena cava to within a short distance of the entrance of the latter into the auricle. The left cavity of the pleura contained 337 THE MASTOID CELLS. about four ounces of a thin fetid matter." In addition to the facts above cited, all that is required is, an account of the exact condition of the ear; and this has been supplied by me in the following case, which occurred to Dr. Heale, at the Free Hospital. Case II. Pus in mastoid cells; caries of the lateral sulcus; pus in the lateral sinus ; secondary deposits. —Harriet G., aged 20, was admitted into the hospital on the 9th March, 1850. She had great fluttering and irregular vibrating action of the heart, resembling erythismus mercurialis, but which subsided in a day or two. She was deaf in the left ear, and had long been subject to intense earache, with occasional fetid discharge from the meatus. She was restless, sleepless, occasionally delirious, and had no appetite. Soon after her admission, an abscess formed just above the left collar-bone, which discharged large quantities of matter until her decease. The disturbance of the heart's action returned after three doses of hyd. c. cretsi, six grains having been given every six hours; but it again subsided in about two days. She then had severe delirium, which abated after a sudden large and fetid discharge from the left ear: finally she had erysipelas, violent delirium, succeeded by coma, and died on the 15th of April. Autopsy. —A very large excavated abscess, with sinuses in various directions, was exposed at the root of the neck on the left side, communicating with and extending through the whole of the carotid sheath. The internal jugular vein was full of matter, which was also found burrowing down in the direction of the vena innominata; a fibrinous clot was found in that vein extending into the descending vena cava; and having been examined by the microscope, was found to contain pus globules. The lungs were filled with a frothy and purulent infiltration, without consolidation, and there was a small circumscribed abscess between the pleura pulmonalis and the right lung, which, however, did not extend into the substance of the latter. The heart was healthy; the liver pale-colored. The cerebrum was healthy; the arachnoid membrane, in parts, appeared smeared over with pus, more particularly in the posterior part, near the falx, joining the tentorium. The tentorium covering the left lobe of the cerebellum was much inflamed, thickened, and had matter between it and the arachnoid covering that lobe of the cerebellum; and immediately beneath this, on cutting into the cerebellum, a circumscribed abscess, about the size of a walnut, was discovered. This was nearer to the falx cerebelli than to the outer margin of the 22 338 THE DISEASES OF THE EAR. cerebellum: the part of the cerebellum in contact with the cranial bones was healthy. The petrous bone was examined by myself, and reported upon as follows:— The meatus externus contained purulent matter. The glandular and periosteal portions of the membranous meatus were much softer than natural, and adhered but slightly to the surface of the bone. The bone forming the upper and outer half of the tube was found to present numerous foramina for the transmission of bloodvessels, which were much larger than natural, and some of them surrounded by delicate layers of new bone: through the larger of these foramina, good-sized bristles could be passed, and they appeared to communicate with canals in the interior of the bone, which were themselves continuous with orifices in the sulcus lateralis at its inner surface. The lateral sinus was of a dark brown color, and the dura mater forming its exterior wall was entire. The sinus was full of coagulated blood, mixed with purulent matter. The dura mater constituting its anterior wall, and which was in contact with the surface of the bone forming the sulcus lateralis, was very thick and soft; portions of it were destroyed by ulceration, and the bone was exposed. This bone was dark in color, and covered by masses of lymph and pus; its surface was rough, presenting throughout numerous orifices and tortuous grooves,—an appearance which was pro duced by the nearly complete absence of the internal table of the skull, that (with the exception of two scales, each measuring about two lines in diameter) having been destroyed by caries. A carious orifice existed between the cavity of the cerebellum and the mastoid cells. The bone forming the jugular fossa was also carious. There was an orifice in the posterior part of the membrana tympani. The tympanic mucous membrane was much thicker than natural, and in the upper osseous wall were observed a few small foramina for bloodvessels, and a carious orifice of a size sufficient to allow the passage of a small pin. The mastoid cells at their upper part formed a cavity about the size of an ordinary horse-bean, and contained pus. This cavity communicated posteriorly with the lateral sulcus by means of an orifice three lines in diameter. Anteriorly, the orifice into the tympanic cavity was not more than two lines in diameter, and was placed above the level of the floor of the cavity containing the pus. 339 THE MASTOID CELLS. It has been already stated that the anterior wall of the mastoid cells is formed by the posterior wall of the osseous external meatus. The latter wall, in some cases, becomes carious, and matter is discharged through it, as was the case in the following interesting instance, but the orifice was not large enough to be effectual in relieving the symptoms. Case III. Pus and scrofulous matter in the mastoid cells; communication with the lateral sinusby the veins ; secondary deposit in pleura. —Kitty D., aged 15, was admitted under my care as an out-patient of St. Mary's Hospital on the 16th of February, 1854. She stated that six months previously she suffered from pain in the left ear, which was followed by dulness of hearing in it, as well as in the right ear, which had remained to the present time, accompanied by a discharge from the left ear. On examining the left ear, a small red polypus was seen at the inferior part of the meatus, near to the membrana tympani: the latter membrane was white. She did not complain of pain in the head. Gentle counter-irritation was ordered behind the ear, which was to be syringed with a weak astringent lotion. The patient continued much the same until March 27th, when she was admitted, in my absence, as an urgent case, under Dr. Sibson, into the hospital. When admitted she was partially unconscious, extremely prostrate, and could not speak: the skin was parched; the tongue brown and dry; pulse 140, very small and thready: pupils sluggish—the left rather more contracted than the right. On inquiry, it was found that, three days before, a marked difference was perceived in her manner, and attributed to the pain in the head and left ear, of which she complained greatly. She was unable to do any work.' On the 25th, she kept her bed ; on the 26th, she became still worse; and on the 27th, application was made at the hospital. Upon being seen by one of the officers, she was at once admitted. Stimulants were freely administered, and the patient somewhat rallied: during the night, she was very restless, and wandered a good deal. 28th.—Seems quite sensible of all that is done to her, but does not speak, muttering only to herself. Pulse 140; skin hot, though some moisture is still apparent. Loud sonorous rhonchus of right lung; the head is held to the right side, the mouth also is drawn to the right; the nostrils are expanded; and there is partial paralysis of some of the muscles on the left side of the face. She was supported by stimulants at the same time that a leech was applied to 340 THE DISEASES OF THE EAR. the neck. 10 P.M.—Very low, surface cold; skin clammy; face livid; subsultus tendinum; pulse feeble and irregular. 29th.—Much as yesterday; rambled during the night; voids urine involuntarily; tongue brown and moist; pulse 140, very small. During the evening very low; voided urine in the bed; muscles suddenly contracting. 30th.—Slept badly; at times wandered much; breathing hurried; pulse 140; nostrils dilated. She gradually became worse, and died at 2.15 P.M. Autopsy— Cerebrum firm; ventricles dry; gray substance very dark. Over the left lobe of the cerebellum, at the posterior part of the petrous bone, is a'dark bluish portion, of the size of half-a-crown. The gray matter of the cerebellum very blue to the depth of oneeighth of an inch, and beneath the discolored spot the substance of the cerebellum was slightly softened. There were considerable adhesions between the lungs and the pleura costalis; and also tubercular deposit covered by an unhealthy plastic, fibrinous exudation; the pleural cavities contained a pint of fluid. The dura mater forming the posterior wall of the lateral sinus (where it is situated in the temporal bone) was of a dark color and soft; the sinus contained, at its upper part, a firm coagulum of dark-colored fibrin; at its lower part it was full of dark-colored pus. The anterior wall of the sinus was attached to the bone much less firmly than natural. The mastoid cells were full of pus and scrofulous matter; and their anterior wall presented an orifice, about two lines in diameter, which opened into the meatus externus. The incus and the thick mucous membrane around it prevented the pus from escaping. The orifices for the passage of the bloodvessels from the mastoid cells to the lateral sinus were somewhat larger than natural. It will be observed that in this case there was no caries of the bone towards the cerebellum ; and the only means by which the disease from the mastoid cells could be propagated to the cavity of the lateral sinus must have been the veins. A sufficient number of facts have now been cited to show how very insidiously disease progresses from the mastoid cells to the cerebellum and lateral sinus, and to prove that the sinus may become influenced, purulent matter developed within it, and secondary abscesses produced, without the occurrence of caries in the bone forming the sinus lateralis. It has been already stated that the cause of disease advancing 341 THE MASTOID CELLS. from the mastoid cells to the lateral sinus and the brain, is the retention of the discharge within these cells, instead of its finding a free egress through the external meatus. In the cases of death from purulent infection which have been detailed, it will have been observed that there was merely a small aperture in the membrana tympani, so that only part of the matter could be discharged from the mastoid cells; and it seems to me probable, that if, in any way, a sufficient portion of the membrana tympani had been removed at the beginning of the attack, to permit of a thorough evacuation of the contents of the mastoid cells, the bone would have remained free from disease—an opinion which seems corroborated by the following case: for it will be noted that the scarlet fever appears to have attacked the mastoid cells of each ear equally. In each, the lower half of the membrana tympani was destroyed; but in the organ of which the bone became diseased, it will be remarked that the lower margin of the remnant of the membrana tympani fell inwards towards the promontory, to which it became attached, and by this means the escape of matter from the mastoid cells was prevented; while, in the other ear, the lower margin of the membrane remained free, and the discharge readily escaped. The case, of which the particulars were sent to me by a friend, together with the petrous bones, is of importance on other grounds, since it shows the coexistence of disease in the mastoidal and tympanic cavities, and the contemporaneous production of disease in the cerebrum and cerebellum. It is further of interest as pointing out how very little relation exists between the condition of the bone forming the lateral sulcus, and the contents of the lateral sinus. In some cases already described, the lateral sinus contained a large quantity of pus, but the bone was not carious; whereas, in the following case, where the bone forming the lateral sulcus was so much diseased that a large portion was necrosed and completely detached from the surrounding parts, there was no pus in the sinus. The explanation of this circumstance, found also in other cases, is most probably to be sought for in the fact, that when there is extensive caries of the substance of the bone, there is more space for the matter, and hence the pressure upon the sinus is comparatively slight. Case IV. Catarrhal inflammation of the mucous membrane lining the mastoid cells of the ear; retention of the discharge in the right ear by the adhesion of the membrana tympani to the promontory; 342 THE DISEASES OF THE EAR. caries of the right lateral sulcus, and abscesses in the cerebrum and cerebellum. —J. R v aged 12, had an attack of scarlet fever two years previously, since which he has had a discharge of matter from each ear, and a considerable diminution of the hearing power. On the 13th of February, 1854, he complained of rigors and general malaise ; these were followed by febrile symptoms and pain behind the left ear. On the 15th, a small abscess was observed behind the ear, which, when opened, discharged a sanguineous fluid. There was a slight degree of stupor, and the discharge continued without relief to the pain. On the 20th, he had somewhat improved; pain less; stupor diminished; discharge from the meatus as well as from the abscess. On the 21st, another abscess formed over the mastoid process; pulse small and frequent, discharge very fetid. 22d.— Decidedly improved in every respect; but the pain and feverish symptoms returned on the 23d, in an aggravated form; the drowsiness much increased, so that he had to be roused up to take his food, and he soon fell back again into the same state. He gradually became weaker; the urine and faeces were passed involuntarily; the stupor was increased; and the prostration was extreme. On the 4th of March, he had two severe rigors, and constantly cried out on account of the severe pain in the head. The pain gradually increased till the sixth of March, when attacks of pain came on every ten minutes, and of so acute a character as to cause him to scream. During the succeeding seven days, he suffered much less pain; and there was a copious sanious discharge from the ear and from the abscess. On the 15th, the stomach became irritable, and rejected everything introduced into it. The pain, at times, was extreme. On the 16th, at twenty minutes past twelve, he suddenly became convulsed, the face and chest were of a deep blue, the pulse was imperceptible at the wrist, the pupils dilated and fixed, and in this state he died. Upon inquiry, it appeared that, since the fever, the patient had suffered from frequent headaches, languor, and drowsiness. Autopsy. —The bloodvessels of the dura mater were highly congested. In the sulcus lateralis was a portion of necrosed bone, about three-quarters of an inch long, and half an inch broad, and quite detached from the surrounding bone; its outer part formed a portion of the mastoid process; between this detached piece of bone and the dura mater was a large quantity of purulent matter, which communicated with the superficial abscess behind the ear. An ab- THE MASTOID CELLS. 343 scess was also found in the substance of the middle lobe of the cerebrum. Upon examining the ear, the lower half of the membrana tympani was found to have been destroyed, and the inferior half of the upper part was attached to the promontory, so that the upper portion of the cavity of the tympanum was closed, and the matter secreted there had no exit. The tympanic mucous membrane was thick, and ulcerated in parts, and the mastoid cells presented a large cavity full of pus. In the opposite ear the lower two-thirds of the membrana tympani were absent, but the upper part was not adherent to the promontory; so that there was ample room for the egress of discharge from the tympanum. The tympanic mucous membrane was thick, but not otherwise diseased; the bone was healthy. A case very similar to the last cited was brought under my notice by Dr. Ogle, who was so good as to give me the preparation. In this case the disease had made way externally, so that the mastoid process was broken up, while the sulcus lateralis was by comparison but slightly affected. The veins seem to have been the medium of communication with the lateral sinus, and the cause of the deposit of pus within it. The question would probably be asked, why, in these cases of disease in the mastoid cells, does not the matter make its way outwards through the external wall of the mastoid process? It will be observed, that this outward advance of the disease has already been noticed in three of the cases; but while this was going on, the internal wall of the mastoid cells, or of the lateral sinus, became so diseased as to destroy life. It must also be borne in mind that cases are of very frequent occurrence where the disease advances externally, destroying part of the mastoid process, which often comes away en masse, and where the brain and its membranes suffer but slightly. Cases of this kind generally originate in an attack of scarlet fever, or of cold; sometimes the symptoms of cerebral irritation are but slight, at others very severe, and usually subside when there is a free discharge externally, as will be seen when speaking of the treatment. In the course of the previous observations, it has been stated that in cases of disease within the tympanic cavity catarrh of the dermoid meatus takes place, as the result of sympathetic action, and without the existence of any orifice in the membrana tympani. It is important to bear this fact in mind, because the attention of the surgeon is apt to be drawn from the real disease towards the affection of the 344 THE DISEASES OF THE EAR. meatus; indeed, in many cases of irritation of the external meatus, arising from obstruction of the Eustachian tube, the primary disease is often overlooked, and the cause of deafness supposed to reside in the irritation of the meatus. The meatus externus not only sympathizes with the condition of the tympanic cavity, by becoming the seat of catarrh, but not unfrequently polypi are developed within it. When this happens in cases where there are symptoms of disease of the bone, great care must be taken not to increase the irritation of the ear by interfering with the polypus. The following case is, in this view, worthy of the most attentive consideration. It was laid before the Pathological Society in 1851, by the late Mr. Avery, and reported upon by myself. Case V. Caries of the mastoid cells; polypi in the external meatus ; abscess in the cerebellum. —A man, aged 35, had suffered for some years from frequent earache of a severe character, accompanied by discharge. About five weeks before his death a large polypus was removed from the external meatus. This was followed soon after by great pain at the back of the head, in the right side, and down the neck and shoulder, of a plunging intermitting character. These pains were treated at first as neuralgic; but they increased in severity and frequency, and rest could only be obtained by the oft-repeated doses of laudanum. The patient appeared generally to be dull, heavy, stupid, and incapable of making any exertion. He several times remarked that people must have thought him intoxicated when in the street, as his gait was so very unsteady that he was often obliged to lay hold of the rails to prevent himself from falling. He ultimately became comatose and died. Autopsy. —The brain was found to fill the cranial cavity, and the convolutions were very closely pressed together. The arachnoid membrane was extraordinarily dry; the lateral ventricles contained a very large quantity of clear limpid fluid, and the fornix and septum lucidum were very white and soft. On separating the cerebellum from the petrous portion of the temporal bone, a gush of thick creamy pus took place, and an abscess was found occupying a cavity in the right lobe, large enough to hold a pigeon's egg. The contents of this cavity were very fetid, and the walls were firm and lined by false membrane, being thin at the point where the cerebellum rested on the aquasductus vestibuli of the temporal bone. At this spot there was a small ulcerated opening in the dura mater, 345 THE MASTOID CELLS. communicating with a carious portion of temporal bone, and it was here that the disease had been continued to the cerebellum. There was no loose lymph in the cavity of the arachnoid, and only a thin film covering it near the ulcerated opening in the dura mater. The unsteadiness of his gait, in connection with the abscess in the cerebellum, was very remarkable; but it could not be ascertained, on repeated inquiry, that the want of power over the regulations of his movements affected one side of the body more than the other. Upon examining the petrous bone, two small polypi were found attached to the upper and posterior part of the membrana tympani, which was very thick, and presented a small orifice at its anterior part. The membranous meatus was easily detached from the bone, which was darker and rougher than natural. The mastoid cells were carious and full of pus. On removing the dura mater from the posterior surface of the petrous bone, the upper part of the sulcus lateralis was found to be carious for a space three lines in diameter, and the orifices in the bone were filled with fibrin. The dura mater covering the sulcus lateralis was softened, but the disease had not penetrated to the cavity of the sinus. The dura mater adjacent to the fossa jugularis was soft and partially destroyed by ulceration. The bone beneath it was carious, and was found to form part of the posterior wall of the inner extremity of the mastoid cells, from which the disease had been propagated. In addition to the other points of interest in this case, is the fact that disease may be propagated to the jugular vein from the mastoid cells, without the intervention of the lateral sinus. I believe it to be rare for disease in the mastoid cells to manifest itself for the first time after the adult period. The following is an instance of the kind. It is impossible to say how long there had been incipient disease; but from the appearances after death, it is probable that it was of long standing. The case is of great interest, from the fact of the existence of so large an amount of disease, and the presence of formidable symptoms for so short a time only before death. Case VI. Caries of the mastoid cells; destruction of the sulcus lateralis; pus discharged behind the ear. —T. D., aged 29, was under the care of a friend, in May, 1851, on account of diabetes. He remained under treatment for ten weeks, during which time he did not complain of pain either in the head or ear. At the expiration of the ten weeks he went into the country for a fortnight, and shortly 346 THE DISEASES OF THE EAR. after his return he began to speak of pain in the head, which was principally referred to the right mastoid process. This pain, accompanied by violent earache, gradually increased, and was attended by a purulent discharge from the ear. Drowsiness, giddiness, and stupor supervened. These symptoms were not relieved by the most active treatment. Six weeks previous to his death, an abscess was opened behind the right ear, from which a large quantity of pus was discharged. No relief followed, the head-symptoms gradually increasing until his death. Autopsy. —The external meatus contained a large quantity of muco-purulent discharge; the surface of its dermoid layer was denuded of epidermis, and its substance much tumefied. The membrana tympani was entire, but of a dull leaden hue, and much softer than natural. The cavity of the tympanum contained a great quantity of purulent matter, and its lining membrane was vascular, thick, and flocculent. The,incus had disappeared; the stapes was in situ, but was surrounded by bands of adhesion. The osseous walls of the Fig. 98. The Right Petrous Bone, showing the carious condition of the Sulcus Lateralis tympanum were healthy. The mastoid cells were full of purulent matter, and the bony laminae dividing the cells were extensively carious, large portions of them having been destroyed. The whole of the posterior wall of these cells, usually forming the sulcus lateralis, was completely destroyed, and in its place was an orifice mea- 347 THE MASTOID CELLS. suring an inch and a quarter from above downwards, and more than half an inch in breadth. The orifice in reality corresponded exactly with the sulcus lateralis, as situated in the temporal bone, with the exception of half an inch before it reaches the fossa jugularis. A circular orifice, about the size of a pea, existed at the posterior part of the mastoid process, which communicated with the aperture just mentioned, on the one hand, and with the abscess behind the ear, on the other. The membranous lateral sinus was much attenuated, and beneath it was a large quantity of pus. The state of the cerebellum was not reported. From the paucity of the notes which accompanied the specimen, the cause of death was not quite clear; but most probably there was, in addition to the other symptoms, disease of the cerebellum. Probably the life of this patient might have been saved, if a free outlet for the discharge had been effected at an earlier period. It is important to notice to how great an extent the osseous sulcus lateralis was destroyed, without ulceration of the lateral sinus contained in it. In this respect the case is analogous to that of P. R. A case of a similar character to the last was published by Mr. Gray, of St. George's Hospital, in the Transactions of the Pathological Society for the Session 1848-9. From previous remarks, it will have been gathered that the existence of long-continued discharge from the ear of the affected side, is one of the most frequent symptoms attendant upon caries of the mastoid portion of the bone. This discharge is usually accompanied by perforation of the membrana tympani, although, as has been pointed out, the discharge usually comes from the surface of the meatus, and is purely sympathetic. The case which follows is of interest, from the fact that the membrana tympani was entire, and yet there was slight discharge from the ear; and is further remarkable for the short duration of the chronic symptoms. It was published by Dr. Budd, of Bristol, in the year 1851, to whom I am indebted for the preparation, and for several additional particulars. Case VII. Catarrh of the mucous membrane lining the mastoid cells ; membrana tympani entire ; caries of the petrous bone ; abscess in the cerebellum. —" George Bell, aged 13, of spare habit and delicate appearance, but never before the subject of serious illness, was laid up, in the beginning of June, 1851, with an attack, which was at first considered to be one of simple fever. Two circumstances were, however, remarked, which the sequel showed to be of great 348 THE DISEASES OF THE EAR. importance. These were severe headaches, chiefly confined to the right temporal region, and a slight discharge from the right ear, with severe deafness on the same side. " For the relief of these complaints, leeches were applied to the temple and behind the ear, followed by a blister to the same spot. Salines and a few gentle doses of mercury were given internally. Under this treatment the pain abated, the febrile symptoms entirely subsided, and in the course of a few days the boy was able to return to school, and resume his usual occupations. The pain in the temple, however, never entirely ceased. It was described as a dull pain, occasionally attended with throbbing. Up to this period there had been no vomiting, and no disorder in the motor or other powers of the nervous centres. " On the 12th of June, he was again laid up, and on the following day, Mr. Tribe, his usual medical attendant, was sent for. The pain in the head had once more become continuous and severe; and was limited still more strictly than before to the right temple, occupying, according to the patient's own description, a space not broader than a crown-piece. It was not either acute or lancinating. There was still great deafness in the right ear, though the discharge had ceased. An entirely new symptom of great significance was now added. Two days previously, the speech had become thick and indistinct, and was now at times almost unintelligible. Mental faculties unimpaired; memory accurate; no strabismus; no lateral or other deviation of the tongue; no sickness; pupils somewhat dilated, but equal and sensitive; vision good; no heat of surface; no thirst; extremities rather cold than otherwise; tongue moist but thickly coated; bowels torpid. Pulse about 100 in the minute, weak, and fluctuating. Complexion pale, and countenance deeply marked with the stamp of suffering. " On the following day, his gait was observed to be insecure, and there was a dragging of the right leg. The face was also drawn, but to which side was not noted. The pain in the head had extended itself across the forehead, and the patient had become drowsy. He had also vomited several times, rejecting everything as soon as taken, except milk, which sat well on the stomach. The bowels had been freely acted upon by an aperient, given the day before. " Under these circumstances, it was decided to put the patient at once under the influence of mercury, and employ extensive counter- 349 THE MASTOID CELLS. irritation. With this view, three grains of blue pill were given every four hours, and a blister was applied to the nape of the neck. " On the following day, four grains of iodide of potassium were given with each dose of blue pill, and a blister was applied to the shaven scalp. "On the 16th, the pain had extended to the back of the head, and there was at times double vision. The vomiting and drowsiness continued. " On the 17th, that is to say, the fifth day after the relapse, marked amendment set in. The pain had much abated, being felt, in fact, only when the head was moved; the utterance had become more distinct, and the distortion of the features had disappeared; the drowsiness had ceased, and the vomiting had become much less frequent. There was still, however, some slight thickness of speech, occasional double vision, and inequality of pulse. " On the 19th, he had so much recovered as to come down stairs; and on the 20th, he dressed himself, and descended without help. During the greater part of this day, he amused himself with his pencil; and several complicated heraldic drawings, executed with a firm and clear outline, which are still extant, show better than any other evidence, how entirely the right arm had recovered its loss of power. " Up to the 1st of July, the amendment had suffered no check; and on that day the patient was down stairs, running about and quite cheerful. It is worth notice, that he occupied himself a good part of that day with a box of carpenter's tools, handling them with his usual freedom and effect. " As the changes revealed by examination after death, coupled with the history already given, leave no doubt that at this time one if not two abscesses of considerable size existed between the folds of the right lobes of the cerebellum, such an amount of recovery as this must be looked upon as a very remarkable circumstance; and as one which might readily lead an incautious practitioner to give a favorable prognosis. The only trace of cerebral disorder still remaining was some slight thickness of speech. " The hopes excited by this favorable change were, however, swept away on the following day, the 2d of July, by a return of the former symptoms in still greater violence than before. "On the 3d of July I saw him for the first time, in consultation 350 THE DISEASES OF THE EAR. with Mr. Tribe, to whom I am chiefly indebted for the notes of the case. " The condition of the patient was then very striking and characteristic of severe intercranial mischief. The pain in the head, at all times severe, was occasionally so acute as to extort moans and cries. A very remarkable characteristic of the pain was the intense degree to which it was aggravated by any, the slightest movement of the head, voluntary or otherwise. The dread he showed at every such attempt could not be readily forgotten by any one who witnessed it.. The chief seat of the pain appeared to correspond with the base of the occipital bone on the right side; although, in less severity, it affected the whole head. His brow was deeply knit, and his whole aspect bore the imprint of great suffering. He was very drowsy withal, so that his whole time was spent in dozing or acute pain. He yawned frequently; his pupils were mueh dilated, but equal and sensitive; and he was very intolerant of light. There was no discharge from the right ear, with which he could hear the ticking of a watch several inches off. Everything in the shape of food or medicine was vomited as soon as swallowed; the pulse varied, being at the time of my visit only forty strokes in the minute. The belly was deeply sunken and retracted; and the skin peculiarly dry and harsh. The grasp of the right hand seemed to be somewhat less firm than that of the left, but there was no impairment or loss of motor power (in the way of paralysis, that is) in any other part. His mind was clear, and memory good; and his speech, though thick, was sufficiently intelligible. There had been no fit or convulsion from the first. The urine was scanty, and of high specific gravity, throwing down, on being boiled, a precipitate, which was immediately redissolved on the application of nitric acid. The tongue was coated with a thick yellow paste. From this time to the 7th of July, there was little change, except that the vomiting became gradually less urgent. On that day, to the surprise of all, he began, for the third time, to amend; the pain in the head abated, the drowsiness lessened, and the sickness became less and less frequent. From this time, he steadily improved, and on the 13th of July was so much better that it was agreed that I should suspend my visits for some days. The head was now almost free from pain, he moved with ease and freedom, and the vomiting had quite ceased. His utterance became much clearer; his tongue much cleaner; he began to take light nourishment with relish; and his bowels acted, for the first time, without THE MASTOID CELLS. 351 medicine. Although there was no derangement amounting to paralysis, he had still a more perfect use of the left than of the right arm ; feeding himself, for instance, by preference with the left hand. " On the 14th the patient was put in a warm bath, which he much enjoyed; and on being taken out, stood for some time leaning for support on his father's shoulder. This amendment was, however, of short duration. " On the following day he became much worse, and in the course of it was several times seized with severe paroxysms of pain, lasting many minutes. During this time, the eyes were fixed, and the pupils gradually dilated more and more, till the agony passed into unconsciousness ; he then remained for some time in a state of deep stupor, from which he slowly recovered. Although there was no convulsion, each of these attacks was followed by great exhaustion. " From this period ke lingered, with very little change and no new phenomena, until the 17th of July, when he expired rather suddenly, after one of the paroxysms just described. " The powers of the left hand and arm were unaffected throughout, with this single exception, that, for a short time on the 9th of July, the fingers were spasmodically bent on the hand. He helped himself to a cup of coffee without difficulty with that hand about half an hour before his death. " The principal agents employed in his treatment were bitters, and mercury, both internally and by inunction. Latterly opiates were given to lull the pain, and alkalies for the sickness; but the latter with little or no effect. " The body was examined twenty-six hours after death. On opening the head, the ventricles of the brain were found to be enormously distended with perfectly transparent serous fluid, the quantity of which was not measured, but must have amounted to at least half a pint; one of the ventricles was in fact accidentally opened by the saw in removing the skull-cap, although the brain was by no means deeply wounded. The convolutions of both hemispheres were so much flattened by the pressure, that the sulci between them were entirely effaced. On pursuing the examination, the explanation of this state of things was found in the condition of the venae Galeni, which were flattened, and contained no blood; the return of blood through them had been obstructed by the pressure of underlying disease, and dropsy of the ventricles had resulted. A few transparent and very minute granulations, which were only visible when 352 THE DISEASES OF THE EAE. looked at obliquely, were scattered over the arachnoid at the base of the brain. With this exception, the state of the cerebral membranes, whether of the surface or ventricles, was perfectly normal; they presented no trace of inflammation, and the structure of the brain itself was sound. The inferior surface of the right lobe of the cerebellum was attached to the dura mater by slight adhesions. On further examination, this lobe was found to be the seat of three distinct abscesses; two of which were situated between a duplication of the deep folds which traverse the lower surface of the cerebellum. It is important to remark, in reference to the history of the case, that their presence involved no breach of fibre or other structure, although from their size they must have exerted severe pressure on the surrounding parts. One of them was about the size of a Spanish nut, the other would easily have contained a large walnut. Both were lined by a distinct membrane, of new formation, to which a somewhat thick layer of concrete pus was adherent. These characters were best marked in the smaller of the two abscesses, which, if any inference may be drawn from such appearances, appeared to be the older of the two. The third abscess was still larger, and was formed at the expense of the substance of the cerebellum itself. The central part of the right lobe was almost entirely converted into pus, so that the whole of this lobe might be represented as a bag of matter whose walls were formed by gray substance. The small portion of white substance still remaining was broken up, and consisted chiefly of diffluent pulp. At one point, corresponding to the root of the rhomboidal body, a small extravasation had occurred. This abscess was lined by no membrane, and had no definite wall, the part in which the suppuration was complete shading off gradually into broken-up nervous tissue. The pus it contained was also much more fluid than that of the other abscesses. From these characters there can be little doubt that it was the most recent of the three. The left lobe and other parts of the cerebellum were free from disease. On examining the interior of the skull itself, a yellow spot, about the size of a pea, was discovered over the petrous portion of the right temporal bone. The dura mater was here separated from the skull beneath by a thin layer of the concrete pus lying upon the carious bone ; but there was no trace of inflammation or other disease in the cerebral aspect of the membrane. Over this space the bone was destroyed in its whole thickness, so that, on lightly scraping it with a scalpel, the cavity 353 THE MASTOID CELLS. of the tympanum was brought into view. This cavity was filled with opaque lymph, of a reddish-yellow color, but on its removal the proper bones and muscular apparatus of the ear were seen to be still in place. The membrana tympani was slightly thickened and opaque; but with this exception was sound, as was also the meatus externus. It was ascertained that the lungs were free from tubercle, and the heart healthy; but the other viscera were not minutely examined." Upon carefully inspecting the bone, it was evident that this case formed no exception to the general rule laid down by me, that when disease, beginning in the mastoid cells after the second or third year of life, injures the brain, the cerebellum is the part affected; for it is clear that the part principally involved lies posterior to the small bones, and that it is in reality included in the mastoid cells. This case gives rise to one or two other important considerations: and first as to the duration of the disease of the ear. Dr. Budd informs me, that the earliest history he had of any affection of the ear was, that two months before the fatal illness, the boy had been kept from school for two days by a slight earache, but the attack seemed to go off. This attack of earache followed an illness supposed to be scarlatina, and it is probable that the attack was the exciting cause of the urgent symptoms; but considering the carious condition of the petrous bone, and the presence of the abscess in the cerebellum, there can, it appears to me, be but little doubt that the disease, in a chronic form, had been in existence for a considerable period. In a letter to me, Dr. Budd says, " It is difficult to find a satisfactory reason why a carious condition of the posterior part of the petrous bone should give rise to abscess in the cerebellum, and caries of the superior part to abscess in the cerebrum; but it seems to me that the difficulties are fewer under the supposition that the disease is generally propagated by the veins than under any other. In the case of George Bell, the notion of propagation by direct proximity was out of the question; for not only was the carious bone at a considerable distance from the cerebellum, but no morbid change of any kind could be detected in the cerebral aspect of the dura mater covering the carious part. Many other reasons, if necessary, could be given for believing that in this and many similar cases, the veins were the channel of the mischief. That it should have had (as under this supposition it would) to run counter for some distance to the current of the blood is no real difficulty; since 23 354 THE DISEASES OF THE EAR. in the inflammation of the femoral vein which is set up by diseased conditions of the uterus, and still more by intestinal ulcer, we have undoubted and frequent examples of such a course; it would at the same time be going too far to deny that in some cases, especially where the abscess is seated in the brain, the disease is propagated by direct continuity." Several cases have been seen by me in which, in a spot exactly corresponding with the cerebral mischief, the dura mater was either ulcerated through, or manifestly diseased. From the peculiar discoloration of the parts in many such cases, I should suppose the putrefactive decomposition of the carious discharges has much to do in the extension of the disease. With regard to the mode in which the disease is propagated from the ear, there appears to me no doubt that the dura mater is affected by direct continuity. To the lateral sinus there seems abundant evidence that it is communicated by the bloodvessels; and although it is impossible to disprove the statement of Dr. Budd, that the disease extends to the brain through the blood also, it has always appeared to me probable, that the existence of an abscess in the bone has by sympathy caused a similar disease to be developed in the brain. It is quite certain that it does not take place by continuity, inasmuch as a considerable layer of healthy brain often intervenes between the petrous bone and the abscess in the cerebrum. It has been before stated, that disease of the mastoid cells produces death by causing suppuration of the lateral sinus, inflammation of the membranes of the cerebellum, or an abscess in the substance of the latter; cases are, however, sometimes met with in which the pneumo-gastric nerve is affected as it emerges through the foramen lacerum posterius. A case of this kind occurred to Mr. Coe, of Bristol, and was brought before the Bath and Bristol Branch of the Provincial Association, in December, 1854. I give it in Mr. Coe's words:— Case VIII. Disease of the mastoid cells, advancing to the lateral sinus and pneumo-gastric nerve. —" An out-patient of the Bristol General Hospital came under my care, complaining of running at the right ear, which had existed for some years, and occasional paroxysms of acute pain in the ear and head whenever the discharge ceased for a time, such being the case at the period of application. Leeches were applied to the mastoid process, and warm fomentations o the side of the head, and mercury was given internally. On the next day symptoms of meningitis having come on, the patient was THE MASTOID CELLS. 355 taken into the house. He progressed favorably for some days; but afterwards began to complain of stiffness and pain in the right side of the neck, and sudden attacks of difficulty of breathing, as if from spasm of the glottis. There was a distinct rope-like swelling descending from the base of the skull, down the side of the neck, in the situation of the carotid sheath; it was very tender to the touch. " The diagnosis was caries of the posterior portion of the temporal bone; meningitis; obstruction of the right lateral sinus, either from extension of inflammation or from secondary purulent deposit; subsequent coagulation of blood in the internal jugular vein; inflammation of its sheath, with involvement of the pneumo-gastric nerve, especially the inferior laryngeal nerve (the phenomena of the irritation of this branch being, at any rate, more manifested than of any other portion of the nerve). " The correctness of the diagnosis was proved by the post-mortem examination." Mr. Leonard, of Bristol, brought forward a case at the same meeting, in which the pneumo-gastric nerve was implicated, and it is interesting to find that the cases of these gentlemen are considered by them corroborative of the opinion advanced by me, "that the parts of the encephalon, secondarily affected in caries of the petrous part of the temporal bone, vary according to the situation of the caries." In concluding this account of the pathology of the mastoid cells, let me glance at a peculiarity sometimes met with in these cases, viz., their being attended with symptoms exactly resembling remittent fever. Dr. Griffin, in the Dublin Journal of Science, published two cases of the kind. One of them, which is also cited by Dr. Watson, is as follows:— A young man, previously healthy, was attacked with fits of shivering, accompanied by pain in the left side of the head. At first the paroxysms were rather irregular, but they soon assumed the form of tertian ague, coming on every other day, at about the same hour: the cold fit commencing at noon, and lasting about half an hour, followed by a hot stage of somewhat longer duration, and terminating in a profuse sweat. In the intermissions the pain in the head was trifling; there was no thirst nor heat of skin, but he did not sleep. A tumor formed over the mastoid process of the left side, and was opened, and a quantity of extremely offensive brownish 356 THE DISEASES OF THE EAR. pus sprang out with great force. This gave much relief. The bone was carious ove*r a space as large as a shilling. After about ten days, the pain in the head and in the mastoid process became very severe; the patient had violent shivering fits many times in the day, great thirst, heat of skin, vomiting, and delirium; his face was flushed, and his pulse hard; and he died within a few hours of the accession of these last symptoms. (c.) NECROSIS OF THE MASTOID PROCESS. On account of their position and peculiar arrangement, disease of the mastoid cells is usually of a more serious character than disease of the tympanum. The difference between the construction of these cells in childhood and in the adult has been already described, and it will have been seen that in each period of life, during disease, there is scarcely any possibility of the whole of the secreted matter being discharged from the ear. In childhood, before the mastoid process is developed, the rudimental cells, as stated, are placed posteriorly and superiorly to the tympanic cavity, and are bounded externally by a portion of the squamous bone. In the instances already detailed of disease occurring in these cells during childhood, it has been shown that it advanced rapidly until it caused the death of the patient; indeed, in those cases the brain, or its membranes, were most probably affected long before the patient's friends applied for relief, and before the diseased portion of bone had become detached, or partially detached, so as to admit the free egress of the matter from the mastoid cells. An examination of a specimen illustrative of this branch of the pathology of the subject will show, that had the portion of necrosed bone, forming the outer wall of the mastoid cells, been capable of removal during the life of the patient, the progress inwards to the brain would probably have been arrested or averted. In the majority of cases of necrosis of the mastoid process which fall under notice among the out-patients of St. Mary's Hospital, the portion of necrosed bone does become detached before the membranes of the brain are affected, and frequently the mass of bone comes away with but very slight cerebral disturbance. Indeed, as a rule, when the portion of necrosed bone is detached, although it 357 THE MASTOID CELLS. may be of considerable size, there is very little fear of injury to the brain or the dura mater. It is not always very easy to distinguish between disease in the tympanic cavity and that occurring in the mastoid cells. As a general rule, when the mastoid cells are affected, the pain is referred to the region of the mastoid process, or to the back of the head; tenderness is experienced upon gently tapping or pressing upon the mastoid process; the attacks of pain and giddiness appear more in the shape of sudden paroxysms, and the giddiness is more violent. It not unfrequently occurs that there is no perforation of the membrana tympani, though the disease in the mastoid cells causes irritation and catarrh of the dermoid meatus. The following particulars relate to what may be considered one of the most favorable cases of caries of the mastoid process. Chronic catarrh of the mucous membrane lining the mastoid cells ; caries of the bone ; removal of the dead portion ; recovery. —Master "W., aged 6, was brought to me on the 4th of September, 1853. His mother said, that four years previously he had an attack of scarlet fever, followed by discharge from both ears, and by dulness of hearing. After the discharge had continued for three months, with pain at the back of the head, and frequent giddiness, an abscess formed behind the right ear, which being laid open, a portion of dead bone was felt, which gradually became detached and was removed. The discharge from the ear continued. On examination of the right ear, the membrana tympani was absent, and the meatus contained polypi. In the left ear, the membrana tympani was perforated; the mucous membrane of the tympanum was red, and poured out an abundant discharge. Posterior to this ear was a small orifice, through which, by means of a probe, dead bone was felt. This was the upper part of the mastoid process, which, by slow degrees, was detached and removed. After its removal, and the constant use of the syringe and warm water, the discharge disappeared. A large number of cases, very similar in detail to the above, might be added. Sometimes the head-symptoms are slight, at others very marked. There is usually polypus in the meatus, resulting from the irritation of the dead bone. If it seriously interferes with the outward progress of the dead bone, the polypus may be removed; otherwise it will generally be found to disappear after the discharge of the bone. In many cases which have fallen under my notice, the 358 THE DISEASES OF THE EAR. portion of necrosed bone has been removed from the meatus, without any incision being made over the mastoid process; a plan which may usually be adopted, since the membranus meatus is capable of being greatly dilated, and the disfigurement is thus less than when an incision is made. It not unfrequently happens, that the loss of a considerable portion of the mastoid cells is unattended with any more serious diminution of the hearing power than that accompanying simple catarrh of the mucous membrane of the tympanum, accompanied by partial or complete loss of the membrana tympani. Paralysis of the portio dura nerve is, however, a not uncommon result. This nerve, it will be remembered, passes internal to the mastoid process, and is apt to become involved in the disease of the bone, as in the following cases. Catarrh of the mucous membrane of the tympanum and mastoid cells after scarlet fever; caries of the mastoid process; paralysis of the portio dura nerye. —Master C, aged 5, was brought to consult me on the 8th of February, 1853. His history is, that seven months ago, he had an attack of scarlet fever, which was followed, a fortnight after, by a discharge from each ear, the loss of the small bones, and complete deafness, so that he does not hear a sound- On examining the right ear, the membrana tympani and ossicles were absent, the mucous membrane of the tympanum was red and thick, and pouring out a copious discharge of mucus. Left ear. —The meatus contains a large polypus, below which is a portion of necrosed mastoid process, that moves on being touched with a probe. The left portio dura nerve is paralyzed. The course of treatment recommended consisted in the use of a syringe and warm water daily, and in the administration of tonic medicines. In the course of a fortnight, the portion of dead bone gradually worked its way to the orifice of the meatus, and was removed; it was about half an inch in length, and a quarter of an inch in breadth. After the bone was extracted, the polypus disappeared, and the discharge ceased. Sometimes, as in the next case, the cerebral symptoms are of great severity. Caries of the mastoid cells; severe cerebral symptoms; paralysis of the portio dura nerve. —Miss J. S., aged 6|, pale and sickly, was brought to me on the 14th of August, 1850. Her mother stated, that a day or two after her birth a discharge was seen to issue from 359 THE MASTOID CELLS. the tube of each ear, but more abundantly from the left. The right ear recovered, except a slight occasional discharge, but it was constant on the left side; and at the age of two years was followed by an abscess at the back of the ear, accompanied by violent pain in the back part of the head, giddiness, and partial insensibility. After the abscess had remained open between two and three months, a rounded portion of dead bone, of the size of a large horse-bean, came away, and about this time the child lost the use of the muscles of the left side of the face. When seen by me, there was so great a dulness of hearing that she had to be loudly spoken to within the distance of a yard. The membrana tympani of each ear was absent; the tympanic mucous membrane was red and thick, and there was a depression behind the left ear, from which the piece of dead bone had been removed. The treatment pursued consisted in the use of frequent injections with warm water, followed by mild astringents. Gentle counter-irritation was kept up behind each ear, and tonic medicines administered. Under these plans the discharge gradually subsided, and the power of hearing somewhat improved. Treatment in the adult. —In the adult, the mastoid process rarely comes away in a considerable portion; and the outer surface is so dense, that the only way in which discharge escapes from the interior is through a small fistulous orifice. The inner wall of the mastoid cells is usually the first to yield, and the sulcus lateralis is partially or wholly destroyed, as has been shown by cases already quoted. The cause of the inward progress of the matter is, doubtless, the difficulty of its escape outwards. In some cases where the membrana tympani has been wholly destroyed, and where the mucous membrane of the tympanum is not so thick as to close or very much diminish the aperture from the mastoid cells, a certain quantity of the matter can escape through the tympanum into the meatus; but often the membrana tympani is either entire, or, as in one case already cited, its lower margin is attached to the promontory, and effectually precludes the escape of the discharge. It is unnecessary to repeat the remarks already made as to keeping an opening in the membrana tympani. When that membrane is evidently preventing the egress of the matter, and where the irritation produced by the operation is not to be feared, there can be no harm in trying the effect of a puncture. Perforation of the mastoid process also suggests itself, and this operation may, doubtless, be 360 THE DISEASES OF THE EAR. performed in those cases where the matter is pent up in the cavity of the ear, and is causing such urgent and serious symptoms, as are likely, if not relieved, to terminate in death. I have never performed this operation, but I should not scruple to do so in a case where the life of the patient was threatened. Considering the large extent of the mastoid cells, it appears to me that the best plan of operating would be to use a trephine over the middle and posterior part of the process, and to remove a portion of bone three-quarters of an inch in diameter. It might be imagined, that when the disease has advanced so far as to produce coma, all attempts to give relief by making an outlet for the matter would be ineffectual. Such, however, is not the case; for in one instance related by Dr. Abercrombie, a young lady, who had lain for three or four days in a state of perfect coma, and whose situation was considered to be perfectly hopeless, was immediately and permanently relieved by a sudden discharge of matter from the affected ear. Dr. Abercrombie adds, "It is, however, by no means certain, that in such a case as this, the discharge came from the cavity of the cranium; for there is reason to believe that extensive suppuration within the cavity of the tympanum is capable of producing symptoms of great urgency, especially if there should be any difficulty of finding an outlet." The treatment, however, on which it seems to me safest to rely for promoting the absorption of the matter and preventing its secretion, so as to bring back the ear to a more healthy condition, is counter-irritation, combined with plans for improving the general health. The following case thus treated is one of great interest, as from the symptoms manifest when the patient was first seen by me, there is no doubt that both dura mater and bone were affected. Disease of the mastoid cells; giddiness; great pain in the head; cured by the use of a seton. —R. D. M., a clergyman, aged 42, tall and thin, and not robust, consulted me on the recommendation of Professor Miller, of Edinburgh. The history of the case is, that since a child, after an attack of earache, has had discharge at times from the left ear until the age of 24; from 24 to 32 had but one attack of pain and discharge; between 32 and 35 had several severe attacks of pain at intervals of a few months; at the age of 35 had a severe attack of pain, after which such attacks became frequent, and the discharge became constant and fetid; at times serous, at others purulent or bloody. By degrees fits of confusion and gid- THE MASTOID CELLS. 361 diness in the head supervened, leading to prostration of nervous energy, and a constant feeling (to use the patient's words) " as if he were on the brink of apoplexy." About four months previous to consulting me, he exerted himself greatly in preaching on one occasion. On the same evening, he afterwards sat listening long to a speaker in a public debate, with his head resting on his right arm. On rising up, he was seized with giddiness and a numb feeling in the right arm, while his pulse was slow and laboring. He got home with difficulty; but, under the influence of rest and gentle purgatives, he speedily recovered. About two months afterwards the giddiness returned, but in a more persistent form, accompanied by double vision. He had a foul tongue, palpitation, and flatulency; and there was a fixed pain in both sides of the forehead over the frontal sinuses. The ordinary discharge from the ear continued, and the numb feeling in the right arm re curred, extending from the elbow to the fingers, and following accurately the course of the ulnar nerve. At this time he was treated with blisters behind the ears, but without much relief. A month before the patient came to me he was under the immediate care of Professor Miller, who stated that he was then relieved by food and stimuli and the administration of tonics. In a day or two the symptoms assumed a pericranic character; they were also intermittent, affecting the left side of the forehead, eye, and face, and were unaccompanied by stuffing of the nostril on that side. The treatment was then changed to Fowler's solution, with an anodyne embrocation ; and in ten days the pain, giddiness, and uneasy feelings in the arm all passed away. At the time of my seeing him he complained of occasional swimming in the head, pain in the ear, and fetid discharge, together with a sensation at the back of the left ear when he walked, as if there were an empty drum there—a sensation which was increased upon tapping the mastoid process. The pain extends over the head from ear to ear, and also over the back part of the head; and when the discharge is very abundant, he suffers from the extreme sensitiveness of a spot three inches posterior to the upper part of the ear. "When he presses upon the left jugular vein, he feels a great weight at the back of the ear, as if something would burst. On inspection, the surface of the meatus was observed to be red and denuded of epidermis; the upper and only visible part of the membrana tympani was also red, and evidently fallen inwards to- 362 THE DISEASES OF THE EAR. wards the promontory. The lower half of the membrana tympani was concealed by a polypus. The discharge was milky and very offensive. Upon slightly blowing the nose with closed nostrils, the air passed through the Eustachian tube into the tympanic cavity; but it did not pass into the meatus; so that the membrana tympani was believed to be entire. The power of hearing was so deteriorated, that the watch was not heard; the crack of the nail was, however, distinctly perceived. The diagnosis formed by me was, that there was a collection of pus, or of pus and mucus, in the cavity of the mastoid cells; and that, probably, the dura mater covering their posterior surface was partially affected. I had no doubt that the discharge from the meatus was purely sympathetic, and the result of the internal irritation : it certainly did not come from that seat of the disease. Acting on this view of the case, I recommended perfect quiet, tonic medicines, and a bracing air; while a constant discharge was to be kept up, first behind the ear, and then between the shoulders, by means of blisters. This treatment producing but partial benefit, in April, 1852, about four months after first seeing him, I ordered a seton to be placed in the nape of the neck. For a time no good result followed, but in July the fetid discharge began to dry up, the power of hearing greatly improved, and the nervous energy much increased. During the two years that the seton has been worn, the patient (to use his own words) has " enjoyed a considerable measure of health and comfort, and feels comparatively well and strong;" and he preaches regularly once a week. He is annoyed now and then by slight attacks of giddiness, which are supposed, however, to depend upon indigestion; and are, he adds, "quite different from the oppressed feeling on the brain which I had two years ago." Occasionally the hearing is clogged fo» a day or two, but this state gives way to the use of the syringe and warm water; the seton continues to discharge. The above case has been cited at some length, because it so fully illustrates the peculiar symptoms of this affection of the mastoid cells, which is far from being uncommon; and because it shows the decided benefit which is to be obtained by counter-irritation long continued. Before concluding the subject of treatment, I will offer a few observations on the relation between the presence of discharge from 363 THE MASTOID CELLS. the ear and disease of the bone or brain. Patients sometimes come to complain of having been objected to-at a Life Insurance Office, on account of a long-standing discharge from one or both ears; or an opinion is requested whether such a discharge is a valid cause against insuring a life. No doubt a discharge from the ear should always be regarded with suspicion; an opinion which is borne out by an inspection of the following table, showing the relations between the duration of the discharge and the acute symptoms. The cases are taken from a paper of mine in the Medico-Ohirurgical Transactions for 1851. 364 THE DISEASES OF THE EAR. DISEASE IN THE BASE OF THE BRAIN. Post-mortem Appearances. Pus in the tympanum and labyrinth, and around the medulla oblongata. Pus in the tympanum and labyrinth; auditory nerve of aj dark color; purulent matter deposited on the medulla' oblongata, crura cerebri, and pons Varolii. Duration of Acute Symptoms causing Death. Pain in the head, ending in coma: five days. Pain in the head and ear: twenty-two days. Dura mater covering the upper wall of the tympanum thick: and ulcerated; bone carious; mucous membrane of tympanum ulcerated. Tympanic cavity full of pus; a large abscess in right middle cerebral lobe. An abscess in the left middle lobe of cerebrum ; dura mater detached from the petrous bone; the bone soft and carious. An abscess as large as a small hen's egg in the left middle cerebral lobe; dura mater over tympanum very thick and ulcerated; carious orifice in upper wall of tympanum; tympanic cavity full of scrofulous matter. An abscess in the right middle cerebral lobe ; dura mater ulcerated ; upper wall of tympanum carious. An abscess in the left middle cerebral lobe; the dura mater partly detached from the petrous bone, thick and darkcolored ; the bone dark, but not carious. A large abscess above the petrous bone, communicating with the external meatus, through petrous bone and dura mater. Dura mater covering the petrous bone detached from it, and full of orifices; an abscess in cerebrum; petrous bone carious ; tympanic cavity and vestibule full of pus. Paralysis of the portio dura nerve a few days before death. Violent pain in the ear and head; pain in ' the back and body; curvature of the neck backwards; delirium five weeks. Pain in the top of the head, followed by cerebral irritation; ten months. Headache, vomiting, chilliness, five days ; was then convalescent; a day after intense pain in the ear came on, ending in death in five days. Pain in the head for fourteen days ; fever, coma, four days. Cerebral irritation; abscess under the temporal muscle; delirium,coma; some days. Severe cerebral symptoms, coma, death in a few days. Violent cerebral irritation during thirteen days. E- M M M P O K a HH K 02 "j H eg 5 Duration of Discharge. 35 years. 12 years. 24 years. Occasionally for 14 years. 14 years. 5 years; also earache at times. 20 years. 3 years. 12 years. I 2 years, followed by intense pain. Age of Patient. 42 17 44 21 23 10 Adult. 24 14 60 365 THE MASTOID CELLS. DISEASE IN THE CEREBELLUM AND LATERAL SINUS. Duration of Discharge. 6 or 7 years. 20 years. Since early life. 7 years. 2 years. At intervals for 5 years. At intervals during 2 years. 2 years. 16 years. Age of Patient. 15 45 27 20 9 19 32 Adult. Post-mortem Appearances. Coats of lateral sinus thickened; coagulum in sinus. The cavernous sinuses full of gray-colored matter; mastoid portion of temporal bone carious. Lateral sinus full of pus; sulcus lateralis carious. Abscess in left lobe of cerebellum ; sulcus lateralis carious ; pus in lateral sinus; secondary abscesses in neck and right lung. Caries of meatus externus and sulcus lateralis; pus in lateral sinus and jugular vein; abscess in neck ; cerebellum soft. Lateral sinus full of pus; sulcus lateralis carious, and its cavity continuous with that of the tympanum; purulent deposits in the lungs. Abscess occupying nearly the whole length of the right hemisphere of cerebellum; petrous bone carious and soft; tympanum full of pus : cerebrum healthy. Abscess in right hemisphere of cerebellum; petrous bone carious; dura mater ulcerated. Abscess in right hemisphere of cerebellum; external meatus and petrous bone carious. Duration of Acute Symptoms causing Death. Pain in right ear; shivering; headache; 1 abscess behind the ear; great prostration ; ten days. Pain in the left side of the head during the ' night only; cerebral irritation ; delirium; eight weeks. • Pain in the head, rigors, fever; an abscess over the mastoid process; stupor, coma; three weeks. Shivering, headache, and pain in the right ear, followed by abscess behind it; cerebral irritation; death in ten days. Pain in the ear and head ; convulsions; great prostration ; three weeks. Pain in the ear and headache; abscess behind the ear; delirium ; convulsions ; five weeks. Intense headache; tenderness of abdomen, great physical prostration. Pain in the ear and side of the head; drowsiness, stupor, and coma; six weeks. Headache, stupor, coma; a few days. 366 THE DISEASES OF THE EAE. It is true that many persons live long, having had, during the whole of life, a discharge from the ear without any disease of the bone; others live many years with a discharge, but at death the bone and dura mater are found affected, and might under many circumstances have assumed an active form of disease, ending in death. It is important, therefore, to be able to form an opinion respecting cases of the kind. To do this, it is first necessary to decide upon the source of the discharge. If it arises from the dermoid meatus, the membrana tympani being entire, there is, as before stated, most probably irritation in the tympanic cavity or mastoid cells, of which irritation the discharge is the symptom. Unless there were simply some eczematous state of the meatus to account for the discharge, and unless the hearing power were perfect, such a case should be looked upon with suspicion, especially if attended with any symptoms of brain or cerebral irritation. Again, if the discharge issues from the tympanic cavity through a small or a valvular opening, and it is requisite to blow the nose forcibly to clear out the tympanum, there probably is, or will be, some affection of the bone from the accumulation of the discharge. If there is a large orifice in the membrana tympani, or that membrane is absent; if there is no ulceration of the mucous membrane of the tympanum; if there is some power of hearing remaining; and if, by pressing and tapping the region round the ear, no pain is felt; and if there are no other symptoms of disease in the ear or head, I think it may be assumed that there is no disease of the bone; and that by attention to daily syringing, and the other plans alluded to when speaking of the treatment of these affections of the ear, there is a fair prospect of the disease remaining confined to the mucous membrane of the ear. On the other hand, it becomes a duty to state that any negligence on the part of the patient, by which the discharge should be allowed to collect so as to fill up the orifice in the membrana tympani—a blow on the ear, an attack of fever, or any severe illness, might cause an irritation in the ear, which, if unattended to, might advance to the bone. CHAPTER XV. THE DISEASES OF THE NERVOUS APPARATUS OF THE EAR, PRODUCING WHAT IS USUALLY CALLED "NERVOUS DEAFNESS." a. DISEASES IN WHICH THE EAR ALONE IS AFFECTED: —1. FROM CONCUSSION—THREE MODES —BLOWS ON THE EAR —LOUD SOUNDS—FALLS. 2. FROM THE APPLICATION OF COLD—COL.D AIR —COLD WATER. 3. FROM THE EFFECT OF MORBID POISONS —RHEU- FEVER —TYPHUS FEVER —8CARLET FEVER—MUMPS —GOUT, h. DISEASES IN WHICH THE BRAIN AS WELL AS THE EAR IS AFFECTED \ —1. MENTAL EXCITEMENT —OVER-STUDY—SORROW. 2. BODILY DEBILITY —WANT OF SLEEP —ACCOUCHEMENTS — OVER-EXHAUSTION IN HOT CLIMATES—FASTING —NEURALGIA. The nervous apparatus which receives the sonorous undulations from the tympanum, and conveys them to the brain—one of the most delicate structures in the human body—is liable to many functional and organic derangements. 1 As some cases of deafness dependent upon the derangement of the nervous apparatus connected with the organ of hearing, appeared to be caused by the condition of the brain generally, or of that part in intimate relation with the acoustic nerve, it has seemed desirable to divide the nervous diseases of the ear into two classes: to the first of which belong those cases where the special nervous apparatus of the organ is alone affected; to the second, those where the brain, conjointly with the ear, seems to be injured. The first class may be subdivided into diseases arising from— (1.) Concussion. (2.) The application of cold. (3.) Various poisons: as that of typhus, scarlet, or rheumatic fevers, of measles and mumps, of gout, of an accumulation of bile in the blood, and of quinine in large doses. And the second into diseases arising from— 1 As I have nothing to add to the descriptions usually given of the anatomy of the labyrinth, I have not entered upon the subject. 368 THE DISEASES OF THE EAR. (1.) Excess of mental excitement. (2.) Physical debility. (a.) DISEASES IN WHICH THE EAE ALONE IS AFFECTED. This section will be occupied with a review of the various kinds of disease comprehended under the first of the above classes, all of which are usually accompanied by more or less of congestion. (1.) Debility of the Nervous Apparatus of the Ear produced by Concussion. Concussion may arise in three ways; either from a blow on the ear, or from the effect of loud sounds, or from a jar of the whole frame. Affections of the nervous apparatus of the ear, as the result of 'blows on the external organs, are not very common, since, as a general rule, the membrana tympani gives way and is ruptured, and consequently the shock on the drum is so far modified in its effect on the ossicles and the fenestra ovalis, that the contents of the labyrinth receive no greater injury than that which causes a slight dulness of hearing for a few days. Cases of more permanent injury to the acoustic nervous apparatus do, however, sometimes happen from the effects of a blow on the ear, as in the following case. Injury to the nervous apparatus of the ear, produced by a blow on that organ. —A physician in London, while playing with his little children, suddenly brought his right ear in contact with the head of one of them, causing a rather severe concussion on that side of his own head. The concussion was instantly followed by a singing in the ears. I saw the patient soon after the accident, but could detect no unnatural appearance in the membrana tympani; and on carefully testing the hearing power by the watch, there appeared to be no dulness of hearing. This physician has been seen by me from time to time since the accident, and he tells me the singing remains as it was on the day the concussion took place. The nervous apparatus of the ear is frequently injured also from the effect of a general concussion of the body, in which case the hearing power is often entirely destroyed. The well known in- 369 NERVOUS DEAFNESS. stance of the late Dr. Kitto, who was rendered wholly deaf by a fall from the top of a house when a boy, may be noticed in illustration, and some others follow which have fallen under my own observation. Fatal deafness in the right ear, and partial deafness in the left, following a fall from a horse. —The Eev. K. F., aged 53. During many years his hearing has been dull during a cold. Five years before seeing me, he had a fall from his horse, and the fall was followed by a discharge of blood from the right ear for the space of two days, and subsequently of matter. For some days after the accident, the air whistled out of his right ear whenever the nose was blown. Since the accident, the right ear has been entirely useless, and the left so deaf that he has to be loudly addressed within a yard of that ear. There has also remained a constant singing noise in the head. On inspection, the hearing of the right ear was found to have been wholly destroyed, and the membrana tympani presented an orifice, the margins of which were opaque and uneven. Left ear. —The membrana tympani was dull on its surface, and in parts calcareous. In some instances, slight amelioration of the deafness following the accident takes place, as in the next case. Total deafness in the right ear following a fall from a phaeton ; gradual improvement. —The Eev. J. L., aged 35, had a deafness in the right ear during a cold four years ago. In the same year he fell from a phaeton, and was unconscious for some days. When he recovered his sensibility, he found that there was a hissing sound, like that from a teakettle, in the right ear, which was completely deaf. During two years, however, subsequent to the accident, the power of hearing gradually improved, so that the patient is able to hear a loud voice with that ear. The noises still continue, and are aggravated by wine, or by bodily or mental fatigue; when writing or studying, these noises become overpowering, but in the morning are much lessened. On inspecting the right ear, the air is distinctly heard by me to enter the tympanic cavity, but the patient experiences no sensation in the ear when it enters. A loud ticking watch is heard. When spoken to through a trumpet, loudly and slowly, the voice is heard, but not till a second or two after the word has been uttered. The membrana tympani was opaque. The violent shock communicated to the nervous system of the ear (most probably through the medium of the membrana fenestras ro- 24 370 THE DISEASES OF THE EAR. tundae) in the act of coughing, sometimes produces deafness; indeed, in some cases, hooping-cough seems rather to cause deafness by this means than by the agency of poison. Nervous system of the ear injured by violent coughing. —Mrs. A. consulted me in 1851, and stated that a week previous to her visit, directly after coughing, she experienced a pain in the left ear, which lasted for two hours, together with a loud singing noise which has never ceased. She complains of an unpleasant sensation as if sounds passed through the ear, and is troubled with a sense of giddiness, and a feeling of confusion in the head. Every step she takes sounds like the beating of a drum. The membrana tympani was fallen in, and its surface dull. The watch was heard only when in contact with the ear. Means having been used to diminish the congestion of the nervous apparatus of the ear, the distressing symptoms of nervousness and giddiness disappeared, but the singing sounds remained. The concussion upon the nervous system of the ear resulting from loud sounds is a very common cause of deafness. In a previous part of this volume, when speaking of the functions of the ossicles and muscles of the tympanum, it was shown that the one use of the tensor tympani muscle is to render tense the membrane of the fenestra rotunda, as well as that of the larger membrane; and in this tense condition the membrane of the fenestra rotunda is thrown into vibratory movements of much less extent than when it is in a relaxed state. When a loud sound is anticipated, the tensor tympani muscle draws the membrana tympani and the membrana fenestras rotundas tense; so that when the approach of a loud sound is expected, it rarely injures the ear. On the contrary, however, when both membranes are comparatively lax, the same sounds throw them into very extended vibrations, and the fluid in the cochlea by the magnified movements of the membrana fenestrae rotundas is so concussed as to injure, and often most seriously, the expansion of the auditory nerve in the labyrinth. Injury to the nervous apparatus of the ear may be produced by a variety of sounds. Cases have been seen by me in which a cannonade at land or sea, or the firing a single cannon, has produced the injury; and others have occurred where an explosion of gas, thunder, a pistol shot, or even loud shouting near the ear, have resulted in the same effect; but the most common cases are those which follow the long-continued sport of shooting, where the deafness almost NERVOUS DEAFNESS. 371 invariably occurs in the left ear, which is turned towards the gun during its explosion, and consequently receives the direct concussion. The treatment in recent cases when the patient is suffering from the immediate effect of the shock, consists in the removal of the congestion by the application of leeches, or by cupping; by the administration of mild aperients; by strengthening the general nervous system as much as possible, and by securing the ear against the effect of loud sounds. Noises in the ears, deafness, and a feeling of deadness in the head following the sound of a pistol shot; relief —Mr. C. S., aged 45, a fortnight before consulting me, fired a pistol, for the first time in his life, in the open air on a cold frosty day. The concussion was instantaneously followed by a hissing noise in each ear, but more especially in the right, and he also felt a shock throughout the whole of the head, followed by a "feeling of deadness" in it. Since the accident, he has been dull of hearing, and has observed, among other things, that he could not hear the "ring of money." Leeches and mustard plasters were applied behind the ears, and small doses of calomel and colocynth were administered. Immediate relief to the head and ears followed the application of the leeches, and in a week the hearing had improved, and the noises diminished. Nervous apparatus injured by the report of a cannon. —W. L. C, Esq., aged 73, about four months before consulting me, his hearing being then perfect, was sitting in the open air at Brighton, looking upon the sea, when a cannon near where he sat was fired, without his having any idea of such a proceeding being about to take place. The concussion was immediately followed by a singing in the ears, or rather about two yards from them, and a sensation as if water were rushing through them. Since the accident, he has heard a whisper very distinctly, but a loud voice causes unpleasant jarring sensations in the ears, and deafness to all sounds. In another case, the ear was "benumbed" for some time after the patient's child had shouted into it. Nervous apparatus of the ear injured by very loud shouting ; very distressing noises ; great relief —When surgeon to the St. George's and St. James's Dispensary, a poor man applied to me for relief from deafness and very distressing noises in the left ear. The latter had lasted several years, and the patient, a strong muscular man, thinks they were caused by the loud shouting he is obliged to 372 THE DISEASES OF THE EAR. practice as a hawker of fish. These noises come on in the left ear, and after remaining there some time advanced to the left side of the head; they have increased lately, sometimes resembling "a rapid tinkling," at others being like the driving of a sledge hammer; but most commonly they resemble the roaring of the sea. When at their loudest, as after exertion, the house seems to go round with him. The ear is quite insensible to any sound but that of these noises. The right ear is healthy. On examination, the membrana tympani of the affected ear was found to be opaque, and the air passed through the Eustachian tube with a loud crackling. As this was a local affection, as the patient was a strong man, and as the symptoms were increased by any cause which increased a flow of blood to the organ, I determined to treat the case as one of congestion, and accordingly ordered the patient to apply twelve leeches below the ear, followed by a cantharidine cerate dressed with unguentum hydrargyra, at the same time that the outer half of the meatus was washed with a solution of nitrate of silver sufficiently strong to produce desquamation. This was followed by the use of a solution of chloride of zinc (six grains to the ounce) to the meatus, so as to cause a discharge. The result of this treatment was satisfactory. The noises, the patient says, " have not been so loud or nearly like it;" and ten days subsequently to this report, he said that his head was much better, and " he could do his work without being obliged to give up." Nervous apparatus of the ear injured by the explosion of bladders of gas. —J. B., aged 64, was admitted under my care at St. Mary's Hospital in 1853. He stated that nine months previously, directly after the explosion of two bladders of gas at the distance of a yard from his head, he suddenly became so hard of hearing, that he could not hear a voice except when spoken to distinctly at a distance of two yards from the head. The explosion was followed by a singing sound in the ears, which gradually subsided. The watch could not be heard at a distance of more than two inches from the right ear, and only when in contact with the left. The treatment consisted in the application of leeches below the ears, but the patient did not return to report progress. The following is a well-marked case in which the nervous apparatus was injured by shooting. Deafness in the left ear, following shooting, and temporarily increased by a day's sport. —F. F., Esq., aged 23, accustomed to 373 NERVOUS DEAFNESS. shoot, has been gradually becoming dull in the left ear. For two years he has not been able to hear general conversation distinctly, and the striking of the clock seems no longer attended by the natural sound. Is more dull of hearing during a cold. Is not aware of any cause that could have produced the deafness. The right ear was in a natural state; by the left the watch was only heard at the distance of half an inch. The treatment consisted in the use of gentle counter-irritants over and around the ear, and in doing all that could be suggested for diminishing local and general congestion. This treatment was followed by great improvement at the end of about three weeks, when the watch could be heard at a distance of four inches—an improvement which continued, with the exception of a considerably increased amount of deafness which ensued upon a morning's shooting. This increased deafness continued for some days, and then gradually diminished. The last time the patient was seen by me, the hearing had not yet regained the previously improved state, for the watch could only be heard in contact with the ear. Not having had the opportunity of ascertaining the condition of the ear by the aid of dissection, I have assumed that in these cases, arising from shooting, the nervous system of the ear is defective. The grounds of this conclusion are, that the noises and defective hearing followed immediately on the concussion, and all the symptoms indicated that a shock had been given to the nervous system. The secondary effect of this concussion, it can scarcely be doubted, may be anchylosis of the stapes to the fenestra ovalis. In cases, iudeed, when the nervous system of the ear has received a very severe concussion, and deafness has subsequently slowly come on, I have convinced myself of this' anchylosis by dissection, and will now relate one or two cases of the kind. Concussion of the nervous apparatus of the ear by thunder ; complete deafness. —T. D., aged 80, is so completely deaf that he cannot hear any sound. He states that, fifteen years ago, when in a thunder-storm on the coast of Guinea, he was rendered thoroughly deaf by a clap of thunder, and since then has not heard a sound. On examination, an orifice was observed in each membrana tympani. No treatment was attempted, but about two years after the examination, the opportunity was given me of dissecting his ears, which were in the following morbid' condition. Right ear. —At the posterior part of the membrana tympani was 374 THE DISEASES OF THE EAR. an orifice about two lines in diameter, the remaining portion of the membrane being white, thick, and tense, and[ more concave externally than natural; parts were also calcareous. In the centre of the remnant of the membrana tympani is a space about half a line in diameter, in which the epidermoid, dermoid, and mucous layers alone remain. The long process of the incus and the crura of the stapes are gone, and the expanded base of the stapes is attached to the fenestra ovalis more firmly than natural. The membranous labyrinth was atrophied, and the nervous fibrillse of the cochlea appeared the same. Left ear. —Like the right; except that the crura of the stapes were only partially absorbed. In another case of total deafness produced by a loud cannonading, the only morbid condition that could be detected by me, on dissection, was that the otoconie was more abundant than natural, while in the vestibule there was a deposit of oval-shaped cells. Results similar to those noticed as following the practice of shooting, also occur to operatives engaged in occupations involving very loud sounds. Thus in a large factory for making steam-boilers, I found a great number of men engaged in riveting the bolts, and therefore obliged to work inside the boiler, who were very deaf. It will be very interesting to ascertain by post-mortem inspection the pathological condition of the ear when subjected to such loud sounds, and some day perhaps the opportunity will be afforded me of doing so. (2.) The effect of the application of cold on the nervous apparatus of the ear. There are two classes of cases in which a diminution of the temperature is found to be injurious to the ear; in the one cold air, in the other cold water, is the agent producing the effect. I have known engine-drivers to suffer from deafness after being exposed to a cold blast, and huntsmen also who have had a sudden " check" when very hot, and have then stood about while a bitter east wind was blowing upon them. The effect of the application of cold seems, in the first instance, to produce congestion; and then to lead to the symptoms of noise in the ear and of deafness, which appear to depend upon a depressed or depraved action, subsequent 375 NERVOUS DEAFNESS. to and resulting from the congestion. In what the depraved action consists, it is, however, difficult to determine. The congestion often yields to the application of leeches; and the depraved action is frequently diminished, sometimes wholly removed, by the use of gentle counter-irritants, tonics, shower-baths, &c. The first series of cases consists of those in which the injury followed exposure to cold air. Total deafness in both ears following exposure to cold by sleeping in the open air. —A farm-laborer, aged 28, was admitted under my care at the St. George's and St. James's Dispensary, in June, 1850, on account of complete deafness in both ears. He said that eighteen months previously, after sleeping in an open cart in which he was riding in the winter, a usual practice with him, intense pain came on between the right temple and ear, which was relieved by the use of veratrine ointment. About three weeks after the exposure to cold the deafness made its appearance, at first for a day or two only, and then disappeared; in the course of a few days, however, it recurred with increasing intensity and once more disappeared. This recurrence and disappearance of the deafness ending after a few more days in total and permanent loss of hearing. At the present time he cannot hear a gun, even if fired close to the head. He complains of loud noises in the head, and of great heaviness and sleepiness. All kinds of empirical treatment had been tried on him; oils of various kinds had been dropped into the ears, with brandy and salt, and then hot baked salt behind them; every species of medicine had been given, and he had been cupped and blistered at the nape of the neck, but without producing any good effect. On examination, the upper part of each membrana tympani was found to be red, the lower part being concave and white; air entered through the Eustachian tube and caused a loud cracking sound. Some relief to the head-symptoms followed a discharge from each meatus, which was kept up by the application from time to time of the chloride of zinc. Deafness and singing in the ears following exposure to cold while skating. —J. V., Esq., aged 49, consulted me in March, 1852. His health was good, and his constitution strong. He stated that twelve or fourteen years previously, while skating on a bitterly cold day, a singing sound suddenly came on in the left ear, which has remained ever since; being at times very loud, and then much subdued. A few years after this exposure, the left ear became gradually dull of 376 THE DISEASES OF THE EAR. hearing, and recently both the singing and dulness of hearing have increased. The power of hearing varies, but is not worse after fatigue or excitement. With the right ear the hearing distance was three inches; with the left half an inch only. Two leeches were ordered to be applied below each ear, and the ears to be syringed with warm water, the object being to remove congestion. This treatment was followed by relief; but with the further progress of the case I am unacquainted. Two other cases of injury produced by the application of cold air to the ear may be briefly alluded to. The first was that of a gentleman, aged 21, who ten months before my seeing him, being exposed to a very cold February wind blowing in the left ear, had a singing and pulsation ensue within that organ; these sensations are unaccompanied with deafness, and are worse while in bed or reading. At times they wholly disappear. The second case is that of a clergyman, aged 66, who having been exposed to cold in a railway carriage, three years before my seeing him, was subsequently attacked by a whizzing sound in the left ear, which has never ceased. By sitting up late at night, or by entering a warm room from the cold air, the sound is increased, but is better rather than worse after dinner. Complains of dulness of hearing, as general conversation is not heard. The following are cases where the application of cold water resulted in injury to the ear:— Deafness following bathing in cold water. —T. F., aged 19, saw me on account of his deafness. He said, that more than a year previously deafness came on slowly, after bathing daily in cold fresh water, and in a month or six weeks he became as deaf as at present. The affection has been stationary for some months. He requires speaking to loudly within the distance of a yard, and at times suffers from a buzzing in the ears. He is not deafer during a cold, and does not hear better in a carriage. The right ear is rather worse than the left. The previous treatment consisted in dropping oils into the ears, and in syringing them with warm water. In each ear the watch was heard only when in contact. The membrana tympani appeared to be slightly more concave than natural, and its surface was dull and congested. The treatment consisted in the application of a vesicating paper behind each ear, and in taking small doses of blue-pill and iodide of potassium, a treatment which was followed by a slight amelioration of the symptoms. NERVOUS DEAFNESS. 377 Deafness produced in two days by dipping the head in cold water. —A girl, aged 14, the daughter of a farmer, consulted me in 1853. She stated, that two years previously, when very much heated, she plunged her head into cold water, and two days afterwards became so deaf that she required to be loudly spoken to close to the head. The deafness varies slightly, being worse during a cold, and at times, from no assignable cause, better. The treatment consisted in keeping up a slight discharge from the surface of each mastoid process, and in giving small doses of the bichloride of mercury (one-thirtieth of a grain) with gentian, daily. The treatment, pursued during two months, resulted in decided improvement. Deafness and noises in the ears after bathing. —A man, aged 29, was admitted under my care at St. Mary's Hospital, in July, 1853. He said, that six years before, after bathing in a canal of cold fresh water, he became rapidly deaf in both ears, and in the course of a week was so deaf as to require to be distinctly spoken to quite close to him; complained from the first of buzzing noises and pulsations. The deafness and the noises increase in damp weather, or when he is tired; and he also hears worse in a carriage and amid loud sounds. The treatment consisted in the application of gentle counter-irritants over each mastoid process, and in taking alteratives, but without any beneficial effect. (3.) Deafness produced by the action of morbid poisons on the nervous apparatus of the ear. As has been stated, in addition to the causes just detailed, the nervous apparatus of the ear often suffers from'' the action of the poisons of gout, typhus fiftver, scarlatina, measles, or mumps. Though unable to furnish any information of the modus operandi of the several poisons enumerated, in some cases where the functions of the organ have been wholly destroyed, the nervous apparatus of the ear, on dissection, has been found by me completely disorganized, and the fluid in the cochlea and vestibule dark colored, and occasionally tinged with blood. Many of the cases of acquired deaf-dumbness originate in the effect of poisons of various kinds. A careful consideration of the symptoms attendant upon these cases, and the results of treatment, indicate that whatever may be the immediate effect of the poison on the nervous tissue, the secondary effect is to produce congestion of that tissue. 378 THE DISEASES OF THE EAR. Noises and deafness after rheumatic fever. —Miss B., aged 36, consulted me in 1851. She stated, that ten years previously she had an attack of rheumatic fever, which was followed by dulness of hearing in the right ear, and accompanied by a constant whizzing sound and a pulsation which extended over the head. The left ear has lately become dull. The watch was heard only when pressed upon the right ear, or at a distance of six inches from the left. Neither ear presented any appearance of disease, except a slight dulness of the surface of the left membrana tympani. The treatment consisted in applying mustard plasters and stimulating liniments to the nape of the neck, and the ethereal solution of cantharides behind the ears. The result of two months' perseverance was such an improvement of the hearing power, that conversation could be more distinctly perceived, and the watch could be heard at half an inch from the right ear. Total deafness following an attack of rheumatic fever. —Mr. M. G., aged 17, a year and a quarter before consulting me, had a bad attack of rheumatic fever, which was followed by noises in both ears and gradually increasing deafness, so that in a month after the fever he could not hear any sounds. Since the attack, has now and then heard loud sounds for a very short time; but when he saw me he was so deaf that he could not hear anything, even when the poker and tongs were knocked against each other. The ears had been syringed, blistered, and galvanized without any effect. There was no appearance of disease in either ear. The case was at once regarded by me as incurable. Partial deafness following an attack of typhus fever. —Miss A. M., aged 16, saw me on March 1st, 1851. Eleven years previously she had an attack of typhus fever, anil during the illness became so deaf as not to be able to hear the human voice. After the symptoms of fever had disappeared, the power of hearing slowly returned, until she was able to hear when loudly spoken to close to the head. There was no appearance of disease in either ear. Partial deafness following fever. —P. A., Esq., aged 49, consulted me in December, 1853. Twenty years before, he had an attack of fever, during and for some time after which he was so deaf as to> require to be spoken to close to the ear. The hearing gradually returned, and at the end of two years he heard perfectly well for a very short time, when the deafness as gradually returning, he soon had to be loudly spoken to within a yard of the head. Does not 379 NERVOUS DEAFNESS. now complain of noises, but has had a ticking sound in the ears. The deafness is worse after flurry, excitement, or fatigue, after dinner, wine or beer; a single glass of either of the latter increases the deafness instantaneously. Is better after a discharge from the nose, and while riding in a carriage. The hearing power of the left ear is gone. On examination, no unnatural appearance was detected in either ear, and the watch was heard when pressed upon the right ear. Total deafness following an attach of fever. —Miss C. J., aged 21, when a child had an attack of fever, since which time she has gradually become deaf, and at the present moment cannot hear even a loud clapping of the hands. Five years ago both tonsils were partially removed, and their remnants have recently been snipped, with no effect except that of producing great mental depression. There was no appearance of disease in any part of the organ. The poison of scarlet fever, like that of typhus, sometimes injures the nervous apparatus of the ear, and not unfrequently complete deafness is the result. The following are illustrative cases. Dulness of hearing following an attach of scarlet fever. —Mrs. S., aged 26, had an attack of scarlet fever, eight years previous to consulting me, and since that time has been troubled with a dulness of hearing, especially during a cold. A year ago, after having suffered much trouble, and after being in weakly health, the power of hearing gradually decreased, and this decline was accompanied for the first time by pain, with irritation and discharge in both ears, together with constant noises like the blowing of bellows. Is unable to hear general conversation, but a single voice is heard distinctly. The left ear is worse than the right. On examination of the right ear, the surface of the meatus was found to be dry and to contain small portions of epidermis; the membrana tympani was opaque, and the Eustachian tube pervious. The left ear was in a similar condition. Complete deafness in the right ear produced by the poison of scarlet fever. —Mr. H., aged 20, had an attack of scarlet fever at four years of age, since which time the right ear has been so deaf as not to be able to hear even the slightest sound. On examination, the right membrana tympani was observed to be more opaque than natural, and the left ear was perfect in every respect. Mumps. —The peculiar poison which causes the disease generally 380 THE DISEASES OF THE EAR. known by the name of mumps is very often the source of complete deafness, which, however, usually occurs in one ear only. In these cases, the nervous apparatus is evidently affected, as the deafness comes on suddenly, is usually complete, and, as a general rule, no appearance of disease can be detected in the meatus, membrana tympani, or tympanic cavity. When the nerve is not wholly paralyzed, and some, although it may be a very slight degree of hearing remains, the only plan of treatment which can be recommended is the use of gentle counter-irritation over and around the ears, at the same time that the ear is exercised by means of the elastic speaking-tube. The circulation of bile mixed with the blood is sometimes a 'cause of deafness, and it is also well known that large doses of quinine are also liable to be followed by temporary deafness. I have met with only one case in which permanent injury to the ear was assigned to the use of large doses of quinine. The poison of gout may also give rise to deafness and other peculiar symptoms in the head. In two cases of this affection which came under my notice, it is interesting to observe that the headsymptom complained of, viz., a feeling of vacancy, was at once relieved by pressure upon the air contained in the external meatus. Distressing sensations produced in the ears by gout. —D. T., Esq., aged 54, consulted me in June, 1857. He said that for the last four or five years he had been subject to attacks of gout, which had at times caused him great inconvenience, and the disease had recently made so much progress as to make him fearful that his brain was weakened by its influence. He added that he was never really clearheaded, excepting just after an attack of gout, when he supposed his blood was temporarily freed from the poison. He had rapidly aged in the course of the previous two years. An extremely distressing symptom had lately presented itself in the form of a peculiar sensation of vacancy in the ears, accompanied sometimes by a low humming sound. There was no deafness, and the patient applied to me only on account of the sensations in the ear. On examination, small deposits of gouty matter were observed in the substance of the right upper eyelid; the surface of the meatus externus was of a bright red color; the circumference of the membrana tympani and of the long process of the malleus were also red; while the surface of the tympanic membrane was very bright. Air passed freely, and with the natural sound, into the tympanic cavity. NERVOUS DEAFNESS 381 The hearing power was perfect. By what, therefore, could the dis. tressing symptoms be caused ? Were they the result of congestion of the nerve ?—a condition which, it seemed to me probable, might render the nerve so exquisitely sensitive, that the ordinary sounds ever floating in the air might become a source of excitement to the ear. Being aware also, from previous experience in similar cases, that pressure upon the external meatus so as to shut out or diminish the sound in the meatus would remove the symptom complained of, I closed with my fingers each external meatus, and the unpleasant symptoms at once disappeared. On subsequently exerting a gentle pressure on the ears by the introduction of cotton steeped in water into each, the patient was enabled to leave in comparative comfort. For the purpose of preventing the recurrence of the symptoms, it was of course requisite to diminish the congestion, for which purpose two leeches were applied below each ear, small doses of colchicum administered, and strict attention to diet enjoined. The quantity of wine was decreased from four to two glasses daily, and in lieu of beef and mutton, of which he had been, in the habit of partaking very abundantly, he was ordered to live principally on poultry, game, and fish, with abundance of farinaceous food and vegetables. The result of this treatment was the removal of the distressing symptoms in the ears, and the gradual disappearance of the attacks of gout. (b.) DISEASES IN WHICH THE BRAIN AS WELL AS THE EAR, APPEARS TO BE AFFECTED. (1.) Debility of the nervous apparatus arising from mental excitement. A young lady, of about 25 years of age, is brought to me by her mother, on account of deafness in both ears, one being much deafer than the other. The patient is pale, rather thin, and has a look of depression. She complains of humming noises in both ears, and hears better in a carriage. Upon examination her pulse is feebler than natural, and the deafness is so considerable that she requires to be loudly spoken to within a yard of her ears. There is no morbid appearance in any part of the ear, and the Eustachian tube is in a natural state. On inquiring as to the origin of the deafness, the parent states that they had not been able to detect any cause. 382 THE DISEASES OF THE EAR. The deafness came on three years previously, when the young lady was in good health, and gradually increased, till in four months the patient had become as deaf as now. She is rather deafer after excitement and during fatigue. There is no hereditary tendency to deafness. The young lady has remained at home with her mother, has taken plenty of exercise in the open air daily, and retired to bed early; but, for some reason or other, her nervous system was not strong, and she was easily excited. On further questioning, it is found, that about the period when the deafness came on, the patient was particularly nervous, and ultimately it turns out, by her confession, that she had been deeply grieved by the conduct of one of her friends, and had often lain awake at night indulging in sorrow, and that, at such periods, the noises came on in increased force. Another young lady, aged 19, is brought just after leaving school, where she was well taken care of, and so liked by all, that she even preferred school to home. Her parents stated that six months before, without .any apparent cause, their daughter had grown gradually deaf, and can at present hear only when very distinctly spoken to, within a distance of two or three yards. The deafness is worse during excitement. There is no appearance of disease in the ears, and the girl is strong, active, and healthy; her nervous system is, however, very sensitive, her feelings most acute, and she broods in silence over slight mental troubles which would pass unheeded by ordinary persons. Perhaps all attempts to find out the cause of the deafness are in vain; and the parents go away with the assurance from the medical man, that at the time the deafness first appeared there must have been some cause of mental excitement to call it forth. After the lapse of a shorter or longer period, the medical man learns, perhaps, that at the time in question the young lady at school suffered a great deal of mental anxiety, owing to her religious views being in an unsettled state. These two cases are good types of the class of nervous deafness now under consideration. The causes may be very numerous, and in some instances are but slight, compared with the distressing symptoms which ensue; but it must be borne in mind that, as a general rule, the nervous system has, from a variety of causes, been allowed to sink into a weakened condition. Thus the child may have been overworked, have suffered from indigestion, had too little exercise or not enough sleep; ventilation also may have been defective. NERVOUS DEAFNESS. 383 In a depressed state of health from any of these causes, an apparently slight additional cause may produce the injurious effects on the nervous system which has been indicated. Sometimes there is no diminution of the hearing power, and the patients complain not of deafness, but rather of singing noises, which are increased by any mental excitement. In some cases the noises are not constant, but only appear after mental emotion; the slightest unpleasant thoughts are sometimes sufficient at once to induce the noises. The deafness and noises in this class of cases, if slight, can be cured by removing the cause (a depressed state of health), and by giving tone to the nervous system by tonics and by local applications to the ear. In some cases, however, of this species of nervous deafness, the symptoms of noises become so greatly aggravated, that unless their peculiar character had been detailed by several patients, it would be difficult to credit their existence. They may commence with a gentle singing, then increase to a hissing or wizzing sound, that suddenly changes to a series of sharp cracks, like pistol-shots, followed by a rushing sound like the wind, or the escape of steam from a boiler, after which a rolling may ensue like thunder. These sounds vary much in intensity, being increased in some by rainy weather, in others by an easterly wind; bodily fatigue may sometimes cause them to be magnified, but the source of increase is usually some discomfort or excitement of mind. A young lady, for instance, comes into my room with her mother to consult me, and she says that the noises became rather worse than usual when told that she was going to see a medical man; that they were accelerated when entering my house and waiting in the diningroom; and that they reached their acme of intensity after the excitement attendant upon my examination of the ears, and questioning her about the symptoms. The important problem for consideration is, can the ears be improved? So far as my present experience extends, I may say that a large number of the worst cases can be but slightly influenced by treatment; but there is still a large number which may be very greatly benefited by measures calculated to brace the nervous system; as tonics, fresh air, exercise, and mental repose. In these cases I am giving electricity a trial. Debility of the nervous apparatus of the ear, produced by overstudy.—Lady D. brought her child to me in June, 1852. The young lady was twelve years of age, thin, rather tall of her age, and pale. The pulse was weak; the tonsils large and red; the mucous mem- 384 THE DISEASES OF THE EAR. brane of the fauces red, thick, and rugous. The sub-maxillary glands were somewhat enlarged, and she had been subject to glandular swellings in the neck. The appetite was good, and she partook freely of meat twice daily. She was taught at home with her sister by two governesses, one being for languages. She devoted between eight and nine hours daily to her studies. The history given me was, that during the last two years, without any assignable cause, the power of hearing had gradually diminished, and there had been slight noises in the ears at times. On inquiry, it was elicited that she was greatly interested in her studies, and very anxious to make progress in them, never much tiring of her lessons. Her interest in them increased to excitement, and she was often agitated and distressed f at not being able to accomplish as much as she desired. On examining the ears, a slight dulness was observable in each membrana tympani; the Eustachian tubes were pervious, but the hearing power was so diminished, that she required to be loudly spoken to within a yard of the head. This deafness was at times so greatly aggravated, that considerable difficulty was experienced in making the patient hear at all. It was, therefore, palpable that there was considerable debility of the nervous apparatus of each ear, for which tonics were prescribed, also a gently-stimulating embrocation; fewer hours were to be devoted to study, and light nutritious food, as game, poultry, fish, was to be taken instead of so much meat. All this resulted in some slight amelioration; but still the deafness was very considerable, and increased greatly at times. Under the circumstances, another consultation took place, at which I clearly traced the attacks of increased deafness to more than usual nervous excitement following more than usual mental work. In addition to the previous tonic measures, entire, rest from study in any shape was enjoined for three months, during the whole of which time the hearing gradually improved, and at the end of six months the patient was declared to be perfectly well; and, although she has resumed her previous plans of study, moderated according to circumstances, the case remains satisfactory. To the above case the details of several others might be added, were not a brief allusion sufficient. Thus a lady, aged 27, consults me for deafness accompanied by noises which gradually came on during the previous four years. The nervous system never was strong, but underwent a severe shock, about the commencement of 385 NERVOUS DEAFNESS. the period mentioned, from the breaking off of a matrimonial engagement. With the continuance of the mental sorrow the deafness and noises had gradually increased, and were always accelerated after much mental dejection. Another lady, of nervous temperament and warm feelings, was sitting at home awaiting the return of a brother to whom she was greatly attached, when he was brought home dead from a fall in the street. For the space of a year the sister gave way to despondency, and, as she told me, the thought of her brother during the whole year was scarcely a moment absent from her mind. At the end of that time, as her spirits began to improve, noises appeared in and head, dulness of hearing followed, and both noises and deafness so greatly increased, that in the course of another year, when seen by me, she was so hard of hearing as to require to be loudly addressed at the distance of a yard or two, while the noises had reached a pitch of extraordinary excitement. There was scarcely any conceivable sound, whether of thunder, cannon, firing guns, bells, hissing, rolling of the sea against the beach in a storm, or winds howling, to which this lady was not subject. These sounds intermixed and alternated in a manner quite indescribable. They remained of the same general intensity, varying somewhat according to the weather for several years; when another severe domestic bereavement occurred, followed by some new noises of a still more intense character, but her deafness remained much the same. Another lady, who married at about 26 years of age, was subjected to severe domestic trials, which, after preying upon her mind for some years, ended in such total deafness, that she could not hear a pistol-shot fired close to her head. The variable amount of deafness in this class of cases is sometimes very marked. Thus, I had for a long while a patient under my care who, when perfectly tranquil, could distinctly hear his daughter reading to him at about the distance of a yard; but if his daughter told him anything which excited his interest, he became so thoroughly deaf as not to be able to hear a sound, and would remain so until the excitement vanished, when his hearing would return. 25 386 THE DISEASES OF THE EAR. (2.) Debility of the nervous apparatus of the ear produced by general bodily debility. It is difficult to draw a correct comparison between the number of cases of deafness dependent upon excess of mental excitement, and those arising from overtasking the body; but from the data before me, perhaps those of the class now to be considered are the most common. They occur in both sexes, but are more frequently met with in the female; and present great variety of form as well as cause. Sometimes they are temporary, and produced by a long walk, heated rooms, late hours, &c, when noises, wfch diminished hearing power, come on, but disappear after rest. Other cases, and even some of those which come on suddenly, may, however, remain more or less permanent. Thus, cases have been met with in my experience, in which patients have become totally deaf after the administration of too violent a purgative, or after an attack of diarrhoea or cholera, and after the nervous exhaustion attendant upon childbirth; in some instances of the latter, the deafness has begun with the birth of the first child, and increased with each successive birth, until at last the nervous power was wholly lost. Perhaps the most common cause of nervous deafness from physical debility is the want of proper care in the management of young persons, and particularly girls, when they are growing fast. In hospital practice, young nurse-maids who carry heavy children, and whose night's rest is often disturbed, and youths just entering laborious situations, are found to suffer. Any cause, in fact, which reduces the nervous energy of the body to a state too low for the due regulation of the functions of the various organs of the frame, may be followed by a manifest depression of the nervous power of the ears, which shows itself not merely in diminished power of hearing, but often by singing and other sensations in the ear, and sometimes by severe pain, like tic douloureux. In cases where debility of the nervous system of the ear is the result of a debilitated state of the body, the pulse, as a general rule, is weak, and there are symptoms of previous or present indigestion. Generally, no unhealthy condition of the organ itself is apparent; though in recent cases, the cerumen may be softer and more abundant than usual, and in old standing cases may even be absent. The treatment of cases of debility of the nervous apparatus of the NERVOUS DEAFNESS. 387 ear arising from bodily debility, consists in imparting, by every possible means, strength to the general system. Exercise in. the open air, a due amount of rest and sleep, well-ventilated rooms by day and night, abundance of nutritious food, stimulants in moderation, tonics in the shape of quinine, bark, creasote, &c, should be prescribed; while locally, gentle stimulants should be applied over and around the ear. I have never found the vapor of ether applied to the tympanic cavity by means of the Eustachian catheter of any service; nor has my limited experience of the use of galvanism and electricity hitherto been favorable to their employment. Some cases are decidedly amenable to treatment, and the noises diminish or disappear, while the deafness is greatly diminished; but if the cause in which the deafness originated be allowed to continue, or if any debilitating influence be present, total deafness may ensue in spite of every remedial effort. The following cases are all interesting. Deafness produced by want of sufficient sleep ; cure. —In the early part of 1855, a young gentleman, aged 14, was brought to me by his father,, on account of gradually increasing deafness. Pie appeared to be in tolerable health, and was at school in the neighborhood of London. No cause could be assigned for the affection, which had so far advanced as to cause him great discomfort from his inability to hear what his masters said to him. On examination, it became apparent that the deafness depended upon debility of the nervous system, for there was no history of any other disease, nor was there any appearance indicative of disease. The patient had, however, occasional noises in the ears, following over-exertion, and he certainly was deafer when he was tired. On inquiry, I could discover no special cause for the deafness, as he followed the same rules and regulations which were pursued by all the boys in the school. I prescribed internally quinine, and a stimulating liniment externally, giving directions that he should not be over-worked. In a month's time the boy was seen again, but remained in much the same state, so I requested to be allowed to see the lady with whom he boarded, in order to ascertain further particulars as to his mode of living. On the most minute questioning no sufficient cause could be detected, except that, being very desirous to prepare his lessons well, he sat up so late that when the time arrived for getting up, he was so sleepy as to be roused with difficulty. It was at once rendered probable that the debility of the nervous apparatus of the 388 THE DISEASES OF THE EAR. ear might be dependent upon the want of sleep; and I therefore requested his friends to see that his duties were so relaxed that he could take as much sleep as he required, and gave directions that he should go to bed at eight o'clock, and sleep until he awoke of his own accord. The result was, that for several successive nights, he slept for fourteen hours, and by degrees the number was reduced to ten, which was his usual allowance for three weeks, at the end of which time he returned to me, when, to the gratification of all, it was found that his hearing was nearly restored, and he was no longer styled " the deaf boy" at school. This patient has been seen by me twice or thrice since, at considerable intervals, in consequence of the deafness returning; but each time it was evident that the nervous system had been too much exhausted, and the administration of quinine, with less work, and an increase in the amount of sleep, soon restored the hearing. Total deafness produced by the nervous shock consequent upon successive accouchements. —Mrs. B., aged 40, pale, and of a nervous temperament, consulted me in 1850, on account of complete deafness in both ears. She stated that she had married in India ten years previously, and at the time of her marriage she could hear perfectly well. On the occasion of her first confinement, previous to which her hearing was still perfect, she suffered a good deal from exhaustion, and this was followed by a great degree of deafness, so that she could scarcely hear what was said to her, even when the voice was much raised. Upon getting up, and growing stronger, the deafness was so much relieved that she merely required to be spoken to a little louder than usual. During each successive confinement in India, amounting in all to four, the deafness greatly increased, and after each recovery became more permanent, until, on the last occasion, she remained as deaf as at present, when she is obliged to have recourse to signs. Indeed, she has never heard the voices of her younger children, and can only by the movements of their lips understand their words. Debility of the nervous apparatus of the ear arising from overexhaustion in India. —Captain T., aged 40, came home from India in 1858, having undergone great fatigue, and his health having been greatly shattered, while his hearing power had so much diminished, that when he consulted me I was obliged to speak very distinctly within a yard of his head. He complained of constant loud singing in the ears, which was increased by the slightest exertion. On ex- 389 NERVOUS DEAFNESS. amining the ears, no alteration from the normal condition could be detected, and the Eustachian tubes were in a natural state. The treatment consisted in sending the patient to the seaside and in giving him quinine, using at the same time a stimulating liniment over the ears and at the back of the neck. In two months his strength had greatly increased, with a corresponding improvement in the hearing. He returned to the seaside to pursue the treatment in capital spirits, and was induced to go out on two consecutive days to evening parties, at which he stayed till very late. Nervous exhaustion followed, and his hearing sank to the same low ebb as when he first consulted me: nor was it until after two months of very quiet life and steady keeping to the prescribed treatment, that he again began to improve. Nervous deafness produced by over-exertion. —E. Clarke, aged 31, a tall muscular carter, was admitted under my care at St. Mary's Hospital, on January 27th, 1859. He stated that, fourteen years before, when out of health, deafness came on in the left ear, accompanied by noises, sometimes like a kettle singing, at others, like the ringing of bells. On recovering his health, he found himself perfectly deaf in the left ear, which has remained so ever since. Eleven weeks ago, when a good deal exhausted by hard work, he took a bad cold, during which singing came on in the right ear, with loud noises, like the ringing of bells, and were accompanied with so serious an amount of deafness, that he required to be spoken to in a loud voice, within a yard of his head. The patient's pulse was weak, and he had a worn aspect, as from exhaustion of the nervous system. On examination, no appearance of disease was visible in either ear, and the Eustachian tubes were pervious. Two grains of quinine were ordered to be taken twice daily, and a stimulating liniment to be rubbed over the surface of the ears, at the back of the neck, and down the spine. In the course of a week the noises decreased greatly, and in a fortnight they had wholly disappeared, while the hearing power gradually increased; so that when he left the hospital, at the end of six weeks, to use his own words, he " at times hears quite nicely." Several cases of a similar character might be cited, in which equally favorable results followed the administration of strychnine, in doses varying from one-thirtieth to one-twentieth of a grain, twice or thrice daily; and in some instances, where neither quinine nor strychnine 390 THE DISEASES OF THE EAR. were of any benefit, doses of creasote, or of morphia, or of both together, were productive of great improvement. Nervous deafness relieved by creasote and morphia. —Miss M., aged 29, in good health, but very easily excited, consulted me in January, 1859, on account of deafness. Four years previously her left ear gradually became deaf, accompanied with noises very difficult to describe, but something like a whizzing, and these noises were increased by any external noise, or if she felt nervous, tired, or excited, and were worse at night. In a few months the right ear was also affected in the same way. In both the deafness was gradually increasing. This deafness was also accompanied by a sudden loss of voice after she had spoken a few words. The only cause to which she can ascribe the deafness was the habit of going for many hours without food, and then eating very rapidly. She had been treated by blisters, whose use had been followed by a rapid advance of the deafness, and she had been told that her case was incurable. At the time of her first consulting me, it was requisite to speak loud within a yard of her head, and she was deaf to all general conversation. On examination, each membrana tympani had a perfectly natural appearance, and the Eustachian tubes were healthy. The treatment consisted in using gentle counter-irritation over each ear, the back of the neck, and down the spine, and in administering creasote and morphia, in doses of two or three minims of the former to one-twelfth of a grain of the latter, twice daily. This treatment was continued perseveringly for four months, at the same time that every measure for restoring the general health as respects food, exercise, and diet, were resorted to, and at the end of the treatment the hearing power was so greatly improved that she could both hear and take part in general conversation. Cases of nervous affection of the ear sometimes occur in which the chief symptom is pain; the treatment does not differ from that of the last class of cases. Pain in the left ear, accompanied by diminished power of hearing, following over-fatigue. —Miss T., aged 25, pale and not strong, was brought to consult me, in May, 1856, on account of a pain in the left ear; this pain had made its first appearance about a year before, after the patient had undergone considerable fatigue by attending several evening parties in succession, and remaining very late; and the pain was much accelerated by any cause which produced fatigue. The hearing power was very slightly affected; and as the other ear 391 NERVOUS DEAFNESS. was perfect, no complaint was made respecting the hearing. On examination, the organ appeared to be quite healthy; and feeling that the pain arose from deranged action of the nerve consequent upon debility, quinine was prescribed internally, and mild stimulants applied over the ear and down the spine. This treatment was followed by considerable success, as the pain disappeared in the course of a month, but returned slightly upon the patient having to undergo great fatigue. CHAPTER XVI. THE DISEASES OF THE NERVOUS APPARATUS {concluded). ULCERATION OF THE MEMBRANOUS LABYRINTH — CARIES AND NECROSIS OF THE PETROUS BONE. 1st the cases hitherto described of disease extending from the tympanic cavity to the brain, the upper osseous wall of the tympanum was the part affected, and the medium through which disease advanced to the middle cerebral cavity. There is, however, another medium by which disease may be conveyed from the tympanic cavity to the brain; and that is through the labyrinth. When it is remembered that at the inner wall of the tympanum a delicate membrane (membrana fenestras rotundas) is all that separates it from the cochlea, and that the base of the stapes with its fine ligaments form the only septum between that wall and the vestibule, it will naturally be inferred that disease in the tympanic cavity would frequently advance to the labyrinth. The occurrence is, however, in fact, very rare, for this reason, that ulceration of the mucous membrane of the tympanum is far from a common disease, while, under the influence of chronic inflammation and of the secretion collected in the tympanum, the membranes both of the fenestra rotunda and ovalis become thickened and turgid. I am not aware that any case has been recorded in which disease had made its way through the fenestra rotunda to the labyrinth; but in the course of my dissections I have found the medium of communication to have been, in one instance, the fenestra ovalis, and, in the other, a carious aperture in the outer arm of the external semicircular canal, where it bulges into the tympanic cavity, and is covered by the tympanic mucous membrane. When suppuration takes place in the labyrinth, the disease readily advances through the cribriform floor of the meatus auditorius internus to the auditory nerve, and thence to the base of the brain and medulla 393 NERVOUS DEAFNESS: oblongata. In certain cases purulent matter is effused beneath the arachnoid over the whole surface of the base of the brain, surrounding the nerves in their cranial course; and the substance of the pons Varolii or medulla oblongata may be destroyed by ulceration, or an abscess may form between the arachnoid and pia mater. In some cases the disease extends a considerable distance down the medulla spinalis. In some cases the labyrinth becomes carious or necrosed, and the dead bone is discharged without the production of any symptoms of cerebral disturbance, as in the following cases. The first occurred to my friend Mr. Hinton, who kindly placed the preparation in my museum. It was of a man set. 55, who suffered from a discharge from the right ear for some years, and at last the cochlea was discharged entire. The second case occurred to Mr. Shaw, and the following report is extracted from the seventh volume of the Transactions of the Pathological Society of London: — Extraction from the left ear of a boy of the greater part of the petrosal portion of the temporal bone, including the meatus auditorius internus and labyrinth, separated by necrosis. "A boy from the country,aet. 7, was admitted into the Middlesex Hospital on the 31st of July, 1855, under Mr. Shaw, for otorrhcea affecting both ears. The disease succeeded a severe attack of scarlet fever, which he had two years and a half ago. From the right ear the discharge of pus was not of great amount. The left external ear projected considerably beyond its proper level, and an irregular piece of bone, surrounded with fungous granulations, protruded from the meatus into the concha. He had paralysis of the muscles of the left side of the face; for a year he had been completely deaf in both ears. "On the 3d of August, he was put under the influence of chloroform, when Mr. Shaw first extracted the piece of bone which projected into the concha; this appeared to have been the posterior border of the external meatus of the temporal bone. " The cartilaginous tube having been ulcerated by the pressure of the loose fragment, the point of the little finger could now be passed inwards to some depth; when another larger piece of bone was felt rolling freely in the cavity. This was seized by the dressing 394 THE DISEASES OF THE EAR. forceps; and after it had slipped once or twice, owing to its hardness and smoothness, it was extracted by employing force and a twisting motion, so as to favor its coming in a proper direction. For a few seconds after the removal dark venous blood flowed rather freely. As a precaution, he was kept in bed for a week; by degrees the discharge lessened, and the ulcer of the tube cicatrized. No outward symptoms arose; and in the end of September, except from the paralysis of the face, the deafness, and a trifling discharge from both ears, he left the hospital in good health." Description of the Specimen. —The density of structure, weight, and shape of the portion of bone last removed, at once showed that it formed nearly the whole of the petrous portion of the temporal bone. It was of irregular cylindrical, or rhomboidal figure; it measured one inch in length; its average thickness in various directions was half an inch; it weighed twenty-two grains. On one side, nearly in its centre, was an opening and cavity with well-defined borders and walls, which was recognized to be the meatus auditorius internus. The depth of the meatus, from the margin to the thin perforated plate through which the auditory nerve penetrates into the labyrinth, was **three-fifths of an inch; and, as that is the full depth of the cavity in its normal state, it was thereby shown that the whole of the internal meatus was included in the specimen. At the bottom of the meatus could be seen the commencement of the canal for the portio dura. On the side of the specimen in relation with the brain, the surface presented the cancellated appearance peculiar to the diploe; whence it was concluded that, in the detaching of the necrosed part, the process of separation had taken place in the diploe—that the cortical layer had retained its vitality, and, remaining in contact with the dura mater, had served as a barrier to prevent disease from extending to the cerebrum. On turning the bone around to view it in its opposite aspect, the side then exposed was seen to be the internal wall or boundary of the tympanic cavity; it was easy to distinguish the " promontory," having above it the "fenestra ovalis," and below it the "fenestra rotunda;" the two latter openings were broken and irregular, and through the enlarged holes thus produced the interior of the "vestibule," with its fossse, the cochlea, modiolus, and lamina spiralis, somewhat injured, were seen. At the posterior part of the specimen portions of the semicircular canals, broken off near their junction with the vestibule, stood up distinctly into view. 395 NERVOUS DEAFNESS. In other instances, although the brain is seriously implicated, the patients recover, as in the following case quoted from Mr. Wilde. He says: "I am indebted to Sir Philip Crampton for an examination of one of the most extraordinary pathological dissections of diseased bones perhaps in existence, consisting of the entire internal ear, cochlea, vestibulum, and semicircular canals, with a small portion of the inner wall of the tympanum, which he drew forth from the meatus of a young lady who, after the most urgent symptoms of inflammation of the brain, with paralysis of the face, arm, and leg, and total deafness of one side, recovered from the bad symptoms and the paralysis of the extremities after a copious discharge from the ear. This discharge, the paralysis of the face, and deafness, continued some time, accompanied by occasional attacks of pain in the ear, till one day Sir Philip, perceiving a portion &f loose bone lying deep in the cavity of the meatus, drew forth the specimen from which the illustration in the volume was made. It does not appear that the hard external enamel of the bone was affected, but the scala cochleae is far more beautifully displayed than could possibly have been done by art." In the following case, which, on several grounds, is one of great interest, the disease advanced through a carious orifice in the semicircular canal to the labyrinth. Disease in the tympanic cavity, extending through a carious orifice in one of the semicircular canals to the labyrinth, and thence by the auditory and facial nerves to the brain. —On the 28th of March, 1851, I was called in by Mr. Such, of Dalby Terrace, City Road, at the request of Mr. Coulson, who had also seen the patient, to see a German gentleman, aged 26, the history of whose case I found to be as follows: —He was of a robust constitution, and had generally enjoyed the best of health : indeed, even when first seen by me, he had the appearance of a stout, healthy man. Between four and five years previously, he complained of occasional pain in the right ear, which was usually followed by a discharge that by degrees became constant. Three weeks before my seeing him, he suffered from a severe attack of pain in the head, which ceased on the occurrence of an increased quantity of discharge. Nothing particular happened further until ten days previous to my visit (excepting a sleepless state at night), when he was suddenly seized with a violent pain in the head, which the ordinary remedies failed to relieve; and by degrees this pain extended to the back of the neck 396 THE DISEASES OF THE EAR. and as low as the sixth dorsal vertebra. About the same time there was paralysis of the right facial nerve. For several days there had been a continual shivering fit about two o'clock p.m. On the evening of the 28th, at which time I saw him, he was suffering from great pain at the back of the neck; was very restless, particularly at times, but talked quite sensibly; the right facial nerve was paralyzed; he squinted, and the pulse was 85. The external meatus was nearly filled by a polypus: the discharge was very fetid and abundant. A large blister was ordered to be applied to the nape of the neck; the ear to be frequently syringed with hot water; and, as the patient was very sensitive to the action of mercury, a quarter of a grain of gray powder, with three grains of extract of henbane, were administered every two hours. -March 29th, 9 p.m.—The mercury has already caused great tenderness of the gums. The symptoms have materially increased; the pain at the back of the head was very violent this morning, the squinting continues, and he sees double. At three o'clock to-day he became insensible, but was roused by a loud noise, and spoke rationally for a minute or two, but then relapsed into a state of incoherency. Pulse as yesterday; respiration oppressed and low; face and head congested and blue; discharge from the ear abundant and fetid. Leeches were applied below the ear. March 30th. —Slight relief followed the application of the leeches, but the patient soon grew rapidly worse. The right side of the body became paralyzed, the breathing stertorous, and the face livid. Insensibility gradually came on, and he died at 6 p.m. Autopsy, twelve hours after death. —With the exception of a large quantity of chocolate-colored fluid in the lateral ventricles, the cerebrum was healthy, as was also the cerebellum. The arachnoidal surface of the dura mater, covering the superior and mastoid surfaces of the petrous bone, was in a healthy state; but upon removing it from the bone, over two small portions of both surfaces, it was found to be softer than natural, and these soft portions covered apertures in the diseased bone. The appearance of disease was, however, so slight, that it was quite manifest that the affection of the ear had not made its way inwards at either of the two points. On removing the brain there was evidence of very extensive disease at its base. Purulent matter was deposited beneath the arachnoid, from the roots of the olfactory bulbs, anteriorly, to the medulla oblongata, posteriorly. In some parts this pus was of a dark color; NERVOUS DEAFNESS. 397 in others, as in the pons Varolii, the arachnoid membrane was ulcerated. The principal seat of the disease was the right side of the pons Varolii, the substance of which was ulcerated to the depth of a line to a line and a half, over a surface as large as a sixpence. All the nerves, at their origins, were surrounded with pus, and the substance of the facial and auditory nerves of the right side was so soft as to be scarcely distinguishable from purulent matter. On examining the petrous bone, the dura mater around the orifice of the meatus auditorius internus was observed to be softened and detached from the denuded bone. The portions of the auditory and facial nerves within the meatus were also in a state of suppuration. The whole of the petrous bone being removed for the purpose of careful dissection, the following was the condition of the parts detected. The external meatus contained two polypi, one of which, as large as a small pea, was attached, by a broad base, to the posterior wall of the meatus, about its middle; the other, and smaller, about the size of a grape-seed, was also attached to the meatus near the former. When the membranous meatus was separated from the bone, there was found in the latter an orifice between two and three lines in diameter, so that a communication existed between the meatus and the mastoid cells; there was, however, no orifice in the membranous meatus, and consequently the discharge from the ear came not from the mastoid cells, but from the surface of the meatus only. The membrana tympani was entire, but quite white and much thicker than natural. The tympanic cavity contained a large quantity of fetid pus, and its lining fibro-mucous membrane was ulcerated at several points. Within the cavity there were also two portions of carious bone, one projecting towards the cavity of the cerebrum and in contact with the outer surface of the dura mater; the other looking towards the cavity of "the cerebellum and also in contact with the dura mater, which membrane, as before stated, was, at the points referred to, thick and soft. The ossicles were present, and the stapes adhered with its usual degree of firmness to the circumference of the fenestra ovalis. On laying open the cavity of the vestibule, it was found to be full of a dark-colored pus, having a fetid odor; the semicircular canals were also full of similar matter, and the osseous wall of the superior canal was carious at two or three points. This purulent matter extended from the vestibule and cochlea to the meatus auditorius internus. While carefully examining the external semicircular canal, where it makes a bulging 398 THE DISEASES OF THE EAR. in the tympanic cavity, a small carious aperture, not larger than a small pin's head, was detected in it, which contained fetid pus, and was the ODly medium through which disease could have been transmitted from the tympanic cavity to the vestibule. Fig. 99. Caries of the External Semicircular Canal. A bristle is placed through the aperture in the Semicircular Canal, showing the communication between the Vestibule and the Tympanic Cavity ; the upper wall of the Tympanum has been cut away. I have described this case as one of disease originating in the tympanic cavity, and extending thence to the vestibule inwards, and to the meatus, outwards. The grounds for my belief that the disease originated in the tympanic cavity are various. In the first place, it is very rare for suppuration to originate in the labyrinth, nor do I recollect ever to have met with a well-marked case of the kind: and had it, in this instance, originated in the labyrinth, it would most probably have produced death before it reached the tympanum. In the second place, the tympanum is, as has been stated, a frequent seat of disease; and the presence of the undetached portions of necrosed bone indicates long-standing disease. The nature and progress of the disease would appear to have been the following : When it first made its appearance, it was probably one of catarrh of the mucous membrane; the quantity of mucus secreted was too large to admit of its entire escape through the Eustachian tube: the membrana tympani was consequently pressed 399 NERVOUS DEAFNESS. upon, and, instead of ulcerating and allowing the matter to escape externally, became itself much thickened and very rigid; the secretion being thus confined in the tympanic cavity, produced caries of the bone and penetrated the labyrinth. There can, it seems to me, be no doubt, that had the membrana tympani been partially destroyed, and free egress been in that way afforded to the secreted matter, the disease in the bone might have been prevented, and the life of the patient by that means saved. Another opportunity was kindly given to me, by the late Mr. Avery, of seeing the post-mortem, and making a careful dissection of the ear, in a second case of disease advancing from the tympa num to the labyrinth. In this instance, the medium of communication was the fenestra ovalis, which had been left open after the removal of the stapes by ulceration. Ulceration of the tympanic mucous membrane; extension of disease to the labyrinth through the fenestra ovalis. —James Warner Smith, aged 17, a sailor, was admitted into the Charing Cross Hospital, on the 14th of January, 1846. The history of his case was, that at five years of age he had an attack of measles, followed by an abundant discharge from the left ear, from which he has never since been perfectly free, although occasionally the quantity was very small. He had usually enjoyed good health. Three months previously, when off the Cape of Good Hope, he was up aloft during a gale, and lost his cap. Great pain in the ear followed this accident, and the quantity of discharge increased. There have been many attacks of pain since, and occasionally a sanguineous discharge. When he came on shore, he took a fresh cold, and the pain in the head and ear became very violent. He now consulted a surgeon, who ordered him injections, drops, and ointments; but not obtaining any relief, he applied to Charing Cross Hospital. At the time of his admission, he complained of constant pain in the left ear, and in the left side of the head as high as the vertex, with a certain degree of pain also on the right side. The muscles on the right side of the face were constantly twitching, and the mouth was as constantly drawn to that side. Some intolerance of light was also observed. An abundant offensive discharge proceeded from the left ear; but there was no tenderness over the mastoid process. January 16th.—Has had a violent paroxysm of pain in the night, but is better this morning, and the twitching has subsided, except in the right eyelid. Calomel and opium were administered. 400 THE DISEASES OF THE EAR. Januarj r 22d.—Much better; slept well; pain abated. January 24th.—Pain returned as violently as ever. January 27th.—Delirious during the whole of the day. January 29th.—Delirium continues: complains of intense pain in both sides of the head; discharge from the ear abundant; head drawn backwards. January 30th.—The delirium has left him, but he is exceedingly drowsy, and is roused with great difficulty. The movements of the limbs and their sensation unaffected. The pupils acted properly. February 1st.—The drowsiness has vanished; has had no delirium ; and has passed a good night; but still complains of considerable pain in the ear and over the eyes. He remained in this state until the 5th, when he gradually sank, without coma or cerebral symptoms of any marked character. The retraction of the head continued to the last. He was quite sensible before he died. Autopsy, thirty-six hours after death. — On removing the dura mater, the surface of the arachnoid was observed to be remarkably dry; the vessels of the pia mater were more than usually injected on the convex surface of the hemispheres; there were two or three small yellow patches beneath the arachnoid. Each lateral ventricle contained at least three ounces of clear fluid; in the posterior corner of the right, and in the inferior of the left, were two patches of bright yellow lymph, as large as half-a-crown, which were covered by a thick creamy purulent fluid. The third ventricle contained a dark clot of blood, of the size of a small walnut, which could be traced into the fourth ventricle, where there was also a small coagulum. The commissura mollis was broken down. Surrounding the lower part of the commissure of the optic nerves, and covering the pons Varolii, crura cerebri, medulla oblongata, and upper part of the medulla spinalis, was a layer of pure yellow pus and lymph, nearly half an inch thick; it embraced the nerves at the base of the brain to their passage through their several foramina. The parts in direct contact with this layer were very soft. Under the pia mater, where the right anterior lobe rests on the orbital plate of the frontal bone, there was a patch of effused blood, the size of a shilling. The dura mater covering each petrous bone was healthy, and the exterior of the bone did not present any appearance of disease. On examining the cavity of the ear, the membrana tympani 401 NERVOUS DEAFNESS. was found to have been destroyed by ulceration, and all the ossicles had disappeared. The tympanic cavity was full of the most offensive secretion, and its lining membrane was ulcerated. The fenestra ovalis was open, and in the cavity of the vestibule, similar matter was found to that in the tympanum. The whole of the natural membranous labyrinth had been destroyed. The auditory nerve was tumefied, and of a dull livid color, the disease having evidently advanced to it through the cribriform floor of the internal auditory meatus, and thence to the base of the brain. It is to be remarked, that in this case there appeared to be no obstacle to the free egress of the matter, except the accumulation of thick masses of it in the cavity of the tympanum. It is far from improbable that, in cases of ulceration of the mucous membrane of the tympanum and loss of the stapes, the thick secretion in the tympanum may be quite sufficient to cause the disease to advance inwards. The case is also another illustration of the necessity there exists for frequently washing out the tympanic cavity with warm water. It is, however, no doubt possible ere the stapes is removed, for the disease to advance to the vestibule without the agency of the pent-up matter in the tympanum. Besides the two cases just described, I have met with two others; and as these four cases are the only instances I have found on record of this peculiar form of the disease, brief particulars of the two latter are subjoined. The first of these cases occurred in the practice of Mr. Streeter, and was laid by him before the Westminster Medical Society on the 13th of January, 1844. Disease extending from the tympanic cavity to the labyrinth, and thence to the medulla oblongata and the base of the brain. —The patient was a lady, aged 42, who had been deaf in the right ear since the age of seven, but from what cause was not known. Two or three months previous to her death, she became affected with a severe headache, for which a blister was applied at the back of the neck. Nothing serious, however, was thought of the matter until the 17th December, when the severity of the pain so increased as to become of a maddening character, and almost to produce delirium. The right portio dura nerve was paralyzed, and there was severe pain down the spine, which was attributed to a fall received when getting out of bed. The pulse did not warrant active depletion, but two or three leeches were applied behind the affected ear; a large 26 402 THE DISEASES OF THE EAR. poultice was applied over the face; the ear was gently syringed with warm water, and saline medicines were ordered. On the 18th she had some sleep in the night, but complained of an almost intolerable pain in the back. The catamenia now appeared, and the cause of the pain remained obscure. She was quite sensible, the pupils acted, but the cornea on the affected side had begun to ulcerate. There was a slight discharge from the right ear, and the left had become somewhat deaf. It was thought that a hole could be observed in the membrana tympani: calomel and opium were administered. December 19th.—She has slept better, and remained somewhat improved until five or six in the evening of the 21st, when she was suddenly seized with coma, and continued in that state until the following morning, when she died. Autopsy. —On examining the brain, slight sub-arachnoid effusion and vascularity of its surface were found, as also some increase of vascularity in the interior; but there was no effusion in the ventricles. An abscess was discovered in the tympanum and labyrinth, and there was a counter-abscess about the size of a large pea, in the condensed arachnoid and pia mater, occupying the fossa where the facial and auditory nerves proceed, from the junction of the medulla oblongata with the pons Varolii and cerebellum. Pus was effused beneath the arachnoid and pia mater, investing the right side of the upper portion of the medulla oblongata, and the adjoining part of the right lobe of the cerebellum, to about the extent of a square inch; but there was neither softening nor apparent lesion of the proper cerebral tissue beneath. The exact condition of the tympanic cavity and labyrinth is not detailed in the above notes by Mr. Streeter; but there can be no doubt that the disease (most probably ulceration of the mucous membrane) had extended from the tympanum to the vestibule, either through the fenestra rotunda or ovalis, or by means of an orifice in the osseous wall of the labyrinth. The state of the portio dura and portio mollis nerves is not stated; but judging from the records of other cases of a similar character to the present, these nerves must have undergone some morbid change, and communicated the disease to the base of the brain. The remaining case is taken from M. Itard's work, 1 and is as 1 Traite des Maladies de l'Oreille, 1821. Tome i. p. 254, Obs. 22. NERVOUS DEAFNESS. 403 follows: A man, aged 22, five weeks before his death, complained of toothache: this was followed by febrile symptoms. On the twelfth day after the attack, discharge took place from the left ear, but symptoms of cerebral irritation increased until his death. Autopsy. —Over the convex surface of the brain, and in its substance, were a number of small purulent deposits. The cerebellum was similarly affected, but in a less degree. The auditory and facial nerves were in a state of suppuration, and almost wholly destroyed: pus was also found in the internal auditory meatus, the vestibule, cochlea, and semicircular canals, and the tympanic cavity. The treatment to be pursued in these cases is similar to that recommended in cases of disease of the tympanum and the mastoid cells. * CHAPTER XVII. MALIGNANT DISEASE OF THE EAR. ORIGIN IN THE MUCOUS MEMBRANE OF THE TYMPANUM—DESTRUCTION OF THE PETROUS t BONE — SOMETIMES MISTAKEN FOR POLYPUS —OPERATIONS TO BE AVOIDED —BRAIN AND DURA MATER INVOLVED—TREATMENT. Cases of malignant disease, advancing from the ear towards the brain, appear to be of rare occurrence. So far as my own experience and the aid of published cases permit me to judge, it appears most probable that the part of the ear in which malignant disease usually originates, is the mucous membrane lining the cavity of the tympanum. After the diseased growth has destroyed the membrana tympani, it advances through the external meatus to the outer orifice, where it shows itself in the shape of a small tumor, which has sometimes been mistaken for a polypus, and the removal of which has caused hemorrhage and an aggravation of the symptoms. At the same time that the disease advances outwards, it also encroaches upon the whole of the parts surrounding the organ of hearing. The osseous wall of the meatus externus and of the tympanic cavity are wholly destroyed; the outer part, and even the whole of the petrous bone, are converted into a mass of disease; the lower part of the squamous bone also disappears, and the tumor advances into the cavity of the skull, where it destroys life, either by its pressure upon the brain or its bloodvessels, or by involving the brain itself in the disease. This malignant disease is sometimes of the nature of fungus haematodes; at other times it has the characters of encephaloid disease. This affection occurs at various periods of life : the ages of the three patients to whose cases reference is about to be made, were respectively 3, 18, and 35; the progress is very rapid generally, and forms a marked contrast with those cases of chronic 405 MALIGNANT DISEASE OF THE EAR. disease of the ear advancing to the brain, to which attention has hitherto been drawn. Sophia W., aged 35, a single woman, was admitted under my care into St. Mary's Hospital, on the 14th July, 1854. The history, as given by herself, is, that after a severe cold, a year previously, the right ear suddenly became painful, though the pain was not very severe. Since the above period, the pain has been gradually increasing accompanied by a tumefaction of the right side of the face. Six months ago a red growth was removed from the tube of the ear, which the surgeon considered to be a polypus, and since then she has had at times a good deal of bleeding from the ear. Lately the pain has greatly increased, and has extended over the side of the head and the face; a small round swelling has also appeared at the orifice of the ear. On examination, the external ear was observed to be much redder than natural, and somewhat hypertrophied; and the orifice of the meatus was closed by a red tumor about the size of an almond, upon pressing one side of which a small quantity of sanious discharge issued from the meatus. The integuments around the ear, for the distance of an inch and a half, were red, soft, and somewhat elevated above the surrounding parts by a tumor beneath them. The left portio dura nerve was completely paralyzed; there was much pain of a pricking and shooting character complained of in the region of the tumor, and this at times extended inwards to the brain. The treatment consisted in occasionally applying a leech or two in the region of the ear, so as by diminishing the congestion, to relieve the pain; small doses of morphia were frequently administered, and the general health supported; the meatus was frequently syringed with warm water, and emollient applications made to the tumor. These remedies, however, led to very transient amelioration of the symptoms; though the pain would sometimes subside, the patient was subject to frequent and severe relapses. She was able, however, to walk about the ward, and a few days previous to her death expressed a wish to leave the hospital in order to visit her friends in the country. On the 23d of October, she did not complain more than usual of the pain in the face and head, but on the 24th and 25th there were symptoms of considerable cerebral congestion ; she wandered a good deal, and the head was evidently a source of great distress to her. The symptoms of congestion gradually increased, and she died on the 28th of October. Autopsy. —The integuments of the external ear, and those cover 406 THE DISEASES OF THE EAR. ing the tumor, were red and tumefied. Upon reflecting the ear and the integuments from the tumor, a large mass was exposed, which extended from the posterior part of the mastoid process, posteriorly, to the body of the malar bone anteriorly, and also from half an inch below the squamous suture to the angle of the inferior maxilla below. The tumor was intimately connected with the integuments, and of a reddish-white color. It presented different degrees of consistence, being in front, where it surrounded the ascending ramus of the lower maxilla, quite hard and firm like the pancreas, while more posteriorly it was softer; and deeper towards the styloid process, there was a large quantity of a white creamy fluid. Both anterior and posterior to the external auditory meatus, the tumor contained small spiculas of bone. The mastoid process was involved in the disease, and was deduced to some detached masses of bone in the middle of a portion of the tumor. The osseous meatus had wholly disappeared, and the remains of the membranous meatus could scarcely be distinguished, its walls having become so much involved in the diseased mass. The only remains of the tympanic cavity were some portions of the mucous membrane, having a dark livid hue, with distended bloodvessels, and small red growths attached to it. Not a remnant was left of the bony cavity. The whole of the squamous bone, from an inch below the squamous suture, and the whole of the outer part of the petrous bone had been destroyed, so that the apex of the petrous bone had no connection with the squamous. The tumor had advanced inwards to the cavities of the cerebrum and cerebellum, through the aperture formed by the destruction of the squamous and petrous bones. In the middle cerebral fossa was a reddish-white tumor, of about the size of a small pear, which consisted of two portions, one below, and the other above, the dura mater. The part below the dura mater was directly continuous with the external tumor, while the large portion above seemed to be an independent growth from the free surface of the dura mater, and connected to the larger mass of the tumor by bloodvessels only. The upper part of this portion of the tumor was adherent to the lower surface of the left middle cerebral lobe, which was softened to the depth of half an inch. The part of the tumor posterior to the petrous bone, and beneath the tentorium, was somewhat smaller and less prominent than that just described in the middle cerebral fossa, was wholly confined to the interior surface of the dura mater, and must have almost entirely arrested the circula- MALIGNANT DISEASE OF THE EAR. 407 tion of the lateral sinus. The whole of the cerebral veins and sinuses were very much distended with dark-colored blood, but there was no appearance of disease in any other part of the cerebral substance than the softened portion of the inferior lobe. On examining the tumor by the aid of the microscope, the harder portions were found to consist of very delicate fibres and nucleated cells, while the softer parts and creamy fluid were almost wholly composed of nucleated cells, circular, fusiform, and angular. There appears every reason to believe that, in this case, the disease originated in the tympanic cavity. It will have been seen that the seat of the pain when first complained of, was the ear. This was followed by a growth from the meatus, similar to a polypus, and then by paralysis of the portio dura nerve. From this centre the disease seems to have spread in all directions, destroying every structure which it approached. In the preparation, a large portion of the osseous wall of the cranium is seen to be absent, so that, by pressing upon the tumor during life, the contents of the cerebral cavity were also subject to pressure. Unfortunately in these cases, little can be done even to alleviate the sufferings of the patient. Local depletion by leeches applied to the vicinity of the tumor, hot fomentations and the administration of opiates, appear to be the only remedies capable of doing any service. It is nevertheless of the utmost importance to be able to decide upon the nature of the disease whenever it does occur, since measures will at least be refrained from that are calculated to aggravate the disease, and no operation will be attempted. In the case in question, it is possible that the removal of part of the tumor, which w r as thought to be a polypus, did material injury, by causing the disease to advance more rapidly. Those who are careful will have no difficulty in distinguishing between an ordinary polypus growing from the walls of the meatus, and a portion of tumor similar to that of the case under discussion. The polypus is smooth and globular, and not covered by epidermis; neither does it present an ulcerated surface, such as would be disclosed by a portion of encephaloid tumor when it exists and gives off secretion. Again, in cases of polypus growing from the external meatus, there is very rarely any tumefaction of the ear or integuments, such as is found in malignant disease. The observation, so frequently made by me, may here be repeated, that as polypoid growths are so often symptomatic of the existence of irritation within the tympanic cavity, and are sometimes coexistent 408 THE DISEASES OF THE EAR. with disease of the bone, great caution should always be used previous to proceeding to extirpation. By referring to a very interesting case of malignant disease of the ear, published by Mr. Wilde at page 206 of his treatise on Aural Surgery, it will be found that he also lays much stress upon the necessity of being careful " in meddling with morbid growths of long standing, without being fully satisfied as to their nature, and the place from which they grow." The cause of death in the patient whose case has here been considered, appears to have been congestion of the brain, produced by the pressure of the tumor on its substance, as well as upon the lateral sinus. The second preparation illustrative of the effects of malignant disease of the ear extending to the brain, which has to be described, was laid before the Pathological Society of London, in 1850, by Mr. Cooper Forster, to whom I am indebted for the specimen. The particulars, copied from the Transactions of the Pathological Society, are as follows:— " A strumous lad, aged 19, was knocked down by a cab nineteen months before his death, and struck on the right side of his head. He soon afterwards became deaf, and suffered severe pain in the right ear; the part became slightly swollen and excessively tender, especially over the mastoid process. The swelling did not increase, but the pain in the head was most intense, and paralysis of the right portio dura nerve took place. No great change occurred until within the last six months, when from another blow on the same spot, the disease seemed to become more active; the side of the head, from above the temporal ridge to two inches below the ear, became enormously enlarged and tender; and the external ear appeared as though pushed away from the side of the head. He experienced great difficulty in swallowing solid food, and was also unable to speak. " About two months before his death, the swelling began to fungate and slough, profuse hemorrhage occurred at intervals, and sloughing very rapidly took place, and at last laid bare the pharynx. To such an extent, ultimately, had the destructive action taken place, that a large chasm formed around the ear, leaving that organ completely isolated. No brain symptoms occurred. The profuse hemorrhage and constant drain of pus quickly destroyed him. " Autopsy. —The brain appeared perfectly healthy except at the lower part of the right hemisphere, which was pulpy and very soft. 409 MALIGNANT DISEASE OF THE EAR. The softening was, without doubt, occasioned by the upward pressure of a hard scrofulous-looking mass, attached to the petrous portion of Che temporal bone, through the intervention of the dura mater, from which it seemed to spring. The mass pressed upon the bone below, and appeared as though inclined to force its way downwards, through the temporal bone, at the junction of the squamous with the petrous portion, a great part of the latter being completely absorbed. Some new bone had formed at the inner side, and the whole of the exterior was occupied by a sloughy mass and carious bone (as below), the surrounding parts being very hypertrophied ; no vestige of meatus or mastoid cells could be discovered; the lateral sinus was filled by a coagulum." Fig. 100. From the history of the case just cited, and an examination of the preparation, there is no doubt on my mind but that the nature of the disease was malignant, very probably encephaloid, and that it commenced in the tympanic cavity. It will have been observed that the early symptoms indicated that the disease was in the ear, both by the pain experienced there, and by the presence of deafness. If the preparation be carefully inspected, it will be seen that 410 THE DISEASES OF THE EAR. the largest amount of destruction, and the most marked appearance of disease, are around the tympanic cavity; from which the progress seems to have been downwards to the pharynx; upwards to the outer surface of the squamous bone, and lastly, inwards and upwards to the cavity of the skull. The orifice communicating between the disease without and that within, is, however, very small in comparison to the extent of the disease externally, and the internal surface of the bone is much less affected than the outer. That the disease was malignant is shown, I think, by the bleeding and fungoid character of the soft growth, and the peculiar expanded and spiculated state of the bone. The third case is one published in the eleventh volume of the Edinburgh Medical and Surgical Journal, by Mr. Wishart, and called by him a case of fungus haematodes. The subject was a child three years old, in whom, after suffering for some weeks from severe pain in the right ear, followed by discharge, a tumor appeared surrounding the ear, and which speedily ulcerated, discharging a large quantity of fetid bloody matter; hemorrhage also frequently occurred. The child died within fifteen weeks after the appearance of the disease. On a post-mortem examination, the tumor was found to be as large as the child's head; externally it had caused the destruction of the condyloid process of the lower jaw; the zygomatic process was also gone. The tumor had advanced inwards, destroying the whole of the petrous bone, and extended upwards, through a large orifice in the squamous bone, so as to form a depression on the middle lobe of the brain, which was in other respects quite sound. As bearing upon the subject, I may as well give briefly the particulars of a case of disease of the petrous bone which occurred in the practice of Mr. Part, of Camden Town, to whom I am indebted for the preparation. The patient was a clergyman, aged twentyfive, subject for five years to a discharge from the right ear, with occasional pain. A year before his death an abscess broke behind the ear, w r hich discharged at times. About a fortnight before his death he suffered from severe pain in the head and vomiting, and had paralysis of the right portio dura nerve. He was not relieved by any treatment, and the head symptoms increased until his death. On a post-mortem inspection, a cavity was found in front of the ear, and another beneath the temporal muscles; both contained a soft caseous substance. The whole of the petrous bone, a portion of the MALIGNANT DISEASE OF THE EAR. 411 basilar process of the occipital and of the sphenoid, were found degenerated into a soft cheesy mass. The malar bone was destroyed, and the mastoid process occupied by the disease. The ventricles contained three ounces of bloody serum; the arachnoid was much injected; while between it and the pia mater was a layer of very yellow pus, extending along the base of the brain. In the middle lobe of the brain was an abscess containing upwards of an ounce of very fetid greenish pus; and a second abscess existed in the middle of the posterior lobe. If the preparation be examined, as in the preceding cases, there will be found to be a large aperture in the squamous bone, and the petrous and mastoid bones are wholly converted into the white cheesy-looking matter. On examination by the microscope, this matter is discovered to consist of cells, varying in form, only few of which have any distinct nuclei; granular matter is also interspersed among the cells. The case may be considered as one of degeneration of the petrous bone, originating in the tympanic cavity. The ulceration at times proceeds most rapidly, extending to the bone, which is soon destroyed. Sometimes the greater part of the squamous bone disappears. A case of the kind has been published by Dr. Russell, of Birmingham, in the Association Journal, for March 31st, 1852, of which I will give a few particulars. Mrs. P., aged 66, was attacked, about nine months before her decease, with pain in the right ear, attended with swelling. A fortnight afterwards, she struck it against a bracket; the swelling broke, and the ear discharged. The discharge and pain continued, and paralysis of the portio dura ensued, while the power of hearing disappeared. At the time she was seen by Dr. Russell, there was intense pain in the ear; mania, coma, and ultimately death, ensued. There was no history of early disease in the ear, but she had been accustomed to pick it with a pin, for a certain degree of itching. On an autopsy, the entire squamous portion of the temporal bone was found to have been destroyed, and the disease had encroached upon the mastoid process, laying open the cells. The petrous bone was also almost entirely destroyed. The dura mater was not injured, except in one spot, where there was a sloughy opening, the size of a crown-piece. Opposite the orifice in the dura mater, the brain was in a state of suppuration; and both ventricles were full of the de*bris of sloughy cerebral tissue. There were about two drachms of thin, purulent fluid at the base of the brain. This spe- 412 THE DISEASES OF THE EAR. cimen, which through the kindness of Dr. Russell I had an opportunity of inspecting, presented a very similar appearance to the one previously described. In each case all vestiges of the tympanic cavity had disappeared. They differ from the great majority of cases of disease in the tympanum, in extending outwards instead of upwards. The treatment in these cases consists in diminishing the symptoms of congestion of the brain, by the occasional application of leeches, and in attempting to allay the pain by the administration of morphia. CHAPTER XVIII. ON THE DEAF AND DUMB. DISEASES PRODUCING DEAF-MUTISM —THE CONDITION OF THE EARS IN THE DEAF AND DUMB, AS ASCERTAINED BY EXAMINATION DURING LIFE — THE CONDITION OF THE EAR IN THE DEAF AND DUMB, AS REVEALED BY DISSECTION —THE MODE OF EXAMINING A CHILD SUPPOSED TO BE DEAF AND DUMB —ON THE MEDICAL TREATMENT OF THE EARS OF THE DEAF AND DUMB —THE AMOUNT OF HEARING POSSESSED BY CHILDREN USUALLY ACCOUNTED DEAF AND DUMB —OF THE EDUCATION OF THE DEAF AND DUMB J WITH CASES. The number of deaf-mute children examined, and from whom the facts in this chapter were obtained, amounted to 411. Of these, 313 were congenital cases, and 98 were the effect of different diseases acquired subsequent to birth. I. THE DISEASES PRODUCING DEAF-MUTISM. On the causes producing congenital deaf-mutism I am unable to offer a decided opinion; but the results of dissection, as detailed in a subsequent part of this chapter, show that the nervous apparatus is very frequently affected. If regard be also paid to the other cases I shall refer to, and the non-appearance of an efficient cause of any other kind, together with the analogy to be drawn from the cases in the chapter on Nervous Deafness, it would be no very violent assumption to suppose that early derangement of the nervous apparatus is at the root of most of the instances of deaf-mutism. Of the causes of acquired deaf-mutism a more accurate estimate may be formed. Thus in the 98 cases of acquired deafness the causes were as follows:— Scarlet Fever 36 Fever, . . ' • 23 Measles, 4 Various diseases, as teething, convulsions, hydrocephalus, a fall, fits, a fright, &c, 35 98 414 THE DISEASES OF THE EAR. II. THE CONDITION OF THE EARS IN THE DEAF AND DUMB, AS ASCERTAINED BY EXAMINATION DURING LIFE. The condition of the ears in the deaf and dumb is very various, and in the majority of the ears there is some abnormal appearance, although it is often very slight. Thus, in only 197 out of 411 patients were the ears healthy. The following table shows the condition of those ears that were not healthy:— In 66 the surface of the membrana tympani was dull. 38 the membrana tympani was opaque. 12 the membrana tympani was more concave than natural. 3 the membrana tympani was very concave and opaque. 1 the membrana tympani was shrivelled. 10 the membrana tympani had fallen inwards. 9 the membrana tympani was perforated. 18 the membrana tympani was absent, from ulceration, 2 the meatus was full of cerumen. 35 the meatus was full of cerumen, and the membrana tympani opaque. 3 the meatus externus formed a cul-de-sac half an inch from the orifice. 1 the meatus contained a polypus. 3 the membrana tympani of one ear was opaque, and in the other it had fallen inwards. 2 the membrana tympani was opaque in one ear and absent in the other. 1 the membrana tympani was normal in one ear and absent in the other. 3 the membrana tympani was fallen in in one ear and perforated in the other. 1 the membrana tympani was natural in one ear and the meatus full of cerumen in the other. 1 the membrana tympani was fallen in in one ear and dull in the other. 1 the membrana tympani was absent in one ear and the meatus contained a polypus in the other. 1 the membrana tympani was very concave in one ear and had fallen inwards in the other. 415 ON THE DEAF AND DUMB. In 1 the membrana tympani was natural in one ear and very concave in the other. 1 the membrana tympani was perforated in one ear and opaque in the other. 1 the membrana tympani was very concave in one ear and absent in the other. It is interesting to observe the difference between the condition of the ears in the acquired and congenital cases. The condition of the ears in the 313 congenital cases: — 172, or nearly three-fifths, had a natural appearance. In the 172 cases of absolute deafness the following was the condition of the ears:— 96 had a healthy appearance. In 37 each membrana tympani was dull. 20 there was an accumulation of cerumen, and each membrana tympani was dull. 12 each membrana tympani was opaque. 1 each membrana tympani had been destroyed by ulceration. 2 one membrana tympani was opaque, the other had fallen in. 1 one membrana tympani was opaque, the other was absent. 1 one membrana tympani was natural, the other was opaque. 1 one membrana tympani was natural and the other was absent. 1 one membrana tympani was fallen in and the other was perforated. 172 The following was the condition of the ears in the 141 congenital cases, in which certain sounds were heard:— (a.) In 11 who heard a clapping of the hands, 7 had a normal aspect. In 2 each membrana tympani was opaque. 1 each meatus was distended by cerumen, and the membrana tympani was opaque. 1 each membrana tympani was concave. 416 THE DISEASES OF THE EAR. (b.) In the 44 who heard a shout:— 21 were apparently natural. In 7 each membrana tympani was dull. 4 " " " " and the meatus full of cerumen. 4 " " " opaque. 4 " " " concave. 2 " " " concave and opaque. 2 " " " perforated. (c.) In the 39 who heard a loud voice:— 24 were apparently normal. In 7 each membrana tympani was dull. 3 " " " " and the meatus full of cerumen. 3 " " " opaque. 1 " " " concave. 1 in one ear the membrana tympani was normal; in the other it was opaque, and the meatus full of cerumen. (d.) In the 43 who heard the vowels and repeated them after me:— 24 appeared to be normal. In 6 each membrana tympani was dull. 5 " " " " and the meatus was full of cerumen. 5 " " " opaque. 1 " " " concave and opaque. (e.) In the 5 who heard words and repeated them:— 2 appeared normal. In 1 each membrana tympani was dull. 1 " " " " and the meatus was full of cerumen. 1 in one ear the membrana tympani was opaque and concave, and in the other it had fallen in towards the promontory. (/.) In the single instance in which short sentences were heard and repeated, the membrana tympani was dull. 417 ON THE DEAF AND DUMB. The condition of the ear in the 98 acquired cases of deafness. Of the entire number, only 23, or about one-fourth, had a natural appearance; of the 75 cases of acquired deafness, in which there was no power of hearing, 19, or about one-quarter, were apparently normal; including those instances in which the surface of the membrana tympani was only slightly dull, 27, or about one-third of the whole had a natural appearance. Of the 25 acquired cases in which there was a certain amount of hearing power, 5, or onefifth, were apparently healthy. Scarlet Fever. In the 36 cases of scarlet fever, only two patients had the ears in a healthy state; in 15 each membrana tympani was absent, and in 5 each membrana tympani was perforated; in 3 each meatus formed a cul-de-sac about half an inch from the orifice. It is clear, therefore, that in the majority of cases of deafness from scarlet fever, the effects of very active disease were apparent; this disease was usually catarrhal inflammation of the tympanic mucous membrane, ending in an ulceration of that membrane, which extended to the labyrinth. As it is interesting to observe the relation between the amount of hearing possessed by a patient, and the condition of the ears, I have arranged the results in the following forms:— (a.) Condition of the ears in the 27 patients who were entirely deaf:— In 1 each ear was apparently healthy. 4 the surface of each membrana tympani was dull. 1 each membrana tympani was concave. 2 " " " fallen in. 3 " " " perforated. 13 " " " absent, and there was catarrh of the tympanic mucous membrane. 3 each meatus formed a cul-de-sac about half an inch from its orifice. (&.) Condition of the 9 patients by whom certain sounds are heard:— 27 418 THE DISEASES OF THE EAR. In the single individual who heard a clapping of the hands, each membrana tympani was absent. Of the Jive who heard a loud voice :— In 1 the membrana tympani was fallen in. 2 " " " perforated, and there was a polypus in the meatus. 2 " " " absent in each ear. Of the two who pronounced the vowels : — In 1 the membrana tympani was dull and opaque. 1 in the right ear the membrana tympani was fallen in; in the left ear it was absent. In the one child who pronounced short words both ears were apparently natural. Condition of the ears in the 23 cases of deafness from fever: — (a.) In the 17 who did not hear any sound :— 3 were apparently healthy. In 2 each meatus was distended by cerumen. 3 each membrana tympani was opaque. 1 " " " dull. 1 " " " white and shrivelled. 2 " " " fallen in. 1 " " " perforated. 1 " " " destroyed by ulceration. 1 each meatus full of paper, each membrana tympani fallen in and red. 1 right ear, the membrana tympani concave and thick; left ear, membrana tympani perforated and fallen in. 1 right ear contained a polypus; in left ear the membrana tympani was absent. (b.) In the 6 who heard sounds. In the four who heard a shout:— 1 each membrana tympani was dull and opaque. 1 " " " perforated; the mucous membrane of the tympanum being thick. 1 each membrana tympani was dull. 1 right ear, the membrana tympani was perforated; left ear, the membrana tympani fallen in and corrugated. ON THE DEAF AND DUMB. 419 In the single instance in which a loud voice was heard, each membrana tympani was opaque; and in the case where the patient tried to articulate words after the speaker, each ear was apparently normal. Condition of the ear in the four cases of measles: — (a.) Of the three who were deaf:— In 1 each ear was apparently normal. 1 each membrana tympani white and thick. 1 right ear, the membrana tympani dull; left ear, membrana tympani dull, and fallen in. (b.) In the patient who heard a clap of the hands, each membrana tympani was thick and white. Condition of the ear in the 35 cases of deafness produced by various diseases, as teething, convulsions, hydrocephalus, a fall, fits, a fright, &c.: — In seventeen cases each ear appeared to be normal. In several of the others the membrana tympani was dull on the surface, opaque, or concave. In three cases it had fallen in; but in only two was it perforated: thus showing a marked difference between the effects of these diseases and those of scarlet fever; where it will be remembered that, in 20 out of 36 cases, each membrana tympani was either absent or perforated. I will give, first, the condition of the ears in the patients entirely deaf, and then the condition of those having various degrees of hearing. (a.) Condition of the ears in the 26 patients who were entirely deaf:— 14 appeared natural. In 2 each membrana tympani was dull. 3 " " opaque. 4 " " concave. 1 " " fallen in. 420 THE DISEASES OF THE EAR. In 1 one ear appeared natural; in the other the membrana tympani was fallen in. 1 in one ear the membrana tympani was opaque; in the other was absent. In the case where the clap of the hands was heard, each ear appeared to be natural. (b.) Of the three who heard a shout:— 1 appeared to be natural. In 1 each membrana tympani was opaque. 1 the membrana tympani of one ear was concave, and it was natural in the other. (c.) Of the four who heard a loud voice:— 1 appeared natural. In 1 each membrana tympani was opaque. 2 the membrana tympani of each ear had fallen in. In the single case where the vowels were heard, the membrana tympani of one ear was opaque, and it was perforated in the other. III. ON THE CONDITION OF THE EAR IN THE DEAF AND DUMB, AS REVEALED BY DISSECTION. It is highly desirable that careful dissections should be made of the ears of deaf and dumb patients, whose cases have been carefully noted during life, in order that the condition of the organ may be compared with the amount of hearing possessed by the patient. Pathological investigations into the condition of the ear in the deaf and dumb have, however, been too seldom conducted to enable us to draw any conclusive general deductions as to the condition of the ear in deaf-mutes. I purpose now to give the details of five dissections performed by myself, and to follow them with a tabular view of the morbid appearances found in all the other dissections of similar cases that have been met with by me. Dissection 1.—A woman, aet. 40, deaf, and consequently dumb, from birth. For the last ten years of her life she was insane, and was confined in a lunatic asylum. The petrous bones were sent to 421 ON THE DEAF AND DUMB. me, immediately after the death of the patient, by the late Mr. Crosse, of Norwick. Bight ear. —The meatus externus, membrana tympani, and the tympanic cavity were in a healthy state. Labyrinth. —The anterior limb of the superior semicircular canal communicated with the vestibule, but was rather larger than natural, and its shape somewhat irregular. Examined as it passes inwards, it was observed to terminate in a cul-de-sac, after having attained only half its usual length. The portion of bone in the situation usually occupied by the inner part of the canal was of an ivoid whiteness, and could be distinctly distinguished from the surrounding bone. The greater part of the posterior semicircular canal was absent, its anterior and posterior extremities presenting two cul-de-sacs, half a line in length. The external semicircular canal, the vestibule, and cochlea, were in a normal state. Left ear. —The superior semicircular canal is in the same incomplete state as that of the right ear. Dissection 2.—J. C, set. 50, died from fever. He was born deaf, and had been educated as a deaf-mute. Bight ear. —Meatus externus in a natural state, excepting that one part of the osseous parietes was quite rough. Membrana tympani thicker than natural, and perforated: a small red polypus was attached to its dermoid layer. A membranous band connected the stapes, incus, and tensor tympani muscle. The osseous semicircular canals were large; but they did not contain any membranous tubes. The cochlea was in a normal state, as were also the tympanic muscles and nerves. Left ear. —The osseous semicircular canals did not contain any membranous tubes. One of the osseous canals was so contracted as to admit of the passage through it of a fine wire only. Dissection 3.—R. B., set. 16, a girl, sharp and intelligent. Her parents stated that she was born deaf; but the child, on the contrary, said that she had heard sounds. Her teacher thought the child's statement to be more likely to be correct, as she pronounced many words according to their proper sounds. None of her relatives were deaf-mutes. Upon making a careful dissection of each ear, no deviation from the normal condition could be detected in the meatus externus, membrana tympani, or tympanic cavity. The stapes adhered to the fenestra ovalis with its usual degree of firmness. The membranous labyrinth in the vestibule was healthy, 422 THE DISEASES OF THE EAR. as also was that in the semicircular canals, with this exception, that in the middle of the superior semicircular canal in the right ear was a quantity of otoconie (ear crystals), which completely obstructed the tube. From the occurrence of an accident to the left ear, it was not possible to ascertain its condition. Dissection" 4.—A boy, set. 15, who had been wholly deaf from his birth. No deviation from the normal state in either ear could be detected by me. Dissection 5.—For the opportunity of making this dissection, I am indebted to Dr. Ormerod, of Brighton. The ears were taken from a young woman deaf and dumb, with discharge from each ear. She died with tubercular inflammation of the brain. Right ear. —The membrana tympani was absent; the mucous membrane of the tympanum red, and of extreme thickness, so as to fill the whole of the tympanic cavity and to conceal the stapes; the tympanum was distended with dark-colored blood. The petrous bone was so intensely hard, that it could with difficulty be cut by the bone forceps. The cochlea, to the naked eye, had a natural appearance, and submitted to microscopic examination, no deviation from the normal structure could be detected, excepting in that portion of the lamina spiralis which is near to the vestibule. This, instead of being composed of a delicate osseous lamina and a fine membrane, the two making a delicate septum between the scala tympani and scala vestibuli, presented a mass of solid bone filling up the scala tympani, and concealing from view the membrana fenestrse rotundse; the inner surface of which it wholly covered. The outer surface of this membrane could, however, be distinctly seen from the tympanic cavity, and it appeared natural. The semicircular canals contained more otoconie than natural. Left ear. —The membrana tympani absent. The mucous membrane of the tympanum thick and red, as in the right ear. The semicircular canals contained more otoconie than natural, and especially the posterior one, which, at its junction with the posterior limb of the superior canal, was wholly distended with crystals for the extent of half a line. The lamina spiralis of the cochlea was of a deep red color, and blood was effused in both scalse. The part of the lamina spiralis near to the vestibule was in the same state as the same portion in the right ear. In the subjoined table the condition of the ears in deaf-mutes, as revealed by various reported dissections, is shown. 423 ON THE DEAF AND DUMB. A TABULAR VIEW OF THE CONDITION OF THE EAR IN THIRTY-SIX DISSECTIONS OF DEAF-MUTES. Meatus Membrana _ T v ¦ »u nr«__« Name of Externus. Tympani Tympanum. Labyrinth. j Nerve. observer. Absent. Absent. Absent. . . .# Destroyed. Do. Partially destroyed. Do. Do. Containing vegetations from the mucous membrane ; ossicles absent. Do. Containing sorofulous matter. Containing calcareous concretions. Full of gelatinous j matter. Containing a yellow fluid. Anchylosis of stapes to fenestra ovalis. All the ossicles wanting. ... I ... i Full of gelatinous matter. Vestibule full of caseous matter. Cochlea consisting of only one turn and a half. Vestibule, cochlea, and semicircular canals absent. Semicircular canals wanting. Itard. Fabrioius. Do. Itard. Do. Do. Mr. Cock. Do. Do. Itard. Do. Rosenthal. Valsalva. Reimarus. Dr. Haighton. Mundini. Meckel. Murer. As soft as mucus. Harder than natural. * Where no entry is made, it is to be assumed that the part of the organ was in a healthy state. 424 THE DISEASES OF THE BAR. Meatus Externus. i Membrana Tympaui. Partially destroyed. Destroyed. Tympanum. * All the ossicles wanting. . . . Mucous membrane thick. Labyrinth. Two of the semicircular canals imperfect. Do. Fenestra rotunda closed by bone in each ear. One semicircular canal incomplete in one ear only ; the other ear healthy. Aquaaductus vestibuli very large. Semicircular canals absent in one ear. Filled with caseeus matter. 1 A portion of one of the membranous semicircular canals filled with otoconie. The superior and posterior semicircular canals incomplete in right; ear; the superior incomplete in the left ear. Membranous semicircular canals absent. Lamina spiralis < near the vestibule filling the seal a tympani. Nerve. Atrophied. Indurated. Wanting. Very hard. Half its usual size. Atrophied. Compressed by a tumor. Otoconie obstructing the canals. Name of Observer. Mr. Cock. Do. Sylvius. Arneman. Morgagni. Mr. Cock. Dr. Thurnam Dairy mple. Rosenthal. Murer. Dr. Haighton. Hoffman. Duverney. Author. Do. Do. Do. Do. 425 ON THE DEAF AND DUMB. IV. ON THE MODE OF EXAMINING A CHILD SUPPOSED TO BE DEAF AND DUMB. From the absence of precise experiments from which accurate conclusions could be drawn, great difference of opinion frequently exists, even among medical men, as to whether a child suspected of being deaf and dumb really is so. It frequently happens, therefore, that a child is reported not to be deaf, because it always starts or looks up when the door of the room is loudly knocked, or the floor over the room is tapped with considerable force, or the fire-irons in the room are permitted to fall, or the piano is played. A similar opinion is often formed because a child can utter some short syllables, as " Mam," " Pa," &c, it being argued that no child could learn to utter these sounds unless it had heard them. It is also asserted that a child could not have been born deaf, because the defect was not discovered until it had reached the age of a year and a half or two years. In reply to the above arguments in favor of a child's being able to hear, it must be borne in mind that loud sounds are always accompanied by more or less vibration of the walls and floor of the apartment, which can be felt by a person whose attention may thus be attracted, although totally deaf. A child may also learn to utter short words by simply imitating the movements of the lips of the parent, or nurse, without the exercise of the sense of hearing. The plan adopted by me to ascertain whether a young child is deaf consists, in the first place, of allowing it to sit on the knee of the nurse or parent, and be amused by something, and then while its eyes are fixed upon the object, to speak loudly, or shout, taking especial care that the breath does not reach the patient. Again, let the child, its attention distracted as before, be placed with its back towards the surgeon, who should, when near it, clap his hands loudly, ring a large bell, or blow a powerful whistle, always taking care that his own shadow is not seen, and that the child is screened from the movements of the air, while the nurse is warned not to start or suddenly look up; or the surgeon may come into a room, the door of which has been some time open, and where the child is seated with its back towards him surrounded by toys, and perform similar experiments. If the child does not evince any symptom of hearing, by suddenly lifting up its eyes, turning round, or starting, 426 THE DISEASES OF THE EAR. it must be concluded that it is wholly deaf; but if, on the contrary, it looks up each time the surgeon shouts, or turns round quickly the instant the hands are clapped, it is evident that some power of hearing exists, and steps should be taken to ascertain the extent of such power, and how far it may enable the child to be orally taught. V. ON THE MEDICAL TREATMENT OF THE DEAF AND DUMB. It is of great importance that the surgeon should be able to decide what treatment, if any, should be pursued when deaf and dumb children are brought to him. The first rule which may be laid down is, that in those cases where there is no hearing power whatever, and in which it is snpposed that the nervous apparatus is either incomplete or much disorganized, no treatment for the purpose of improving the hearing should be resorted to. The friends of the child should be told that there is no hope of any change, and that it will have to be educated as a deaf-mute. On the contrary, should there be a certain decided amount of hearing power, some attempt, it is obvious, should be made to develop it. Where the child is evidently born deaf, general medicinal treatment is not required; and the only remedy is the use of means to excite the nervous system of the ears to natural action. By the persevering use of the long elastic tube, the hearing power has, in some cases, been decidedly increased. In cases where by disease subsequent to birth, either the membrana tympani, or the mucous membrane lining the tympanum, has been thickened, counter-irritation over the mastoid process will aid the use of trumpets; and in those where the membrana tympani has been partially or wholly destroyed by ulceration, and where there is a constant discharge of mucus from the surface of the tympanic mucous membrane, it is desirable for the ears to be syringed, and occasionally with a weak astringent, so as to prevent the membrane becoming ulcerated, and the bone which it covers, carious. The artificial drum may also be resorted to. 427 ON THE DEAF AND DUMB. VI. THE AMOUNT OF HEARING POSSESSED BY CHILDREN EDUCATED AS DEAF AND DUMB. The examination of a large number of children usually considered to be wholly deaf, and consequently educated as deaf-mutes, shows that a large proportion are not totally deaf, but that, on the contrary, certain sounds are distinctly heard. Thus, it will be observed, that of the 411 children examined at the Deaf and Dumb Asylum, 245, or three-fifths were quite deaf, not hearing any sound; while 166, or two-fifths, heard certain sounds. The 166 cases in which certain sounds were perceptible, may be classified as follows:— 14 heard a clapping of the hands. 51 heard a shout close to the ears. 50 heard a loud voice close to the ears. 44 distinguished vowels, and repeated them. 6 repeated short words. 1 repeated short sentences. 166 Of the 411 children it has already been stated that 313 were cases of congenital deafness, while 98 were acquired cases. Of the 313 congenital cases —• 172, or about five-ninths, were deaf —t. e., no sounds were heard by them. 141 heard certain sounds. 313 congenital cases. The 141 cases in which certain sounds were heard may be classi fied as follows:— 11 heard a clapping of the hands near to the head. 44 heard a shout. 39 heard a loud voice. 41 heard the vowels, and repeated them. 5 heard words, and repeated them. I heard short sentences, and repeated them. 428 THE DISEASES OF THE EAR. Of the 98 acquired cases — 73, or about three-fourths, were deaf. 25 heard certain sounds. The 25 acquired cases in which certain sounds were heard may be particularized as follows:— Arising from scarlet fever, 9 :— 1 hears a clapping of the hands. 5 hear a loud voice. 2 pronounce the vowels. 1 pronounces short words. Fever, 6:— 4 hear a loud shout. 1 hears the voice. 1 hears the voice, and tries to imitate it. Measles, 1: — 1 hears a loud clapping of the hands Various Diseases, 9 :— 1 hears a loud clapping of the hands. 3 hear a shout. 4 hear a loud voice. 1 repeats the vowels. VII. ON THE EDUCATION OF THE DEAF AND DUMB. The observations to be offered upon the system usually adopted for the education of the deaf and dumb, have reference to two points: first, the improvement of the power of hearing; second, the use of the vocal organs. 1. Of the improvement of the power of hearing. It would be very interesting to know how far the facts respecting the hearing power of so-called deaf and dumb children, cited in a ON THE DEAF AND DUMB. 429 previous part of this chapter, are corroborated by the observations of others. Itard hazarded the opinion that one-half of the pupils at the Deaf and Dumb Institution at Paris were wholly deaf, and that the other half heard some sounds. It is assumed by the writer of the very interesting article on the Deaf and Dumb, in the " Penny Cyclopaedia," that the same proportion of the totally deaf to those who hear a little, will be met with in our English institutions. If there exist throughout the deaf and dumb in England relatively, as many cases of a large amount of hearing as in the London Institution, steps taken to improve the hearing power might be productive of the most valuable results; especially as my own limited experience warrants the assertion that this power is capable of considerable development, as may be seen by the cases appended. Though one of these does not belong to the category of the deaf and dumb, yet the long duration of nearly total deafness in one ear, followed by so great a restoration of its dormant power, renders the case of great interest in the present inquiry. The treatment calculated to improve the hearing consists in the use of trumpets, whereby the nervous apparatus may be gradually excited, as to become sensitive to ordinary sonorous undulations and external stimulants. While quite agreeing with Mr. Wilde, that we cannot hope to cure cases of deaf-mutism, I still think, when there already exists the power to hear the vowels so distinctly as to distinguish and repeat them, that from the exercise of the ear considerable improvement may reasonably be anticipated; sufficient, in fact, to aid in carrying out the end above all things to be desired, viz., the exercise of the organs of speech. The influence of the use of the vocal organs upon the general health has, it seems to me, scarcely been sufficiently considered in the education of the deaf and dumb. Sir H. Holland, with his usual acuteness, has placed the subject in its just light. He says: " Might not more be done in practice towards the prevention of pulmonary diseases, as well as for the improvement of the general health, by expressly exercising the organs of respiration; that is, by practising according to some method, those actions of the body, through which the chest is alternately in part filled or emptied of air ? Though suggestions to this effect occur in some of our best works on Consumption, as well as in the writings of certain continental physicians, they have hitherto had less than their due influence, and the principle as such is little recognized or brought 430 THE DISEASES OF THE EAR. into general application. In truth, common usage takes, for the most part, a directly opposite course, and, under the notion or pretext of quiet, seeks to repress all direct exercise of this important function in those who are presumed to have a tendency to pulmonary disorders."— Medical Notes, c. xx, b. 422. To this, I may be allowed to add, in reference to the deaf and dumb, that in those cases where the organs of speech are not used, and where, consequently, the lungs, and the muscles of the chest, and heart, are not duly exercised by the act of articulation, the general health always suffers. But the great advantage of calling forth the auditory power of so-called deaf-mutes is, that they may be enabled to hear their own voices, and to modulate them; for the extreme harshness and monotony of the sounds produced by deaf-mutes arise from the impossibility of regulating the tones of a voice which they cannot distinguish. CASES. Miss L. L., set. 23, consulted me in the early part of the year 1857. Her history was, that since childhood she had heard only certain loud sounds, and was quite deaf to all conversation. Her means of comprehending what was spoken were derived from watching the movements of the lips, and the sounds she uttered appeared to be the result of her attempts at imitating the movements she saw. Upon examination, having found that the voice was heard when spoken into the ears, I recommended counterirritation and the use of a long elastic tube. At first she could hear only for from three to five minutes at a time. In a fortnight there was decided improvement in the hearing power, and she began to experience a painful sensation in the ears when too loudly spoken to. To use the words of her sister (who devoted herself to the poor patient in a way that only a sister or parent could), "During the third week the improvement was wonderful. This was not so perceptible with the tube as in her hearing generally. Everything was so much louder to her, but not more distinct. The noise in the street now quite annoyed her: she called it dreadful, although, when we arrived in town, she did not notice it." She left me at the end of a month's treatment, and I directed her to be spoken to daily, but only in words of one syllable, which she was to repeat to 431 ON THE DEAF AND DUMB. herself. Then very simple sentences were tried; which she heard and understood when spoken to through the tube in the ordinary way of conversing, and replied by speaking through the tube herself, so that she was able to hear her own voice and modulate it. Her sister writes: "In October, 1857, she spent three weeks at , and there she was seen by people who saw her just before she came to consult you: they said they should not have believed it possible for her to have improved so much in hearing and articulation ; her mind, too, had come out so. During the three weeks she was from home, she had a complete holiday (e. e., the tube was not used), and when she came back, the hearing had not retrograded generally, but she did not hear so well through the tube. Since her return from a visit, she has gone steadily on with the use of the tube. Latterly,"—this was wrtiten on February 2d—"for some weeks, I have talked through the tube daily an hour divided into three or four intervals. Two or three times, when much amused, she bore its use, without fatigue, half an hour at a time, and she said she could have borne it longer. Even when she has had a difficulty in comprehending what was said, I have never allowed her once to see my lips while talking through the tube. We spelt the words which she could not make out, and she never once failed to find them out by the aid of the ear alone. One afternoon she could not understand a single word of sentences she had distinctly heard in the morning. By degrees, however, she made out a word here and there, and in a few minutes heard everything I said. She had been absorbed in writing a letter till a minute or so before the use of the tube. Several times now, I observed that she heard far more easily at the end of our talk than at the beginning. To her best ear I am obliged to talk in a high treble, not loud. The left ear requires a deeper, stronger voice. Great distinctness and slowness are necessary—a monotonous tone suits her best. The final consonants must be strongly uttered. She says she now hears them, but she never did so before. She notices the difference of touch in persons playing on the piano, and can often understand much that is said without seeing the mouth. A few days since she exclaimed, 'You are talking French.' Lately, she has gained many new phrases, trying to apply those she hears in conversation, very often making wonderful mistakes. Not long ago, she said, ' That tree is a great assortment for the birds,' meaning 'resort for.' At another time she said, ' I hope you will not think me liberty,' meaning, ' I 432 THE DISEASES OF THE EAR. hope you will not think I take a liberty.' She began to read half an hour a day; it was hard work, although the book was written for a child. As hearing improved, articulation and intelligence improved, and lately I have often wondered at the change. We increased the reading to an hour, my sister constantly saying, 'I feel as if something were coming to my mind,' and expressing surprise that she could understand what she never could comprehend before. She now quite distinguished between my mode of pronouncing and her own, and we never had the tube while reading to her, as I knew its use would have distracted her thoughts from her book. Occasionally, when the word was a very difficult one, she made it out, and then had the tube used to convince her of her correctness. Numbers of people have remarked my sister's improvement. A lady saw her the first time in the beginning of August last, and she saw her no more till November, when she said to me in astonishment, ' I could not understand a word your sister said in August; now I can understand everything she says.' When I began your plans, I had to ask my sister, as a favor to myself, to allow me to talk to her sometimes; she was annoyed, and then did not hear so well. Now things are very different. She very often proposes the use of the tube, and says she wishes you could know what we had done for her." Another case, very similar to the above, also occurred to me lately. A young lady, set. between twenty and thirty, like the case above cited, had never heard sounds so as to be able to speak or read with any degree of distinctness. I subjected her to a treatment similar to that pursued in the above case, and the result was also satisfactory. In about four months I received the following report in a letter from her sister: " I do think she (the patient) is improving; a good many of her friends also think so." In another letter the same sister writes: " I really do think the improvement gradually continues, although slowly, which perhaps is the best and surest." The patient herself writes: "I cannot tell how much I have improved in hearing, reading, and speaking; but I now read much better, and I know the numbers very well by the tube. I hear everything continually. The G.'s, during my visit there, and Aunt F., say my improvement is much in speaking; they understand me very well, and I am glad of it." 433 ON THE DEAF AND DUMB. The right ear useless for sixty years; at the age of seventy so greatly improved as to hear conversation all over the room, by means of a trumpet. I was called into the country in great haste in the spring of 1856, to see a nobleman, set. 70, who was suffering from an attack of intense inflammation of the mucous membrane lining the left tympanic cavity. At the time of my seeing the patient, the inflammation had extended internally as far as the labyrinth, and the power of hearing was destroyed. The only means of communication with my patient was by writing. Having but slight hope of doing anything towards the improvement of the hearing power of the left ear, I turned my attention to the right, the drum of which had, I found, been inflamed and damaged in early life. I proposed, amid opposition at the supposed utter uselessness of the experiment, to try the effect of a loud voice spoken into the right ear. The result was decided, the sound of the voice was distinctly heard, and some words were understood. Feeling that the nervous system of this ear was lying torpid, from the circumstance that ordinary sonorous undulations had not been able to reach it through the diseased condition of the membrana tympani and mucous membrane of the tympanum, and also from the weak state of the nerve itself, I determined to try a plan of treatment having a twofold object,—the excitement of the nervous apparatus of the ear by the healthy stimulus of sonorous vibrations, through the use of ear-trumpets, and an improvement of the condition of the drum, as also of the mucous membrane of the tympanum, by remedial applications. The former of these objects was attempted at once with a most satisfactory result, for the hearing power gradually increased. In short, by the means in question, the latter of the two being principally gentle counter-irritation, the patient's power of hearing in this ear, which had been so defective during sixty years that its faculty was considered "lost," became, in the course of eighteen months, so improved, that for a long time previous to his death, he could hear a voice speaking near to the ear, and with the aid of a trumpet on his table could carry on a conversation with persons sitting in different parts of an ordinary sized room. In this case I am confident that 28 434 THE DISEASES OF THE EAR. no good would have resulted from the treatment, if the nervous apparatus of the ear had not been stimulated at the same time by the influence of sounds; and my experience tells me that hundreds of persons are living with one ear supposed to be perfectly deaf, and in reality useless, but which might be made very serviceable, were the sonorous undulations conveyed to it by artificial means. CHAPTER XIX. EAR-TRUMPETS AND THEIR tfSfi. In some cases of diminished power of hearing, there can be no doubt that ear-trumpets afford great assistance, and are a source of much comfort to the sufferers. On the other hand, if imprudently used, they are apt to increase the deafness and to cause additional distress. They are decidedly injurious, for instance, in the early stages of deafness arising from debility of the nervous apparatus, and the noises are likely to be increased by their use; while in the old standing cases of the same disease they often prove most serviceable : they are also equally advantageous in cases of partial anchylosis of the stapes to the fenestra ovalis. Ear-trumpets may be considered under three different classes, according to their use, in as many degrees of deafness. The first class consists of instruments to be worn on or in the ears, without the aid of the hand; and by means of which more voices than one, or even general conversation, can be heard. The most useful of this class of instruments are the small cornets made by Mr. Rein, which are connected by a spring passing over the head, that serves also to hold them in the ears. The cornets can be concealed by the hair or worn under the bonnet. A variety of this class is a small cornet, which can equally be concealed by the hair, and which fits into the ear, where it is retained by a convolution which passea around the ear and dispenses with the spring. The second class consists of instruments held in the hand, by means of which one voice, and sometimes more, spoken near the extremity, can be heard. To this class belong all the varieties of trumpet of different lengths and shapes, whether made of tin, gutta-percha, &c, and consisting of a narrow portion inserted into the ear, which gradually 436 THE DISEASES OF THE EAR. expands into a wide mouth. These trumpets must be held in the hand, and the expanded portion can be directed to any person or persons whose voices are desired to be .heard. The third class embraces a variety of elastic tubes, one end being placed in or on the patient's ear, and the other held in the hand of the speaker, whose mouth being applied near or in its free extremity, his single voice is heard. APPENDIX. LIST OF PUBLISHED PAPERS ON THE STRUCTURE, FUNCTIONS, AND DISEASES OF THE EAR. On the structure of the membrana tympani in the human ear. With numerous engravings. Philosophical Transactions, 1851. Part I. On the functions of the membrana tympani. 1 Proceedings of the Royal Society, 1852. On the muscles which open the Eustachian tube. Proceedings of the Royal Society, 1853. On the mode in which sonorous undulations are conducted from the membrana tympani to the labyrinth, in the human ear. Proceedings of the Royal Society, 1859. Pathological researches into the diseases of the ear. Medico- Ohirurgical Transactions, vol. xxiv, 1841. Pathological researches into the diseases of the ear. Second series. Medico-Ohirurgical Transactions, vol. xxvi, 1843. Pathological researches into the diseases of the ear. Third series. Medico-Ohirurgical Transactions, vol. xxxii, 1849. Pathological researches into the diseases of the ear. Fourth series. Medico-Ohirurgical Transactions, vol. xxxiv, 1851. Pathological researches into the diseases of the ear. Fifth series. Medico-Ohirurgical Transactions, vol. xxxviii, 1855. Pathological researches into the diseases of the ear. Sixth series. Medico-Ohirur gical Transactions, vol. xxxviii, 1855. On the diagnosis of the condition of the Eustachian tube, by means of the otoscope, without the use of the catheter. Proceedings of the Royal Medical and Ohirurgical Society. Medical Times and Gazette, April 9, 1853. 438 THE DISEASES OF THE EAR. The results of some inquiries respecting the deaf and dumb. Proceedings of the Royal Medical and Ohirurgical Society. Medical Times and Gazette, 1856. On anchylosis of the stapes to the fenestra ovalis (stapedio-vestibular articulation) associated with rheumatism and gout; illustrated by more than one hundred dissections. Proceedings of the Royal Medical and Ohirurgical Society, 1858. A case of deaf-dumbness, of more than twenty years' duration, in which the hearing and the articulation were greatly benefited. Proceedings of the Royal Medical and Ohirurgical Society, 1858. On the nature and treatment of those diseases of the ear which have hitherto been designated otorrhoea and otitis. Transactions of the Provincial Medical and Surgical Association, vol. xviii. On osseous tumors growing from the walls of the meatus externus of the ear, and on the enlargement of the walls themselves, with cases. Wood-cuts. Proceedings of the Provincial Medical and Surgical Association. The Journal of the Association, 1849. On the use of an artificial membrana tympani, in cases of perforation or destruction of the organ. Proceedings of the Provincial Medical and Surgical Association. The Journal, 1852. Disease of the tympanic cavity, causing caries of the bone and paralysis of the portio dura nerve. Osseous tumors developed from the parietes of the external auditory meatus. Disease of the external auditory meatus, with suppuration of the brain. Series of preparations, illustrative of the diseases of the membrana tympani. Bony stricture of the Eustachian tube. Transactions of the Pathological Society of London, vol. i, 1849-1850. A series of cases, illustrating diseases in the cerebral cavity, origi- nating in affections of the auditory meatus. Neuroma of the auditory nerve. Molluscous tumors developed in the external auditory meatus. APPENDIX. 439 The effects of molluscous tumors on the petrous bone, when developed in the external auditory meatus. Preparations illustrative of hypertrophy in the epidermoid and dermoid laminae of the membrana tympani. Caries of the petrous bone and abscess of the cerebellum. Transactions of the Pathological Society, vol. ii, 1850-1851. Congenital malformation of the external ear and meatus on each side. Calcareous matter in the cavity of the vestibule. Examination of the ears of a deaf and dumb child, in which a portion of one of the membranous semicircular canals was distended with otoconie. Disease of the base of the brain, extending from the tympanum through the labyrinth. Necrosis of the squamous portion of the temporal bone, originating in catarrhal inflammation of the external meatus. Cholesterine in the mastoid cells. Transactions of the Pathological Society, vol. iii, 1851-1852. Case of ulceration of the fibrous laminae of the membrana tympani. Case of complete bony anchylosis of the stapes to the fenestra ovalis. A case of perforate membrana tympani treated by the substitution of an artificial membrane. On the mode of dissecting the ear for pathological investigation. Neuroma of the auditory nerve. Transactions of the Pathological Society, vol. iv, 1852-1853. Caries of the temporal bone, and disease of the brain produced by retention of the discharge in the tympanum, after scarlet fever, by the thickened membrana tympani. Anchylosis of the stapes. Disease of the ear affecting the lateral sinus and cerebellum. Transactions of the Pathological Society, vol. v, 1853-1854. Encephaloid disease of the tympanic cavity, extending to the brain. Acute inflammation of the mastoid cells extending to the brain. On the causes of accumulations of cerumen in the meatus audito- rius externus, and their effects on different parts of the ear Transactions of the Pathological Society, vol. vi, 1855-1856. 440 THE DISEASES OF THE EAR. Dissection of a case of malformation in the ears of a child. Edinburgh Monthly Journal of Medical Science, 1847. On the pathology and treatment of the deafness attendant upon old age. Monthly Journal and Retrospect of the Medical Sciences. Nos. 98 and 99, 1849. Case of stricture of the Eustachian tube, with an account of the appearances presented on dissection. Monthly Journal of Medical Science, 1850. On the tubular ear speculum. The Lancet, Oct. 1, 1850. On the removal of foreign bodies from the ear. Provincial Medical and Surgical Journal, 1850. On the nature and treatment of polypi of the ear. Medical Times and Gazette, 1852. On the excision of the tonsils and uvula in the treatment of deafness. Medical Times and Gazette, 1853. On the removal of polypi from the ear by the lever-ring forceps and the dressing-ring forceps. Medical Times and Gazette. On the functions of the muscles of the tympanum in the human ear. British and Foreign Medico- Ohirurgical Review, 1853. On the use of an artificial membrana tympani in cases of deafness dependent upon perforation or destruction of the natural organ. Octavo. 1853. Do., do., Sixth Edition, 1858. A course of clinical lectures on the pathology and treatment of the affections of the ear causing disease in the brain or its membranes, delivered at St. Mary's Hospital. With engravings. Medical Times and Gazette, 1855. A course of lectures on the nature and treatment of the diseases of the ear delivered at St. Mary's Hospital Medical School. Medical Times and Gazette, 1856. A descriptive catalogue of preparations illustrative of the diseases of the ear in the museum of the author. 8vo. 1857. THE END. 19 HENEY O. LE^l'S (LATE LEA & BLANCHARD'S) CLASSIFIED CATALOGUE OF MEDICAL AND SUEGIOAL PUBLICATIONS. In asking the attention of the profession to the works contained in the following pages, the publisher would state that no pains are spared to secure a continuance o the confidence earned for the publications of the house by their careful selection and accuracy and finish of execution. It will be observed that the prices during the last four years have not been advanced in anything like proportion to the increased cost of manufacture, and there is no probability of a decrease of cost that will warrant a reduction during the coming season. The printed prices are those at which books can generally be supplied by booksellers throughout the United States, who can readily procure for their customers any works not kept in stock. Where access to bookstores is not convenient, books will be sent by mail post-paid on receipt of the price, but no risks are assumed either on the money or the books, and no publications but my own are supplied. Gentlemen will therefore in most cases find it more convenient to deal with the nearest bookseller. An Illustrated Catalogue, of 64 octavo pages, handsomely printed, will be forwarded by mail, postpaid, on receipt of ten cents. HENRY C. LEA. Nos. 706 and 708 Sansom St., Philadelphia, March, 1867. ADDITIONAL INDUCEMENT FOR SUBSCRIBERS TO THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. THEEE MEDICAL JOUENALS, containing over 2000 LAEGE PAGES, Pree of Postage, for SIX D0LLAES Per Annum. TERMS—IN" ADVANCE: The American Journal of the Medical Sciences, and \ Five Dollars per annum, The Medical News and Library, J in-advance. The Medical News and Library, separate, One Dollar per annum, in advance. Banking's Half- Yearly Abstract of the Medical Sciences, separate, Two Dollars and a Half per annum in advance. on, The American Journal of the Medical Sciences, published quarterly, with The Medical News and Library, published monthly, and Banking's Abstract of the Medical Sciences, published half-yearly, (ALL FREE OF POSTAGE.) Six Dollars per annum in advance. In thus offering to the profession this unprecedented amount of valuable practical matter, the publisher can only be saved from loss by a very large increase in the sub- Gentlemen receiving this Catalogue would confer a favor on the Publisher by communicating it to their professional friends. Henry C. Lea's Publications— (Am. Journ. Med. Sciences). 2 scription list. It is his desire to furnish to the practitioner in every section of the country the utmost that can be supplied for an amount within the reach of every one, and his long connection with the profession warrants him in the hope that his efforts will be seconded by the interest which all practitioners must feel in insuring the success of his undertaking and rendering it permanent. It is only by a circulation hitherto unknown in the history of American medical journalism that so vast an amount of the choicest reading can be afforded at so moderate a sum, and the publisher therefore relies on the co-operation of the profession at large to respond to his endeavor to lay on the table of every physician a monthly, a quarterly, and a halfyearly journal, at a price which is without example. These periodicals are universally known for their high professional standing in their several spheres. I. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by ISAAC HAYS, M. D., is published Quarterly, on the first of January, April, July, and October. Each number contains nearly three hundred large octavo pages, appropriately illustrated, wherever necessary. It has now been issued regularly for over forty years, during nearly the whole of which time it has been under the control of the present editor. Throughout this long period, it has maintained its position in the highest rank of medical periodicals both at home and abroad, and has received the cordial support of the entire profession in this country. Among its Collaborators will be found a large number of the most distinguished names of the profession in every section of* the United States, rendering the department devoted to ORIGINAL COMMUNICATIONS full of varied and important matter, of great interest to all practitioners. Thus, during 1866, contributions have appeared in its pages from the following gentlemen* H. ALLEN, M. D., Asst. Surg. U. S. A. JOHN ASHHUEST, Jr., M. D., Philadelphia. WALTER F. ATLEE, M. D., Philadelphia. E. P. BENNETT, M. D., Danbury, Ct. BENJ. L. BIRD, Jr., M. D. J. R. BLACK, M. D., Newark, 0. ROBERT BURNS, M. D., Frankford, Pa. WM. 0. BALDWIN, M. D., Montgomery Co., Ala. ROBERTS BARTHOLOW, M. D., Cincinnati, 0. JOHN G. BIGHAM, M. D., Millersburg, O. JOHN H. BRINTON, M. D., Philadelphia. JOSEPH CARSON, M. D., Philadelphia. EDWARD T. CASWELL, M. D., Providence, R. I. EDWARD H. CLARK, H. D., Boston, Mass. D. F. CONDIE, M. D., Philadelphia. EDWARD M. CURTIS, M. D., Brasher Falls, N. T. S. HENRY DICKSON, M. D., Philadelphia. I. C. DALTON, M. D., New York. PLINY EARLE, M. D., Northampton, Mass. D. B. JBLSON, M. D., Cleveland, 0. H. Y. EVANS, M. D., Philadelphia. AUSTIN FLINT, M. D., New York. CLARKSON FREEMAN, M. D., Milton, Canada West. C. C. GRAY, M. D., Asst. Surg. U. S. A. W. W. GERHARD, M. D., Philadelphia. R. GLISAN, M. D., Portland, Oregon. GEO. C. HARLAN, M. D., Philadelphia. JOHN HAKT, M. D., Boston, Mass. EDWARD HARTSHORNE, M. D., Philadelphia. PHILIP HARVEY, M D., Burlington, Iowa. R. E. HAUGHTON, M D., Richmond, Indiana. ISAAC HAYS, M. D., Philadelphia. H. L. HODGE, M. D., Philadelphia. J. H. HUTCHINSON, M. D., Philadelphia. HENRY HARTSHORNE, M.D., Philadelphia. B. HOWARD, M. D., late U. S. A. WM. HUNT, M. D., Philadelphia. A. REEVES JACKSON, M.D., Stroudsburg, Pa. SAMUEL J. JONES, M. D., Surgeon U. S. N. SAMUEL JACKSON, M. D., Philadelphia. CHARLES H. JONES, M. D., Asst. Surgeon U. S. A. M. KEMPF, M. D., Fairmont, Ind. W. KEMPSTER, M. D., Syracuse, N. Y. A. W. KING, M. D., Illinois. J. J. LEVICK, M.D., Philadelphia. M. CAREY LEA, Esq., Philadelphia. JOHN A. LIDELL, M. D., Surgeon U. S. V IRVING. W. LYON, M. D., Hartford, Ct * Communications are invited from gentlemen in all parts of the country All elaborate articles inserted by the Editor are paid for by the Publisher. ™" M verted Henry C. Lea's Publications— (Am. Journ. Med. Sciences). 3 H. C. MATHIS, M. D., Taylorsville, Ky. CHARLES M. MATSON, M. D., Brookville, Pa. R. B. MAURY, M. D., Port Gibson, Miss. E. McCLELLAN, M. D., U. 8. A. RICHARD McSHERRY, M.D., Baltimore, Md. M. L. MEAD, M. D., Albany, N. Y. J. AITKEN MEIGS, M. D., Philadelphia. A. P. MERRILL, M. D., New York. S. W. MITCHELL, M. D., Philadelphia. W. P. MOON, M. D., St. Louis. J. W. MOORMAN, M. D., Hardinsburg, Ky. THOS. G. MORTON, M. D., Philadelphia. LOUIS MACKALL, Jr., M. D., Georgetown, D. C. R. B. MO WRY, M. D., Allegheny City, Pa. J. H. PACKARD, M. D., Philadelphia. GEORGE PEPPER, M. D., Philadelphia. WILLIAM PEPPER, M.D., Philadelphia. J. S. PRETTYMAN, M. D., Milford, Del. DAVID PRINCE, M. D., Jacksonville, 111. E. R. PEASLEE, M. D., New York. DEWITT C. PETERS, M. D., Surgeon U. S. A. D. B. St. JOHN ROOSA, M. D., New York. A. ROTHROCK, M. D., McVeytown, Pa. W. S. W. RUSCHENBURGER, M.D., Surgeon U. S. A. J. H. SALISBURY, M. D., Cleveland, O. ELI D. SARGENT, M. D., U. S. Navy. J. W. SHERFY, M.D., Act'g Passed Ass't Surg. U.S.N. CHARLES C. SHOYER, M.D., Leavenworth, Kansas. ALFRED STILLE, M. D., Philadelphia. CHARLES SMART, M. D , Assist. Surgeon U. S. A. STEPHEN SMITH, M. D„ New York. L. H. STEINER, M. D., Baltimore, Md. W. B. TRULL, M. D., Asst. Surgeon U. S. V. J. D. TWINING, M. D., Act'g Assist. Surg. U. S. A. JAMES TYSON, M. D., Philadelphia. CLINTON WAGNER, M. D., Assist. Surgeon U. S. A. J. J. WOODWARD, M. D., Assist. Surgeon U. S. A. THOS. C. WALTON, M.D., Passed Ass't Surg. U.S N. ISRAEL B. WASHBURN, M. D., late Surg. U.S.T. W. A. WETHERBY, M. D., New York. H. WILLIAMS, M.D, Philadelphia. WM. J. WILSON, M. D., Macon, Mo. EDWARD WHINERY, M. D., Fort Madison, Iowa. HORATIO C. WOOD, Jr., M.D., Philadelphia. Following this is the "Review Department," containing extended and impartial reviews of all important new works, together with numerous elaborate "Bibliographical Notices" of nearly all the publications of the day. This is followed by the " Quarterly Summary of Improvements and Discoveries in the Medical Sciences," classified and arranged under different heads, presenting a very complete digest of all that is new and interesting to the physician, abroad as well as at home. Thus, during the year 1866, the "Journal" has furnished to its subscribers One Hundred and Twenty Original Communications, Sixty-five Reviews and Bibliographical Notices, and Two Hundred and Thirty-two articles in the Quarterly Summaries, making a total of over Four Hundred articles emanating from the best professional minds in America and Europe. To old subscribers, many of whom have been on the list for twenty or thirty years, the publisher feels that no promises for the future are necessary; but gentlemen who may now propose for the first time to subscribe may rest assured that no exertion will be spared to maintain the "Journal" in the high position which it has so long occupied as a national exponent of scientific medicine, and as a medium of intercommunication between the profession of Europe and America—to render it, in fact, necessary to every practitioner who desires to keep on a level with the progress of his; science. The subscription price of the "American Journal of the Medical Sciences " ftas never been raised, during its long career. It is still Five Dollars per annum in advance, for which sum the subscriber receives in addition the "Medical News and Library," making in all about 1500 large octavo pages per annum, free of postage. II. THE MEDICAL NEWS AND LIBRARY is a monthly periodical of Thirty-two large octavo pages, making 384 pages per annum. Its "News Department" presents the current information of the day, with Clinical Lectures and Hospital Gleanings; while the "Library Department" is devoted to publishing standard works on the various branches of medical science, paged separately, so that they can be removed and bound on completion. In this manner subscribers have received, without expense, such works as " Watson's Practice," 4 Henry C. Lea's Publications— (Am. Journ. Med. Sciences). "Todd and Bowman's Physiology," "West on Children," "Malgaigne's Surgery," &c. &c. Professor Erichsen's new and valuable practical work " On Railway and other Injuries of the Nervous System" is commenced in the number for January, 1867, rendering this a particularly desirable time for new subscriptions. As stated above, the subscription price of the "Medical News and Library" is One Dollar per annum in advance; and it is furnished without charge to all subscribers to the "American Journal of the Medical Sciences." III. BAKKIM'S ABSTRACT OF THE MEDICAL SCIENCES is issued in half-yearly volumes, which will be delivered to subscribers about the first of March, and first of September. Each volume will contain nearly 300 closely printed octavo pages, making nearly six hundred pages per annum. "Banking's Abstract" has now been published in England regularly for more than twenty years, and has acquired the highest reputation for the ability and industry with which the essence of medical literature is condensed into its pages. It purports to be "An Analytical and Critical Digest of the principal British and Continental Medical Works published in the preceding Six Months," and, in addition to the matter thus derived from independent treatises, it presents an abstract of all that is important or interesting in about sixty British and Continental journals. About four hundred articles are thus annually presented to its readers, affording a very complete view of the progress of medical science throughout the world. Each volume is systematically arranged and thoroughly indexed, thus facilitating the researches of the reader in pursuit of particular subjects, and enabling him to refer without loss of time to the vast amount of information contained in its pages. The subscription price of the "Abstract," mailed free of postage, will be Two Dollars and a Half per annum, payable in advance. Single volumes, $1 50 each. As stated above, however, it will be supplied in conjunction with the "American Journal of the Medical Sciences" and the "Medical News and Library," the whole free of postage, for Six Dollars per annum in advance. For this small sum the subscriber will therefore receive three periodicals, each of the highest reputation in its class, containing in all over two thousand pages of the choicest reading, and presenting a complete view of medical progress throughout the world. In this effort to bring so large an amount of practical information within the reach of every member of the profession, the publisher confidently anticipates the friendly aid of all who are interested in the dissemination of sound medical literature. He trusts, especially, that the subscribers to the "American Medical Journal" will call the attention of their acquaintances to the advantages thus offered, and that he will be sustained in the endeavor to permanently establish medical periodical literature on a footing of cheapness never heretofore attempted. ' %* Gentlemen desiring to avail themselves of the advantages thus offered will do well to forward their subscriptions at an early day, in order to insure the receipt of complete sets for the year 1867. The safest mode of remittance is by postal money order, drawn to the order of the undersigned. Where money order post-offices are not accessible, remittances for the "Journal" may be made at the risk of the publisher, by taking the postmaster's certificate of the inclosure and forwarding of the money. Address, HENRY C. LEA, Nos. 706 and 708 Sansom St., Philadelphia, Pa. Henry C. Lea's Publications— (Dictionaries). 5 JJUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. MEDICAL LEXICON; A Dictionary op Medical Science: Containing a concise explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of the Terms, and the French and other Synonymes; so as to constitute a French as well as English Medical Lexicon. Thoroughly Revised, and very greatly Modified and Augmented. In one very large and handsome royal octavo volume of 1048 double-columned pages, in small type; strongly done up in extra cloth, $6 00; leather, raised bands, $6 75. The object of the author from the outset has not been to make the work a mere lexicon or dictionary of terms, but to afford, under each, a condensed view of its various medical relations, and thus to render the work an epitome of the existing condition of medical science. Starting with this view, the immense demand which has existed for the work has enabled him, in repeated revisions, to augment its completeness and usefulness, until at length it has attained the position of a recognized and standard authority wherever the language is spoken. The mechanical execution of this edition will be found greatly superior to that of previous impressions. By enlarging the size of the volume to a royal octavo, and by the employment of a small but clear type, on extra fine paper, the additions have been incorporated without materially increasing the bulk of the volume, and the matter of two or three ordinary octavos has been compressed into the space of one not unhandy for consultation and reference. It would be a work of supererogation to bestow a word of praise upon this Lexicon. We can only wonder at the labor expended, for whenever we refer to its pages for information we are seldom disappointed in finding all we desire, whether it be in accentuation, etymology, or definition of terms. — New York Medical Journal, November, 1865. It would be mere waste of words in us to express our admiration of a work which is so universally and deservedly appreciated. The most admirable work of its kind in the English language. As a book of reference it is invaluable to the medical practitioner, and in every instance that we have turned over its pages for information we have been charmed by the clearness of language and the accuracy of detail with which each abounds. We can most cordially and confidently commend it to our readers. — Glasgow Medicfd Journal, January, 1866. A work to which there is no equal in the English language.— Edinburgh Medical Journal. It is something more than a dictionary, and something less than an encyclopedia. This edition of the well-known work is a great improvement on its predecessors. The book is one of the very few of which it may be said with truth that every medical man should possess it.— London Medical Times, Aug. 26, 1S65. , Few works of the class exhibit a grander monument of patient research and of scientific lore. The extent of the sale of this lexicon is sufficient to testify to its usefulness, and to the great service conferred by Dr. Robley Dunglison on the profession, and indeed on others, by its issue.— London Lancet, May 13, 1865. The old edition, which is now superseded by the new, has been universally looked upon by the medical profession as a work of immense research and great value. The new has increased usefulness ; for medicine, in all its branches, has been making such progress that many new terms and subjects have recently been introduced : all of which may be found fully defined in the present edition. We know of no other dictionary in the English language that can bear a comparison with it in point of completeness of subjects and accuracy of statement. — N. Y. Druggists' Circular, 1865. For many years Dunglison's Dictionary has been the standard book of reference with most practitioners in this country, and we can certainly commend this work to the renewed confidence and regard of our readers. — Cincinnati Lancet, April, 1865. It is undoubtedly the most complete and useful medical dictionary hitherto published in this country. — Chicago Med. Examiner, February, 1S65. What we take to be decidedly the best medical dictionary in the English language. The present edition is brought fully up to the advanced state of science. For many a long year "Dunglison" has been at our elbow, a constant companion and friend, and we greet him in his replenished and improved form with especial satisfaction. — Pacific Med. and Surg. Journal, June 27, 1865. This is, perhaps, the book of all others which the physician or surgeon should have on his shelves. It is more needed at the present day than a few years back.— Canada Med. Journal, July, 1865. It deservedly stands at the head, and cannot be surpassed in excellence. — Buffalo Med. and Surg. Journal, April, 1865. We can sincerely commend Dr. Dunglison's work as most thorough, scientific, and accurate. We have tested it by searching its pages for new terms, which have abounded so much of late in medical nomenclature, and our search has been successful in every instance. We have been particularly struck with the fulness of the synonymy and the accuracy of the derivation of words. It is as necessary a work to every enlightened physician as Worcester's English Dictionary is to every one who would keep up his knowledge of the English tongue to the standard of the present day. It is, to our mind, the most complete work of the kind with which we are acquainted.— Boston Med. and Surg. Journal, June 22, 1865. We are free to confess that we know of no medical dictionary more complete; no one better, If so well adapted for the use of the student; no one that may be consulted with more satisfaction by the medical practitioner.— Am. Jour. Med. Sciences, April, 1865. The value of the present edition has been greatly enhanced by the introduction of new subjects and terms, and a more complete etymology and accentuation, which renders the work not only satisfactory and desirable, but indispensable to the physician.— Chicago Med. Journal, April, 1865. No intelligent member of the profession can or will be without it. — St. Louis Med. and Surg. Journal, April, 1865. It has the rare merit that it certainly has no rival in the English language for accuracy and extent of references.— London Medical Gazette. JJDBLYN {RICHARD D.), M.D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. A new American edition, revised, with numerous additions, by Isaac Hays, M.D., Editor of the "American Journal of the Medical Sciences." In one large royal 12mo. volume of over 500 double-columned pages; extra cloth, $1 50 ; leather, $2 00. It is the best book of definitions we have, and ought always to be upon the student's table.— SoutJum Med. and Surg. Journal. 6 Henry C. Lea's Publications — {Manuals). -\TEILL (JOHN), M.D., and OMITH (FRANCIS G.), M.D., Prof, ofthe Institutes of Medicine in tlie Univ. of Penna. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, of about one thousand pages, with 374 wood cuts, extra cloth, $4; strongly bound in leather, with raised bands, $4 75. The Compend of Drs. Neill and Smith is incomparably the most valuable work of its class ever published in this country. Attempts have been made in various quarters to squeeze Anatomy, Physiology, Surgery, the Practice of Medicine, Obstetrics, Materia Medica, and Chemistry into a single manual; but the operation has signally failed in the hands of all up to the advent of" Neill and Smith's" volume, which is quite a miracle of success. The outlines of the whole are admirably drawn and illustrated, and the authors are eminently entitled to the grateful consideration of the student of every class.— N. 0. Med. and Surg. Journal. This popular favorite with the student is so well known that it requires no more at the hands of a medical editor than the annunciation of a new and improved edition. There is no sort of comparison between this work and any other on a similar plan, and for a similar object.— Nash. Journ of Medicine. There are but few students or practitioners of medicine unacquainted with the former editions of this unassuming though highly instructive work. The whole science of medicine appears to have been sifted, as the gold-bearing sands of El Dorado, and the precious facts treasured up in this little volume. A complete portable library so condensed that the student may make it his constant pocket companion.—Western Lancet. To compress the whole science of medicine in less than 1,000 pages is an impossibility, but we think that the book before us approaches as near to it as is possible. Altogether, it is the best of its class, and has met with a deserved success. As an elementary textbook for students, it has been useful, and will continue to be employed in the examination of private classes, whilst it will often be referred to by the country practitioner.— Va. Med. Journal. As a handbook for students it is invaluable, containing in the most condensed form the established facts and principles of medicine and its collateral sciences.— N. H. Journal of Medicine. In the rapid course of lectures, where work for the students is heavy, and review necessary for an examination, a compend is not only valuable, but it is almost a sine qua non. The one before us is, in most of the divisions, the most unexceptionable of all books of the kind that we know of. The newest and soundest doctrines and the latest improvements and discoveries are explicitly, though concisely, laid before the student. Of course it is useless for us to recommend it to all last course students, but there is a class to whom we very sincerely commend this cheap book as worth its weight in silver—that class is the graduates in medicine of more than ten years' standing, who have not studied medicine since. They will perhaps find out from it that the science is not exactly now what it was when they left it off.— TJie Stethoscope. Having made free use of this volume in our examinations of pupils, we can speak from experience in recommending it as an admirable compend for students, and especially useful to preceptors who examine their pupils. It will save the teacher much labor by enabling him readily to recall all of the points upon which his pupils should be examined. A work of this sort should be in the hands of every one who takes pupils into his office with a view of examining them; and this is unquestionably the best of its class. Let every practitioner who has pupils provide himself with it, and he will find the labor of refreshing his knowledge so much facilitated that he will be able to do justice to his pupils at very little cost of time or trouble to himself. — Transylvania Med. Journal. W (J. L.), M. D., A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended and enlarged. Wkh 370 illustrations. In one handsome royal 12mo. volume of 816 large pages, extra cloth, $3 25; leather, $3 75. The arrangement of this volume in the form of question and answer renders it especially suitable for the office examination of students, and for those preparing for graduation. We know of no better companion for the student during the hours spent in the lecture-room, or to refresh, at a glance, his memory of the various topics crammed into his bead by the various professors to whom he is compelled to listen.— Western Lancet. As it embraces the whole range of medical studies it is necessarily voluminous, containing 816 large duodecimo pages. After a somewhat careful examination of its contents, we have formed a much more favorable opinion of it than we are wont to regard such works. Although well adapted to meet the wants of the student in preparing for his final examination, it might be profitably consulted by the practitioner also, who is most apt to become rusty in the very kind of details here given, and who, amid the hurry of his daily routine, is but too prone to neglect the study of more elaborate works. The possession of a volume of this kind might serve as an inducement for him to seize the moment of excited curiosity to inform himself on any subject, and which is otherwise too often allowed to pass, unimproved.— St. Louis Med. and Surg. Journal. JiANNER (THOMAS HAWKES), M.D., A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS. Third American, from the second enlarged and revised English edition. To which is added The Code of Ethics of the American Medical Association. In one handsome volume I2mo. (Preparing for early publication.) This work, after undergoing a very thorough revision at the hands of the author, may now be expected to appear shortly. The title scarcely affords a proper idea of the range of subjects embraced in the volume, as it contains not only very full details of diagnostic symptoms properly classified, but also a large amount of information on matters of every day practical importance, not usually touched upon in the systematic works, or scattered through many different volumes. Henry C. Lea's Publications— (Anatomy). 7 QRA Y (HENRY), F. R. S., Lecturer on Anatomy at St. George's Hospital, London. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital; the Dissections jo'intly by the Author and Dr. Carter. Second American, from the second revised and improved London edition. In one magnificent imperial octavo volume, of over 800 pages, with 388 large and elaborate engravings on wood. Price in extra cloth, $6 00 { leather, raised bands, $7 00. The author has endeavored in this work to cover a more extended range of subjects than is customary in the ordinary text-books, by giving not only the details necessary for the student, but also the application of those details in the practice of medieine and surgery, thus rendering it both a guide lor the learner, and an admirable work of reference for the active practitioner. The engravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference, with descriptions at the foot. They thus form a complete and splendid series, which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the .exigencies of practice the necessity of recalling the details of the dissecting room j while combining, as it does, a complete Atlas of Anatomy, with a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of essential use to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Notwithstanding its exceedingly low price, the work will be found, in every detail of mechanical execution, one of the handsomest that has yet been offered to the American profession ; while the careful scrutiny of a competent anatomist has relieved it of whatever typographical errors existed in the English edition. Thus it is that hook after book makes the labor of the student easier than before, and since we have seen Blanchard & Lea's new edition of Gray's Anatomy, certainly the finest work of the kind now extant, we would fain hope that the bugbear of medical students will lose half its horrors, and this necessary foundation of physiological science will be much facilitated and advanced.— N. 0. Med. News. The various points illustrated are marked directly on the structure; that is, whether it be muscle, process, artery, nerve, valve, etc. etc.—we say each point is distinctly marked by lettered engravings, so that the student perceives at once each point described as readily as if pointed out on the subject by the demonstrator. Most of the illustrations are thus rendered exceedingly satisfactory, and to the physician they serve to refresh the memory with great readiness and with scarce a reference to the printed text. The surgical application of the various regions is also presented with force and clearness, impressing upon the student at each step of his research all the important relations of the structure demonstrated. — Cincinnati Lancet. This is, we believe, the handsomest book on Anatomy as yet published in our language, and bids fair to become in a short time the standard text-book of our colleges and studies. Students and practitioners will alike appreciate this book. We predict for it a bright career, and are fully prepared to endorse the statement of the London Lancet, that "We are not acquainted with any work in any language which can take equal rank with the one before us." Paper, printing, binding, all are excellent, and we feel that a grateful profession will not allow the publishers to go unrewarded. — Nashville Med. and Surg. Journal. &MITH (HENR Y H), M.D., and JJORNER ( WILLIAM E.), M.D., Prof, of Surgery in the Univ. of Penna., &c. Late Prof, of Anatomy in tlie Univ. ofPenna., Ac AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful figures. $4 50. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its superb artiitical execution, have been already pointed out. We must congratulate the student upon the completion of this Atlas, as it is the most convenient work of the kind that has yet appeared; and we must add, the very beautiful manner in which it is "got up" is so creditable to the country as to be flattering to our national pride.— American Medical Journal. JJORNER (WILLIAM E.), M.D., SPECIAL ANATOMY AND HISTOLOGY. Eighth edition, extensively revised and modified. _ In two large octavo volumes of over 1000 pages, with more than 300 wood-cuts; extra cloth, $6 00. QHARPEY (WILLIAM), M.D., and Q VAIN (JONES §• RICHARD). HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidy, M.D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo volumes, of about 1300 pages, with 511 illustrations; extra cloth, $6 00. The very low price of this standard work, and its completeness in all departments of the subject, should command for it a place in the library of all anatomical students. (J.M.), 31. D. THE PRACTICAL ANATOMIST; or, The Student's Guide in the Dissecting Room. With 266 illustrations. In one very handsome royal 12nio. volume, of over 600 pages; extra cloth, $2 00. One of the most useful works upon the subject ever written.— Medical Examiner. Henry C. Lea's Publications — (Anatomy). 8 TUILSON (ERASMUS), F.R.S. A SYSTEM OF HUMAN ANATOMY, General and Special. A new and revised American, from the last and enlarged English edition. Edited by W. H. Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical College of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In one large and handsome octavo volume, of over 600 large pages; extra cloth, $4 00 ; leather, $5 00. The publisher trusts that the well-earned reputation of this long-established favorite will be more than maintained by the present edition. Besides a very thorough revision by the author, it has been most carefully examined by the editor, and the efforts of both have been directed to introducing everything which increased experience in its use has suggested as desirable to render it a complete text-book for those seeking to obtain or to renew an acquaintance with Human Anatomy. The amount of additions which it has thus received may be estimated from the fact that the present edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged page requisite to keep the volume within a convenient size. The author has not only thus added largely to the work, but he has also made alterations throughout, wherever there appeared the opportunity of improving the arrangement or style, so as to present every fact in its most appropriate manner, and to render the whole as clear and intelligible as possible. The editor has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the number 1 of illustrations, of which there are about one hundred and fifty more in this edition than in the last, thus bringing distinctly before the eye of the student everything of interest or importance. JflY THE SAME AUTHOR. THE DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy. Third American, from the last revised and enlarged English edition. Modified and rearranged by William Hunt, M. D., late Demonstrator of Anatomy in the University of Pennsylvania. In one large and handsome royal 12mo. volume, of 582 pages, with 154 illustrations; extra cloth, $2 00. JTODGES, (RICHARD if.), M.D., Late Demonstrator of Anatomy in the Medical Department of Harvard University. PRACTICAL DISSECTIONS Second Edition, thoroughly revised. In one neat royal 12mo. volume. (Just Ready.) A second edition of this little work being called for, the author has endeavored, by a very thorough and careful revision, to adapt it still more completely to the wants of the student in the dissecting room. MACLISE (JOSEPH). SURGICAL ANATOMY. By Joseph Maclise, Surgeon. In one volume, very large imperial quarto; with 68 large and splendid plates, drawn in the best style and beautifully colored, containing 190 figures, many of them the size of life; together with copious explanatory letter-press. Strongly and handsomely bound in extra cloth. Price $14 00. As no complete work of the kind has heretofore been published in the English language, the present volume will supply a want long felt in this country of an accurate and comprehensive Atlas of Surgical Anatomy, to which the student and practitioner can at all times refer to ascertain the exact relative positions of the various portions of the human frame towards each other and to the surface, as well as their abnormal deviations. The importance of such a work to the student, in the absence of anatomical material, and to practitioners, either for consultation in emergencies or to refresh their recollections of the dissecting room, is evident. Notwithstanding the large size, beauty and finish of the very numerous illustrations, it will be observed that the price is so low as to place it within the reach of all members of the profession. We know of no work on surgical anatomy which can compete with it.— Lancet. The work of Maclise on surgical anatomy is of the highest value. In some respects it is the best publication of its kind we have seen, and is worthy of a place in the library of any medical man, while the student could scarcely make a better investment than this.— The Western Journal of Medicine and Surgery. No snch lithographic illustrations of surgical regions have hitherto, we think, been given. While the operator is shown every vessel and nerve where an operation is contemplated, the exact anatomist is refreshed by those clear and distinct dissections, which every one must appreciate who has a particle of enthusiasm. The English medical press has quite exhausted the words of praise, in recommending this admirable treatise. Those who have any curiosity to gratify, in reference to the perfectibility of the lithographic art in delineating the complex mechanism of the human body, are invited to examine our specimen copy. If anything will induce surgeons and students to patronize a book of such rare value and everyday importance to them, it will be a survey of the artistical skill exhibited in these fac-similes of nature. — Boston Med. and Stirg. Journal. pEASLEE (E.R.), M.D., -*¦ Professor of Anatomy and Physiology in Dartmouth Med. College, N. H. HITMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology; for the use of medical students. With four hundred and thirty-four illustrations. In one handsome octavo volume of over 600 pages, extra cloth. $3 75. We would recommend it as containing a summary of all that is known of the important subjects which it treats: of all that is in the great works of Simon and Lehmann, and the organic chemists in general. Master this one volume, and you know all that is known of the great fundamental principles of medicine, and we have no hesitation in saying that it is an honor to the American medical profession.— St. Louis Med. and Surg. Journal. Henry C. Lea's Publications— (Physiology). 9 (JA RPENTER ( WILLIAM B.), M. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine. A new American from the last and revised London edition. With nearly three hundred illustrations. Edited, with additions, by Francis Gtjrney Smith, M. D., Professor of the Institutes of Medicine in the University of Pennsylvania, UMSTEAD {FREEMAN J.), M.D., Lecturer on Materia Medica and Venereal Diseases at the Col. of Phys. and Surg., New York, &c. THE PATHOLOGY AND TREATMENT OP YENEREAL DISEASES. Including the results of recent investigations upon the subject. A new and revised edition, with illustrations. In one large and handsome octavo volume of 640 pages, extra cloth, $5 00. (Lately Issued.) During the short time which has elapsed since the appearance of this work, it has assumed the position of a recognized authority on the subject wherever the language is spoken, and its translation into Italian shows that.its reputation is not confined to our own tongue. The singular clearness with which the modern doctrines of venereal diseases are set forth renders it admirably adapted to the student, while the fulness of its practical details and directions as to treatment makes it indispensable to the practitioner. . The few notices subjoined will show the very high position universally accorded to it by the medical press of both hemispheres. Well known as one of the best authorities of the present day on the subject.— British and For. Med.- Chirurg. Review, April, 1866. A regular store-house of special information.— London Lancet, Feb. 24, 1866. A remarkably clear and full systematic treatise on the whole subject.— Lond. Med. Times and Gazette. The best, completest, fullest monograph on this subject in our language.— British American Journal. Indispensable in a medical library. -—Pueiflc Med. and Surg. Journal. We have no doubt that it will supersede in America every other treatise on Venereal.— San Francisco Med. Press, Oct. 1864. A perfect compilation of all that is worth knowing on venereal diseases in general. It fills up a gap which has long been felt in English medical literature. — Brit, and Foreign Med.-Ohirurg. Review, Jan., '65. We have not met with any which so highly merits our approval and praise as the second edition of Dr. Buinstead's work.— Glasgow Med. Journal, Oct. 1864. We know of no treatise in any language which is its equal in point of completeness and practical aim* plicity.— Boston Medical and Surgical Journal, Jan. 30, 1864. The book is one which every practitioner should have in his possession, and, we may further say, the only hook upon the subject which ho should acknowledge as competent authority.— Buffalo Medical and Surgical Journal, July, 1864. The best work with which we are acquainted, and the most convenient hand-book for the busy practitioner.—Cincinnati Lancet, July, 1864. The author has spared no labor to make this edition worthy of the reputation acquired by the last, aud we believe that no improvement or suggestion worthy of notice, recorded since the last edition was published, has been left unnoticed. — Dublin Quarterly Journal of Medical Science, August, 1864. BLAKISTON ON CERTAIN DISEASES OF THE CHEST. In one volume octavo. $1 25. BUCKLER ON FIBRO-BRONCHITIS AND RHEUMATIC PNEUMONIA. In one octavo vol., extra cloth, pp. 150. $1 25. FISKE FUND PRIZE ESSAYS.—LEE ON THE EFFECTS OF CLIMATE ON TUBERCULOUS DISEASE. AND WARREN ON THE INFLUENCE OF PREGNANCY ON THE DEVELOPMENT OF TUBERCLES. Together in one neat octavo volume, extra cloth, $1 00. HUGHES' CLINICAL INTRODUCTION TO AUS- CULTATION AND OTHER MODES OF PHYSICAL DIAGNOSIS. Second edition. One volume royal 12mo., extra cloth, pp. 304. $125. WALSHE'S PRACTICAL TREATISE ON DISEASES OF THE LUNGS. Third American/from the third revised and much enlarged London edition. In one neat octavo volume of nearly 500 pages, extra cloth Price $3 00. WALSHE'S PRACTICAL TREATISE ON THE DISEASES OF THE HEART AND GREAT VESSELS. Third American, from the third revised and much enlarged London edition. In one handsome octavo volume of 420 pages, extra cloth. $3 00. (P.), M.D. LETTERS ON SYPHILIS. Translated by W. P. Lattimobje, M.D. In one neat octavo volume, of 270 pages, extra cloth, $2 00. JgUDD (GEORGE), M.D. ON DISEASES OF THE LIVER. Third American, from the third and enlarged London edition. In one very handsome octavo volume, extra cloth, with four beautifully colored plates, and numerous wood-cuts. pp. 500. $4 00. ROCHE (R.), M.D. YELLOW FEVER, considered in its Historical, Pathological, Etiological, and Therapeutical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia from 1699 to 1854, with an examination of the connections between it and the fevers known under the same name in other parts of temperate as well as in tropical regions. In two large and handsome octavo volumes, of nearly 1500 pages, extra cloth, $7 00. JfY THE'SAME AUTHOR. PNEUMONIA ; its Supposed Connection, Pathological, and Etiological, with Autumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one handsome octavo volume, extra cloth, of 500 pages. $3 00. JjYONS (ROBERT D.), K. C. C. A TREATISE ON FEVER; or, Selections from a Course of Lectures on Fever. Being part of a Course of Theory and Practice of Medicine. In one neat octavo volume, of 362 pages, extra cloth. $2 25. CLYMER ON FEVERS; THEIR DIAGNOSIS, PA- tholocjy and Treatment. In one ootavo volume of 600 pages, leather. $1 75. TODD'S CLINICAL LECTURES ON CERTAIN ACUTE Diseases. In one neat octavo volume, of 320 pages, extra cloth. $2 60. Henry C. Lea's Publications— (Practice of Medicine). 20 ROBERTS ( WILLIAM), M. D., Lecturer on Medicine in the Manchester School of Medicine, Sec. A PRACTICAL TREATISE ON URINARY AND RENAL DISEASES, including Urinary Deposits. Illustrated by numerous cases and engravings. In one very handsome octavo volume of 516 pp., extra cloth. $4 50. (Now Ready.) The want has for some time been felt of a work which should render accessible to the American profession in a compendious and convenient form, the results of the numerous and important researches which have of late years elucidated the pathology of Urinary and Renal Diseases. It has been the aim of the author in the present volume to set forth in a form divested of undue technicality, the practical condition of the subject in its most advanced stage of progress. In endeavoring to accomplish this, he has refrained from crowding the volume with minute chemical and physiological details, which would unfit it for its object of affording to the physician a guide in his daily practice, and to the student a condensed and intelligible compendium of all that is practically important on the subject. To aid in this, numerous cases and illustrations have been introduced throughout the work. In carrying out this design, he has not only made good use of his own practical knowledge, but has brought together from various sources a vast amount of information, some of which is not generally possessed by the profession in this country. We must now bring our notice of this book to a close, regretting only that we are obliged to resist the temptation of giving further extracts from it. Dr. Roberts has already on several occasions placed before the profession the results of researches made by him on various points connected with the urine, and had thus led us to expect from him something good—in which expectation we have been by no means disappointed. The book is, beyond question, the most comprehen- sive work on urinary and renal diseases, considered in their strictly practical aspect, that we possess in the English language.— British Medical Journal, Dec. 9, 1865. We have read this book with much satisfaction. It will take its place beside the best treatises in our language upon urinary pathology and therapeutics. Not the least of its merits is that the author, unlike some other book-makers, is contented to withhold much that he is well qualified to discuss in order to impart to his volume such a strictly practical character as cannot fail to render it popular among British readers.— London Med. Times and Gazette, March 17, 1866. a% " Bird on Urinary Deposits," being for the present out of print, gentlemen will find in the above work a trustworthy substitute. MORLAND ON THE MORBID EFFECTS OF THE RETENTION IN THE BLOOD OF THE ELE- MENTS OF THE URINARY SECRETION. In one small octavo volume, 83 pages, extra cloth. 75 cents. BLOOD AND URINE (MANUALS ON). By J. W. Griffth, G. O. Reese, and A. Markwick. One volume, royal 12mo., extra cloth, with plates, pp. 460. $1 25. J>UCKNILL (J. C), M.D., and TkANIEL H. TUKE, M.D., -'-'Med. Superintendent of the Devon Lunatic Asylum.-*--' Visiting Medical Officer to the York Retreat. A MANUAL OF PSYCHOLOGICAL MEDICINE; containing the History, Nosology, Description, Statistics, Diagnosis, Pathology, and Treatment of Insanity. With a Plate. In one handsome octavo volume, of 536 pages, extra cloth. $4 25. A work alike characterized by great classical elegance and a careful and judicious discrimination on the diagnosis, pathology and treatment of this dreadful malady.— Va. Med. and Surg. Journal. We do not know where anything can be found in the literature of the specialty to compare with these essays, in complete and logical treatment, and the clear, practical manner in which their subjects are discussed. They will be cited as authority wherever the language is used, and will, no doubt, bo extensively translated. — Amer. Journal of Insanity. HARRISON'S ESSAY TOWARDS A CORRECT THEORY OF THE NERVOUS SYSTEM. In one octavo volume of 292 pp. fl 50. SOLLY ON THE HUMAN BRAIN; its Structure, Physiology, and Diseases. From the Second and much enlarged London edition. In one octavo volume of 500 pages, with 120 wood-cuts; extra cloth. $2 50. JgMITH {EDWARD), M.D. CONSUMPTION; ITS EARLY AND REMEDIABLE STAGES. In one neat octavo volume of 254 page's, extra cloth. $2 25. £f ALTER (H. H.), M.D. ASTHMA; its Pathology, Causes, Consequences, and Treatment. In one volume, octavo, extra cloth. $2 50. JgLADE (D. D.), M.D. DIPHTHERIA; its Nature and Treatment, with an account of the History of its Prevalence in various Countries. Second and revised edition. In one neat royal 12mo. volume, extra cloth. $1 25. (Just issued.) TONES {0. HAND-FIELD), M. D., V Physician to St. Mary's Hospital, Sec. CLINICAL OBSERVATIONS ON FUNCTIONAL NERVOUS DISORDERS. In one handsome octavo volume of 348 pages, extra cloth, $3 25. (Now Ready.) The wide scope of the treatise, and its practical character, as illustrated by the large number of cases reported in detail by the author, can hardly fail to render it exceedingly valuable to the profession. Henry C. Lea's Publications— (Diseases of the Skin). 21 jyiLSON (ERASMUS), F.R.S., ON DISEASES OF THE SKIN. The sixth American, from the fifth and enlarged English edition. In one large octavo volume of nearly 700 pages, extra cloth. $4 50. Also— A SERIES OF PLATES ILLUSTRATING "WILSON ON DISEASES OF THE SKIN;" consisting of twenty beautifully executed plates, of which thirteen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and embracing accurate representations of about one hundred varieties of disease, most of them the size of nature. Price, in extra cloth, $5 50. Also, the Text and Plates, bound in one handsome volume, extra cloth. Price $9 50. This classical work has for twenty years occupied the position of the leading authority on cutaneous diseases in the English language, and the industry of the author keeps it on a level with the advance of science, in the frequent revisions which it receives at his hands. The large size of the volume enables him to enter thoroughly into detail on all the subjects embraced in it, while its very moderate price places it within the reach of every one interested in this department of practice. Such a work as the one before us is a most capital and acceptable help. Mr. Wilson has long been held as high authority in this department of medicine, and his book on diseases of the skin has long been regarded as one of the best text-books extant on the subject. The present edition is carefully prepared, and brought up in its revision to the present time. In this edition we have also included the beautiful series of plates illustrative of the text, and in the last edition published separately. There are twenty of these plates, nearly all of them colored to nature, and exhibiting with great fidelity the various groups of diseases treated of in the body of the work. — Cincinnati Lancet, June, 1863. No one treating skin diseases should be without a copy of this standard work. — Canada Lancet. August, 1863. We can safely recommend it to the profession as the best work on the subject now in existence in the English language.— Medical Times and Gazette. Mr. Wilson's volume is an excellent digest of the actual amount of knowledge of cutaneous diseases; it includes almost every fact or opinion of importance connected with the anatomy and pathology of the skin.— British and Foreign Medical Review. These plates are very accurate, and are executed with an elegance and taste which are highly creditable to the artistic skill of the American artist who executed them.— St. Louis Med. Journal. The drawings are very perfect, and the finish and coloring artistic and correct; the volume is an indispensable companion to the book it illustrates and completes.— Cliarleston Medical Journal. JftY THE SAME AUTHOR. THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Diseases of the skin. In one very handsome royal 12mo. volume. $3 50. (Now Ready.) This new class-book will be admirably adapted to the necessities of students.— Lancet. Thoroughly practical in the best sense.— Brit. Med. Journal. Jjr THE SAME AUTHOR. HEALTHY SKIN; a Popular Treatise on the Skin and Hair, their Preservation and Management. One vol. 12mo., pp. 291, with illustrations, cloth. $1 00 (J. MO ORE), M. D., M. R. I. A., A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Fifth American, from the second and enlarged Dublin edition by T. W. Belcher, M. D. In one neat royal 12mo. volume of 462 pages, extra cloth. $2 25. (Now Ready.) D7 THE SAME AUTHOR. ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, with exquisitely colored plates, &c, presenting about one hundred varieties of disease. Extra cloth, $5 50. The diagnosis of eruptive disease, however, under all circumstances, is very difficult. Nevertheless, Br. Neligan has certainly, "as far as possible," given a faithful and accurate representation of this class of diseases, and there can be no doubt that these plates will be of great use to the student and practitioner in drawing a diagnosis as to the class, order, and species to which the particular case may belong. While looking over the "Atlas" we have been induced to examine also the "Practical Treatise," and we are inclined to consider it a very superior work, combining accurate verbal description with sound views of the pathology and treatment of eruptive diseases. It possesses the merit of giving short and condensed descriptions, avoiding the tedious minuteness of many writers, while at the same time the work, as its title implies, is strictly practical.— Glasgow Med. Journal. A compend which will very much aid the practitioner in this difficult branch of diagnosis. Taken with the beautiful plates of the Atlas, which are remarkable for their accuracy and beauty of coloring, it constitutes a very valuable addition to the library of a practical man.— Buffalo Med. Journal. TJILLIER (THOMAS), M.D., Physician to the Skin Department of University College Hospital, &c. HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. In one neat royal 12mo. volume of about 300 pages, with two plates; extra cloth, $2 25. (Just Issued.) The work of Dr. Hillier will unquestionably serve the student as a useful and faithful guide to the acquirement of a knowledge of skin diseases. The treatment laid down by the author is simple, rational, and in accordance with the results of an extended experience. Dr. H. avoids all unnecessary multiplication of remedies, and rejects all of doubtful value. — Am. Journal Med. Sciences, July, 1865. A text-book well adapted to the student, and the information contained in it shows the author to be au niveau with the scientific medicine of the day.—¦ London Lancet, Feb. 25, 1865. In the 350 pages, the practitioner will find scattered a great deal of very valuable information not to be met with in more pretentious and extensive works — Med. and Surg. Review (Australasian), Oct. 1, 1865. Henry C. Lea's Publications — (Diseases of Children). 22 T/fTEST (CHARLES), M.D., Physician to the Hospital for Sick Children, &c. LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. Fourth American from the fifth revised and enlarged English edition. In one large and handsome octavo volume of 656 closely-printed pages. Extra cloth, $4 50; leather, $5 50. (Just issued.) This work may now fairly claim the position of a standard authority and medical classic. Five editions in England, four in America, four in Germany, and translations in French, Danish, Dutch, and Russian, show how fully it has met the wants of the profession by the soundness of its views and the clearness with which they are presented. Few practitioners, indeed, have had the opportunities of observation and experience enjoyed by the Author. In his Preface he remarks, " The present edition embodies the results of 1200 recorded cases and of nearly 400 post-mortem examinations, collected from between 30,000 and 40,000 children, who, during the past twentysix years, have come under my care, either in public or in private practice." The universal favor with which the work has been received shows that the.author has made good use of these unusual advantages. Of all the English writers on the diseases of children, there is no one so entirely satisfactory to us as Dr. West. For years we have held his opinion as judicial, and have regarded him as one of the highest living authorities in the difficult department of medical science in which he is most widely known. His writings are characterized by a sound, practical common sense, at the same time that they bear the marks of the most laborious study and investigation. We commend it to all as a most reliable adviser on many occasions when many treatises on the same subjects will utterly fail to help us. It is supplied with a very copious general index, and a special index to the formula? scattered throughout the work. — Boston Med. and Surg. Journal, April 26, 1866. Dr. West's volume is, in our opinion, incomparably the best authority upon the maladies of children that the practitioner can consult. Withal, too—a minor matter, truly, but still not one that should be neglected—Dr. West's composition possesses a peculiar charm, beauty and clearness of expression, thus affording the reader much pleasure, even independent of that which arises from the acquisition of valuable truths. — Cincinnati Jour, of Medicine, March, 1866. We have long regarded it as the most scientific and practical book on diseases of children which has yet appeared in this country.— Buffalo Medical Journal. Dr. West's book is the best that has ever been written in the English language on the diseases of infancy and childhood.— ColurrJms Review of Med. and Surgery. To occupy in medical literature, in regard to diseases of children the enviable position which Dr. Watson's treatise does on the diseases of adults is now very generally assigned to our author, and his book is in the hands of the profession everywhere as an original work of great value.— Md. and Va. Med. and Surg. Journal. Dr. West's works need no recommendation at this date from any hands. The volume before us, especially, has won for itself a large and well-deserved popularity among the profession, wherever the English tongue is spoken. Many years will elapse before It will be replaced in public estimation by any similar treatise, and seldom again will the same subject be discussed in a clearer, more vigorous, or pleasing style, with equal simplicity and power.— Charleston Med. Jour, and Review. There is no part of the volume, no subject on which it treats which does not exhibit the keen perception, the clear judgment, and the sound reasoning of the author. It will be found a most useful guide to the young practitioner, directing him in his management of children's diseases in the clearest possible manner, and enlightening him on many a dubious pathological point, while the older one will find in it many a suggestion and practical hint of grea.t value.— Brit. Am. Med. Journal. (JONDIE (D. FRANCIS), M.D. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fifth edition, revised and augmented. In one large octavo volume of over 750 closelyprinted pages, extra cloth. $4 50. Dr. Condie's scholarship, acumen, industry, and practical sense are manifested in this, as in all his numerous contributions to science.— Dr. Holmes's Report to the American Medical Association. Taken as a whole, in our judgment, Dr. Condie's treatise is the one from the perusal of which the practitioner in this country will rise with the greatest satisfaction. — Western Journal of Medicine and Surgery. We pronounced the first edition to be the best work on the diseases of children in the English language, and, notwithstanding all that has been published, wo still regard it in that light.— Medical Examiner. The value of Works by native authors on the diseases which the physician is called upon to combat will be appreciated by all, and the work of Dr. Cour die has gained for itself the character of a safe guide fur students, and a useful work for consultation by those engaged in practice.— N. Y. Med. Times. QHURCHILL [FLEETWOOD), M.D., M.R.I.A., Prof, of Midwifery and Diseases of Women and Children in the Dublin College of Physicians. ON THE DISEASES OF INFANTS AND CHILDREN. Second American edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M. D. In one large and handsome volume of over 700 pages, extra cloth. $4 50. JT)EWEES [WILLIAM P.), M.D., Late Professor of Midwifery, &c., in the University of Pennsylvania, &c. A TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILDREN. Eleventh edition, with the author's last improvements and corrections. In one octavo volume of 548 pages. $2 80. Henry C. Lea's Publications— (Diseases of Women). 23 JUTEIGS {CHARLES D.), M. D., Late Professor of Obstetrics, &c. in Jefferson Medical College, Philadelphia. WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Lectures to his Class. Fourth and Improved edition. In one large and beautifully printed octavo volume of over 700 pages, extra cloth, $5 00; leather, $6 00. That this work has been thoroughly appreciated by the profession of this country as well as of Europe, is fully attested by the fact of its having reached its fourth edition in a period of less than twelve years. Its value has been much enhanced by many important additions, and it contains a fund of useful information, conveyed in an easy and delightful style. Every topic discussed by the author is rendered so plain as to be readily understood by every student: and, for our own part, we consider it not only one of the most readable of books, but one of priceless value to the practitioner engaged in the practice of those diseases peculiar to females.— N.Am. Med.-Chir. Review. We read the book and find him more—an original thinker, an eloquent expounder, and a thorough practitioner. The book is but twelve years old, but it has been so much appreciated by the profession that edition after edition has been demanded, and now the fourth is on the table by us. We recom- mend with great pleasure a much improved edition of a work in which we saw little room for improvement — Nashville Medical Journal. We greet this new edition of Dr. Meigs' work on woman with much pleasure, and commend it to the profession, especially to the younger members, who may receive much valuable instruction from its pages, conveyed in a pleasing style. The teaching throughout the work reflects the highest credit upon the head and heart of the author.— Chicago Medical Journal. The rules of the art here described, the obstetrical opinions here expressed, the general directions and advice given and suggested, are, beyond any cavil, unexceptionably sagacious and prudent. They are founded on a large practice, have been tested by a long experience, and come from lips to whose teaching thousands have listened for many years, and never without profit.— Charleston Med. Journal and Review. J$Y THE SAME AUTHOR. ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome octavo volume of 365 pages, extra cloth. $2 00. QHUR CHILL (FLEETWOOD), M. D., M. R. I. A. ON THE DISEASES OF WOMEN; including those of Pregnancy and Childbed. A new American edition, revised by the Author. With Notes and Additions, by D. Francis Condie, M. D., author of " A Practical Treatise on the Diseases of Children." With numerous illustrations. In one large and handsome octavo volume of 768 pages, extra cloth, $4 00; leather, $5 00. From the Author's Preface. In reviewing this edition, at the request of my American publishers, I have inserted several new sections and chapters, and I have added, I believe, all the information we have derived from recent researches; in addition to which the publishers have been fortunate enough to secure the services of an able and highly esteemed editor in Dr. Condie. As an epitome of all that is known in this department of medicine, the book before us is perhaps the fullest and most valuable in the English language. — Dublin Medical Press. It was left for Dr Chprchill to gather the scattered facts from their various sources, and reduce them to a general system. This he has done with a masterly hand in the volume now before us ; in which, to the results of his own extensive observation, he has added the views of all British and foreign writers of any note; thus giving us in a complete form, all that is known upon this subject at the present day. To Dr. Churchill, then, are the profession deeply indebted for supplying them with so great a desideratum—the achievement of which deservedly entitles his name, already intimately associated with the diseases of women, to rank very high as an authority upon this subject. We would briefly characterize it as one of the most useful which has issued from the press for many years. To all it bears its own recommendation ; and will be found to be invaluable to the student as a text-book, no less than as a compendious work of reference to the qualified practitioner.— Glasgow Med. Journal. JftY THE SAME AUTHOR. ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PECULIAR TO WOMEN. Selected from the writings of British Authors previous to the close of the Eighteenth Century. In one neat octavo volume of about 450 pages, extra cloth. $2 50. /THOMAS (T. GAILLARD), M. D„ JL Professor of Obstetrics, &c in the College of Physicians and Surgeons, N. Y., &c. A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF FEMALES. In one large and handsome octavo volume, with illustrations. (Preparing.) JgRO WN {ISAAC BAKER), M. D. ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREATMENT. With handsome illustrations. One volume 8vo., extra cloth, pp. 276. $1 60. ASHWELL'S PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third and revised London edition. In one octavo volume, extra cloth, of 528 pages. $3 50. RIGBT ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES. In one neat royal 12mo. volume, extra cloth, of about 250 pages. %\ 00. DEWEES'S TREATISE ON THE DISEASES OF FEMALES. With illustrations. Eleventh Edition, with the Author's last improvements and corrections. In one octavo volume of 536 pages, with plates, extra cloth, $3 00. COLOMBAT DE L'ISERE ON THE DISEASES OF FEMALES. Translated by C. D. Meigs, M. D. Second edition. In one vol. 8vo, extra cloth, with numerous wood-cuts. pp. 720. $3 75. Henry C. Lea's Publications — (Diseases of Women). 24 JJODGE (HUGH L.), M.D. ON DISEASES PECULIAR TO WOMEN; including Displacements of the Uterus. With original illustrations. In one beautifully printed octavo volume of nearly 500 pages, extra cloth. $3 75. Indeed, although no part of the volume is not eminently deserving of perusal and study, we think that the nine chapters devoted to this subject are especially so, and we know of no more valuable monograph upon the symptoms, prognosis, and management of these annoying maladies than is constituted by this part of the work. We cannot but regard it as one of the most original and most practical works of the day—one which every accoucheur and physician should most carefully read: for we are persuaded that he will arise from its perusal with new ideas, which will induct him into a more rational practice in regard to many a suffering female who may have placed her health in his hands.— British American Journal, Feb. 1861. JfyTEST (CHARLES), M.D. LECTURES ON THE DISEASES OF WOMEN. Second American, from the second London edition. In one neat octavo volume of about 500 pages, extra cloth. $3 25. We have thus embodied, in this series of lectures, j one of the most valuable treatises on the diseases of the female sexual system unconnected with gestation, j in our language, and one which cannot fail, from the lucid manner in which the various subjects have been treated, and the careful discrimination used in dealing only with facts, to recommend the volume to the careful study of every practitioner, as affording his safest guides to practice within our knowledge. We ha ve seldom perused a work of a more thoroughly practical character than the one before us. Every j page teems with the most truthful and accurate information, and we certainly do not know of any other work from which the physician, in active practice, can more readily obtain advice of the soundest character upon the peculiar diseases which have been made the subject of elucidation.— British Am. Med. Journal. We return the author our grateful thanks for the vast amount of instruction he has afforded us. His valuable treatise needs no eulogy on our part. His graphic diction and truthful pictures of disease all speak for themselves.— Medico-Chirurg. Review. Most justly esteemed a standard work It bears evidence of having been carefully revised, and is well worthy of the fame it has already obtained. —Dub. Med. Quar. Jour. I As a writer, Dr. West stands, in our opinion, se! cond only to Watson, the "Macaulay of Medicine;" i he possesses that happy faculty of clothing instruction in easy garments; combining pleasure with profit, he leads his pupils, in spite of the ancient proverb, along a royal road to learning. His work is one which will not satisfy the extreme on either side, but it is one that will please the great majority who are seeking truth, and one that will convince the student that he has committed himself to a candid, safe, and valuable guide.— N. A. Med.-Chirurg Review. We must now conclude this hastily written sketch with the confident assurance to our readers that the work will well repay perusal. The conscientious, painstaking, practical physician is apparent on every page.— K Y. Journal of Medicine. We have to say of it, briefly and decidedly, that it is the best work on the subject in any language, and that it stamps Dr. West as the facile princeps of British obstetric authors. — Edinburgh Med. Journal. We gladly recommend his lectures as in the highest degree instructive to all who are interested in ob- I stetric practice.— London. Lancet. We know of no treatise of the kind so complete, I and yet so compact.— Chicago Med. Journal. JfY THE SAME AUTHOR. AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCERATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 25. gIMPSON (SIR JAMES Y.), M.D. CLINICAL LECTURES ON THE DISEASES OF WOMEN. With numerous illustrations. In one handsome octave volume of over 500 pages, extra cloth. $4. The principal topics embraced in the Lectures are Vesico-Vaginal Fistula, Cancer of the Uterus, Treatment of Carcinoma by Caustics, Dysmenorrhoea, Amenorrhoea, Closures, Contractions, Ac, of the Vagina, Vulvitis, Causes of Death after Surgical Operations, Surgical Fever, Phlegmasia Dolens, Coccyodinia, Pelvic Cellulitis, Pelvic Hasmatoma, Spurious Pregnancy, Ovarian Dropsy, Ovariotomy, Cranioclasm, Diseases of the Fallopian Tubes, Puerperal Mania, Sub-Involution and Super-In volution of the Uterus, &c. Ac. RENNET (HENRY), M.D. A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. Sixth American, from the fourth and revised English edition. In one octavo volume of about 500 pages, extra cloth. $3 75. (Recently Issued.) From the Author's Preface. During the past two years, this revision of former labors has been my principal occupation, and in its present state the work may be considered to embody the matured experience of the many years I have devoted to the study of uterine disease. Indeed, the entire volume is so replete with information, to all appearance so perfect in its details, that we could scarcely have thought ano.ther page or paragraph was required for the full description of all that is now known with regard to the diseases under consideration if we had not been so informed by the au- thor. To speak of it except in terms of the highest approval would be impossible, and we gladly avail ourselves of-the present opportunity to recommend it in the most unqualified manner to the profession, — Dublin Med. Press. JjY THE SAME AUTHOR. A REVIEW OF THE PRESENT STATE OF UTERINE PATHO- LOGY. In one small octavo volume, extra cloth. 50 cents. Henry C. Lea's Publications— (Midwifery). 25 TJODGE (HUGH L.), M.D., Late Professor of Midwifery, &e. in the University of Pennsylvania, &o. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illustrated with large lithographic plates containing one hundred and fifty-nine figures from original photographs, and with numerous wood-cuts. In one large and beautifully printed quarto volume of 550 double-columned pages, strongly bound in extra cloth, $14. (Lately ptcblished.) From the Author's Preface. "Influenced by these motives, the author has, in this volume, endeavored to present not simply his own opinions, but also those of the most distinguished authorities in the profession; so that it may be considered a digest of the theory and practice of Obstetrics at the present period." In carrying out this design, the ample space afforded by the quarto form has enabled the author to enter thoroughly into all details, and in combining the results of his long experience and study with the teachings of other distinguished authors, he cannot fail to afford to the practitioner whatever counsel and assistance may be required in doubtful cases and emergencies. A distinguishing feature of the work is the profuseness of its illustrations. The lithographic plates are all original, and, to insure their accuracy, they have been copied from photographs taken expressly for the purpose. Besides these, a very full series of engravings on wood will be found scattered through the text, so that all the details given by the author are amply elucidated by the illustrations. It may be added that no pains or expense have been spared to render the mechanical execution of the work in every respect worthy of the character and value of the teachings it contains. Specimens of the plates and letterpress will be forwarded to any address free by mail on receipt of six cents in postage stamps. The work of Dr. Hodge is something more than a simple presentation of his particular views in the department of Obstetrics; it is something more than an ordinary treatise on midwifery; it is, in fact, a cyclopedia of midwifery. He has aimed to embody in a single volume the whole science and art of Obstetrics. An elaborate text is combined with accurate and varied pictorial illustrations, so that no fact or principle is left unstated or unexplained.— Am. Med. Times, Sept. 3, 1864. We should like to analyze the remainder of this excellent work, but already has this review extended beyond our limited space. We cannot conclude this notice without referring to the excellent finish of the work. In typography it is not to be excelled; the paper is superior to what is usually afforded by our American cousins, quite equal to the best of English books. The engravings and lithographs are most beautifully executed. The work recommends itself for its originality, and is in every way a most valuable addition to those on the subject of obstetrics.— Canada Med. Journal, Oct. 1864. It is very large, profusely and elegantly illustrated, and is fitted to take its place near the works of great obstetricians. Of the American works on the subject it is decidedly the best.— Edinb. Med. Jour., Dec. '64. We have examined Professor Hodge's work with great satisfaction; every topic is elaborated most fully. The views of the author are comprehensive, and concisely stated. The rules of practice are judicious, and will enable the practitioner to meet every emergency of obstetric complication with confidence. — Cliicago Med. Journal, Aug. 1864. More time than we have had at our disposal since we received the great work of Dr. Hodge is necessary to do it justice. It is undoubtedly by far the most original, complete, and carefully composed treatise on the principles and practice of Obstetrics which has ever been issued from the American press.— Pacific Med. and Surg. Journal, July, 1S64. We have read Dr. Hodge's book with great pleasure, and have much satisfaction in expressing our commendation of it as a whole. It is certainly highly instructive, and in the main, we believe, correct. The great attention which the author has devoted to the mechanism of parturition, taken along with the conclusions at which he has arrived, point, we think, conclusively to the fact that, in Britain at least, the doctrines of Naegele have been too blindly received. — Glasgow Med. Journal, Oct. 1864. MONTGOMERY (W. F.), M.D., Professor of Midwifery in the King's and Queen's College of Physicians in Ireland. AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREGNANCY. With some other Papers on Subjects connected with Midwifery. From the second and enlarged English edition. With two exquisite colored plates, and numerous wood-cuts. In one very handsome octavo volume of nearly 600 pages, extra cloth. $3 75. liflLLER (HENRY), M.D., *™ Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. PRINCIPLES AND PRACTICE OF OBSTETRICS, &c; including the Treatment of Chronic Inflammation of the Cervix and Body of the Uterus considered as a frequent cause of Abortion. With about one hundred illustrations on wood. In one very handsome octavo volume of over 600 pages, extra cloth. $3 75. TYLER SMITH ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OF OBSTETRICS. In one royal 12mo. volume, extra cloth, of 400 pages. $1 50. RIGBY'S SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. Second American edition. One volume octavo, extra cloth, 422 pages. $2 50. DEWEES'S COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occasional cases and many engravings. Twelfth edition, with the author's last improvements and corrections. In one octavo volume, extra cloth, of GOO pages. $3 50. 26 Henry C. Lea's Publications— (Midwifery). (FRANCIS H), M.D. THE PRINCIPLES iND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., Professor of Obstetrics, &c, in the Jefferson Medical College, Philadelphia. In one large and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised bands; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in all nearly 200 large and beautiful figures. $7 00. We will only add that the student will learn from it all he need to know, and the practitioner will find it, as a book of reference, surpassed by none other. — Stethoscope. The character and merits of Dr. Ramsbotham's work are so well known and thoroughly established, that comment is unnecessary and praise superfluous. The illustrations, which are numerous and accurate, are executed in the highest style of art. We cannot too highly recommend the work to our readers.— St. Louis Med. and Surg. Journal. To the physician's library it is indispensable, while to the student, as a text-book, from which to extract the material for laying the foundation of an education on obstetrical science, it has no superior.— Ohio Med. and Surg. Journal. When we call to mind the toil we underwent in acquiring a knowledge of this subject, we cannot but envy the student of the present day the aid which this work will afford him.— Am. Jour, of the Med. Sciences. MEIGS (CHARLES D.), 31. D., Lately Professor of Obstetrics, &c, in the Jefferson Medical College, Philadelphia. OBSTETRICS: THE SCIENCE AND THE ART. Fourth edition, revised and improved. With one hundred and twenty-nine illustrations. In one beautifully printed octavo volume of 730 large pages. Extra cloth, $5 00; leather, $6 00. We have, therefore, great satisfaction in bringing under our readers' notice the matured views of the highest American authority in the department to which he has devoted his life and talents. They coinprise not only the "fruit of many years of paiuful toil in the acquisition of clinical experience and knowledge," but they contain also the evidences of an extended acquaintance with European medical literature, both continental and British. This feature, together with the elevation of tone and eloquence in style often exhibited by the author, constitute no slight merit in works on the subjects with which the author is here occupied.— London Med Gazette. We have made a somewhat careful examination of this new edition of the Science and the Art of Obstetrics, and are satisfied that there is no better or more useful guide to the educated practitioner.— New Orleans Monthly Med. Register. QHUR CHILL (FLEETWOOD), M.D., M. R.I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With notes and additions by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Children," &c. With one hundred and ninety-four illustrations. In one very handsome octavo volume of nearly 700 large pages. Extra cloth, $4 00; leather, $5 00. In adapting this standard favorite to the wants of the profession in the United States, the editor has endeavored to insert everything that his experience has shown him would be desirable for the American student, including a large number of illustrations. With the sanction of the author, he has added, in the form of an appendix, some chapters from a little "Manual for Midwives and Nurses," recently issued by Dr. Churchill, believing that the details there presented can hardly fail to prove of advantage to the junior practitioner. The result of all these additions is that the work now contains fully one-half more matter than the last American edition, with nearly onehalf more illustrations; so that, notwithstanding the use of a smaller type, the volume contains almost two hundred pages more than before. No effort has been spared to secure an improvement in the mechanical execution of the work equal to that which the text has received, and the volume is confidently presented as one of the handsomest that has thus far been laid before the American profession; while the very low price at which it is offered should secure for it a place in every lecture-room and on every office table. These additions render the work still more complete and acceptable than ever; and with the excellent style in which the publishers have presented this edition of Churchill, we can commend it to the profession with great cordiality and pleasure.—Cincinnati Lancet. Few works on this branch of medical science are equal to it, certainly none excel it, whether in regard to theory or practice, and in one respect it is superior to all others, viz., in its statistical information, and therefore, on these grounds a most valuable work for the physician, student, or lecturer, all of whom will find in it the information which they are seeking.— Brit. Am. Journal. The present treatise is very much enlarged and amplified beyond the previous editions but nothing has been added which could be well dispensed with. An examination of the table of contents shows how thoroughly the author has gone over the ground, and the care he has taken in the text to present the subjects in all their bearings, will render this new edition even more necessary to the obstetric student than were either of the former editions at the date of their appearance. Ho treatise on obstetrics with which we are acquainted can compare favorably with this, in respect to the amount of material which has been gathered from every source.— Boston Med. and Sara. Journal. There is no better text-book for students, or work of reference and study for the practising physician than this. It should adorn and enrich every medical library.— Chicago Med. Journal. Henry C. Lea's Publications— (Surgery). 27 QROSS (SAMUEL D.), M.D., Professor of Surgery in the Jefferson Medical College-of Philadelphia. A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, andfOperative. Illustrated by upwards of Thirteen Hundred Engravings. Fourth edition, carefully revised, and improved. In two large and beautifully printed royal octavo volumes of 2200 pages, strongly bound in leather, with raised bands. $15 00. The continued favor, shown by the exhaustion of successive large editions of this great work, proves that it has successfully supplied a want felt by American practitioners and students. Though but little over six years have elapsed since its first publication, it has already reached its fourth edition, while the care of the author in its revision and correction has kept it in a constantly improved shape. By the use of a close, though very legible type, an unusually large amount of matter is condensed in its pages, the two volumes containing as much as four or five ordinary octavos. This, combined with the most careful mechanical execution, and its very durable binding, renders it one of the cheapest works accessible to the profession. Every subject properly belonging to the domain of surgery is treated in detail, so that the student who possesses this work may be said to have in it a surgical library. It must long remain the most comprehensive work on this important part of medicine.— Boston Medical and Surgical Journal, March 23, 186~5. We have compared it with most of our standard works, such as those of Erichsen, Miller, Fergusson, Syme, and others, and we must, in justice to our author, award it the pre-eminence. As a work, complete in almost every detail, no matter how minute or trifling, and embracing every subject known in the principles and practice of surgery, we believe it stands without a rival. Dr. Gross, in his preface, remarks "my aim has been to embrace the whole domaiu of surgery, and to allot to every subject its legitimate claim to notice;" and, we assure our readers, he has kept his word. It is a work which we can most confidently recommend to our brethren, for its utility is becoming the more evident the longer it is upon the shelves of our library.— Canada Med. Journal, September, 1865. The first two editions of Professor Gross' System of Surgery are so well known to the profession, and so highly prized, that it would be idle for us to speak in praise of this work. — Chicago Medical Journal, September, 1865. We gladly indorse the favorable recommendation of the work, both as regards matter and style, which we made when noticing its first appearance.— British and Foreign Medico-Chirurgical Review, Oct. 1865. The most complete work that has yet issued from the press on the science and practice of surgery.— London Lancet. This system of surgery is, we predict, destined to take a commanding position in our surgical literature, and be the crowning glory of the author's well earned fame. As an authority on general surgical subjects, this work is long to occupy a pre-eminent place, not only at home, but abroad. We have no hesitation in pronouncing it without a rival in our language, and equal to the best systems of surgery in any language.— N. Y. Med. Journal. Not only by far the best text-book on the subject, as a whole, within the reach of American students, but one which will be much more than ever likely to be resorted to and regarded as a high authority abroad.— Am. Journal Med. Sciences, Jan. 1865. The work contains everything, minor and major, operative and diagnostic, including mensuration and examination, venereal diseases, and uterine manipulations and operations. It is a complete Thesaurus of modern mirgery, where the student and practi- tioner shall not seek in vain for what they desire.— San Francisco Med. Press, Jan. 1S65. Open it where we may, we find sound practical information conveyed in plain language. This book is no mere provincial or even national system of surgery, but a work which, while very largely indebted to the past, has a strong claim on the gratitude of the future of surgical science.— Edinburgh Med. Journal, Jan. 1865. A glance at the work is sufficient to show that the author and publisher have spared no labor in making it the most complete "System of Surgery" ever published in any country.—St. Louis Med. and Surg. Journal, April, 1865. The third opportunity is now offered during our editorial life to review, or rather to indorse and recommend this great American work on Surgery. Upon this last edition a great amount of labor has been expended, though to all others except the author the work was regarded in its previous editions as so full and complete as to be hardly capable of improvement. Every chapter has been revised; the text augmented by nearly two hundred pages, and a considerable number of wood-cuts have been introduced. Many portions have been entirely re-written, and the additions made to the text are principally of a practical character. This comprehensive treatise upon surgery has undergone revisions and enlargements, keeping pace with the progress of the art and science of surgery, so that whoever is in possession of this work may consult its pages upon any topic embraced within the scope of its department, and rest satisfied that its teaching is fully up to the present standard of surgical knowledge. It is also so comprehensive that it may truthfully be said to embrace all that is actually known, that is really of any value in the diagnosis and treatment of surgical diseases and accidents. Wherever illustration will add clearness to the subject, or make better or more lasting impression, it is not wanting; in this respect the work is eminently superior.— Buffalo Med. Journal, Dec. 1864. A system of surgery which we think unrivalled tn our language, and which will indelibly associate his name with surgical science. And what, in our opinion, enhances the value of the work is that, while the practising surgeon will find all that he requires in it, it is at the same time one of the most valuable treatises which can be put into the hands of the student seeking to know the principles and practice of this branch of the profession which he designs subsequently to follow.— The Brit. Am. Journ., Montreal. JjY THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND, AND THE URETHRA. Second edition, revised and much enlarged, with one hundred and eighty-four illustrations. In one large and very handsome octavo volume, of over nine hundred pages, extra cloth. $4 00. Whoever will peruse the vast amount of valuable practical information it contains will, we think, agree with us, that there is no work in the English ian- guage which can make any just pretensions to be its equal.— N. Y. Journal of Medicine. THE SAME AUTHOR. A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PASSAGES. In one handsome octavo volume, extra cloth, with illustrations, pp. 468. $2 75. 28 Henry C. Lea's Publications— (Surgery). JfJRICHSEN {JOHN), Professor of Surgery in University College, London. THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical Injuries, Diseases, and Operations. New and improved American, from the Second enlarged and carefully revised London edition. Illustrated with over four hundred wood engravings. In one large and handsome octavo volume of 1000 closely printed pages; extra cloth, $6; leather, raised bands, $7. We are bound to state, and we do so without wishing to draw invidious comparisons, that the work of Mr. Erichsen, in most respects, surpasses any that has preceded it. Mr. Erichsen's is a practical work, combining a due proportion of the "Science and Art of Surgery." Having derived no little instruction from it, in many important branches of surgery, we can have no hesitation in recommending it as a valuable book alike to the practitioner and the student. —Dublin Quarterly. Gives a very admirable practical view of the science and art of surgery.— Edinburgh Med. and Surg. Journal. We recommend it as the best compendium of surgery in our language.— London Lancet. It is, we think, the most valuable practical work on surgery in existence, both for young and old practitioners — Nashville Med. and Surg. Journal. The limited time we have to review this improved edition of a work, the first issue of which we prized as one of the very best, if not the best text-book of surgery with which we were acquainted, permits us to give it but a passing notice totally unworthy of its merits. It may be confidently asserted, that no work on the science and art of surgery has ever received more universal commendation or occupied a higher position as a general text-book on surgery, than this treatise of Professor Erichsen.— Savannah Journal of Medicine. In fulness of practical detail and perspicuity of style, convenience of arrangement and soundness of discrimination, as well as fairness and completeness of discussion, it is better suited to the wants of both student and practitioner than any of its predecessors. — Am. Journal of Med. Sciences. After careful and frequent perusals of Erichsen's surgery, we are at a loss fully to express our admiration of it. The author's style is eminently didactic, and characterized by a most admirable directness, clearness, and compactness.— Ohio Med. and Surg. Journal. J£Y THE SAME AUTHOR. ON RAILWAY, AND OTHER INJURIES OF THE NERVOUS SYSTEM. To make one small octavo volume. (Publishing in the "Medical News and Library" for 1867.) This new work of the distinguished author has been selected for publication in the " Medical News and Library" for 1867, under the impression that its able treatment of a subject comparatively novel, and yet of wide importance, will prove eminently satisfactory to subscribers. JiTILLER (JAMES), JJJ- Late Professor of Surgery in the University of Edinburgh, &c. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume of 700 pages, with two hundred and forty illustrations on wood, extra cloth. $3 75. JjY THE SAME AUTHOR. THE PRACTICE OF SURGERY. Fourth American, from the last Edinburgh edition. Revised by the American editor. Illustrated by three hundred and sixty-four engravings on wood. In one large octavo volume of nearly 700 pages extra cloth. $3 75. It is seldom that two volumes have ever made so profound an impression in so short a time as the " Principles" and the " Practice" of Surgery by Mr. Miller, or so richly merited the reputation they have acquired. The author is an eminently sensible, practical, and well-informed man, who knows exactly what he is talking about, and exactly how to talk it. — Kentucky Medical Recorder. piRRIE ( WILLIAM), F. R. S. E., Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited b y John Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania Hospital, Ac. In one very handsome octavo volume of 780 pages with 316 illustrations, extra cloth. $3 75. (F. W.), M.D. ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. New edition, with an additional chapter on Military Surgery. One handsome roval 12mo. volume, of nearly 400 pages, with 184 wood-cuts. Extra cloth, $1 75. Exceedingly convenient and valuable to all mem- We cordially commend this volume as one which bers of the Medical Examiner, the medical student should most closely study ¦ and May, lbtw. to the surgeon in practice it must prove itself instruct- The very best manual of Minor Surgery we have lve . on many points which he may have forgotten.— seen.— Buffalo Med. Journal. ' Brit. Am. Journal, May, 1862. We cordially commend this volume as one which the medical student should most closely study; and to the surgeon in practice it must prove itself instructive on many points which he may have forgotten.— Brit. Am. Journal, May, 1862. MALGAIGNE'S OPERATIVE SURGERY. With numerous illustrations on wood. In one handsome octavo volume, extra cloth, of nearly 600 pp. $2 ,10. SKEY'S OPERATIVE SURGERY. In one very handsome octavo volume, extra cloth, of over 600 pages, with about 100 wood-cats. $3 25. FERGUSSON'S SYSTEM OF PRACTICAL SURGFRV Fourth American f™™ ih a t*i~A «VSi J~ T " % 1"edmoT"^^^and uSSfftlSSt octavo volume of about 700 pages, with 393 handsome illustrations. Leather, $1. Henry C. Lea's Publications— (Surgery). 29 JJRUITT (ROBERT), M.R. C.S., frc. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American, from the eighth enlarged and improved London edition. Illustrated with four hundred and thirty-two wood-engravings. In one very handsome octavo volume, of nearly 700 large and closely printed pages. Extra cloth, $4 00; leather, $5 00. All that the surgical student or practitioner could desire.— Dublin Quarterly Journal. It is a most admirable book. We do not know when we have examined one with more pleasure.— Boston Med. and Surg. Journal. In Mr. Druitt's book, though containing only some seven hundred pages, both the principles and the practice of surgery are treated, and so clearly and perspicuously, as to elucidate every important topic. The fact that twelve editions have already been called for, in these days of active competition, would of itself show it to possess marked superiority. We have examined the book most thoroughly, and can say that this success is well merited. His book, moreover, possesses the inestimable advantages of having the subjects perfectly well arranged and classified, and of being written in a style at once clear and succinct.— Am. Journal of Med. Sciences. Whether we view Druitt's Surgery as a guide to operative procedures, or as representing the latest theoretical surgical opinions, no work that we are at present acquainted with can at all compare with it. It is a compendium of surgical theory (if we may use the word) and practice in itself, and well deserves the estimate placed upon it.— Brit. Am. Journal. Thus enlarged and improved, it will continue to rank among our best text-books on elementary surgery.—Columbus Rev. of Med. and Surg. We must close this brief notice of an admirable work by recommending it to the earnest attention of every medical student.— Charleston Medical Journal and Review. A text-book which the general voice of the profession in both England and America has commended as one of the most admirable "manuals," or, "vade mecum," as its English title runs, which can be placed in the hands of the student. The merits of Druitt's Surgery are too well known to every one to need any further eulogium from us.— Nashville Med. Journal. JJAMILTON (FRANK H), M.D., Professor of Fractures and Dislocations, &e. in Bellevue Hosp. Med. College, New York. A PRACTICAL TREATISE ON FRACTURES AND DISLOCATIONS. Third edition, thoroughly revised. In one large and handsome octavo volume of 777 pages, with 294 illustrations, extra cloth, $5 75. (Now ready.) The demand which has so speedily exhausted two large editions of this work shows that the author has succeeded in supplying a want, felt by the profession at large, of an exhaustive treatise on a frequent and troublesome class of accidents. The unanimous voice of the profession, abroad as well as at home, has pronounced it the most complete work to which the surgeon can refer for information respecting all details of the subject. In the preparation of this new edition, the author has sedulously endeavored to render it worthy a continuance of the favor which has been accorded to it, and the experience of the recent war has afforded a large amount of material which he has sought to turn to the best practical account. The volume before us is (we say it with a pang of wounded patriotism) the best and handiest book on the subject in the English language. It is in vain to attempt a review of it; nearly as vain to seek for any sins, either of commission or omission.— Edinburgh Med. and Surg. Journal. From the great labor and time bestowed upon its preparation, we had been led to anticipate a very thorough and elaborate monograph, and an attentive perusal of its pages has satisfied us that our expectations have been fully realized. The work is by far the most complete disquisition on fractures and dislocations in the English language. It is not our intention to present anything like a formal analysis of this work; to do so would carry us far beyond the limits which we have assigned to us, to say nothing of the fact that it would be a matter of supererogation, inasmuch as no intelligent practitioner will be likely to be without a copy of it for ready use. No library, however extensive, will be complete without it.— North American Medico-Chirurgical Review. This is a valuable contribution to the surgery of most important affections, and is the more welcome, inasmuch as at the present time we do not possess a single complete treatise on Fractures and Dislocations in the English language. It has remained for our American brother to produce a complete treatise upon the subject.— London Lancet. fJURLING (T.B.), F.R.S, Surgeon to the London Hospital, President of the Hunterian Society, &c. A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPERMATIC CORD, AND SCROTUM. Second American, from the second and enlarged English edition. In one handsome octavo volume, extra cloth, with numerous illustrations, pp. 420. $2 00. , T>AR WELL (RICHARD), F. R. C. S., Assistant Surgeon Charing Cross Hospital, &c. A TREATISE ON DISEASES OF THE JOINTS. Illustrated with engravings on wood. In one very handsome octavo volume of about 500 pages; extra cloth, $3. BRODIE'S CLINICAL LECTURES ON SURGERY. 1 vol. Svo., 350 pp.; cloth, $1 25. COOPER ON THE STRUCTURE AND DISEASES OF the Testis, and on the Thymus Gland. One vol. imperial 8vo., extra cloth, with 177 figures on 29 plates. $2 50. COOPER'S LECTURES ON THE PRINCIPLES AND Practice op Surgery. In one very large octavo volume, extra cloth, of 750 pages. $2 00. GIBSON'S INSTITUTES AND PRACTICE OP SURGERY. Eighth edition, improved and altered. With thirty-four plates. In two handsome octavo volumes, about 1000 pages, leather, raised bands. $6 50 Henry C. Lea's Publications— (Surgery). 30 rPOYNBEE (JOSEPH), F.R.S., Aural Surgeon to and Lecturer on Surgery at St. Mary's Hospital. THE DISEASES OF THE EAR: their Nature, Diagnosis, and Treatment. With one hundred engravings on wood. Second American edition. In one very handsomely printed octavo volume of 440 pages; extra cloth, $4. The appearance of a volume of Mr. Toynhee's, therefore, in which the subject of aural disease is treated in the most scientific manner, and our knowledge in respect to it placed fully on a par with that which we possess respecting most other organs of the body, is a matter for sincere congratulation. We may reasonably hope that henceforth the subject of this treatise will cease to be among the opprobria of medical science.— London Medical Review. The work, as was stated at the outset of our notice, is a model of its kind, and every page and paragraph of it are worthy of the most thorough study. Considered all in all—as an original work, well written, philosophically elaborated, and happily illustrated with cases and drawings—it is by far the ablest monograph that has ever appeared on the anatomy and diseases of the ear, and one of the most valuable contributions to the art and science of surgery in the nineteenth century.—if. Am. Med.-Chirurg. Review. T A TJRENCE (JOHN Z.), F. R. C. S., and MO ON (ROBER T C), Editor of the Ophthalmic Review, &c. House Surgeon to the Southward Oph' thalmic Hospital, &c. A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of Practitioners. With numerous illustrations. In one very handsome octavo volume, extra cloth. $2 50. (Now Ready.) (PROM THE AUTHORS' PREFACE.) "In writing these pnges it has been our aim to bring the principles and practice of modern ophthalmic surgery within a small compass, to supply the wants of the busy practitioner, who may have neither time nor opportunity to read the innumerable contributions that ophthalmic surgery and science have received within the last fifteen years. "In describing symptoms, we have limited ourselves to those which are essential for the recognition of disease; in describing operations. &c, to those details which are essential for its treatment." TONES (T. WHARTON), F.R.S., Professor of Oplithalmic Med. and Surg, in University College, London. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. With one hundred and seventeen illustrations. Third and revised American, with Additions from the second London edition. In one handsome octavo volume of 455 pages, extra cloth. $3 25. We know of no work which contains the same amount of information in the same compass; we especially re- commend the book to the American physician and me- dical student. — San Francisco Med. Press. | It is an excellent practical treatise on the medical and surgical diseases of the eye, and is well adapted to the wants both of the student and practitioner.— Chicago Med. Examiner. MA CKENZIE ( W.), M. B., Surgeon Oculist in Scotland in ordinary to her Majesty, &c. A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE EYE. To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section of the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the fourth revised and enlarged London edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to Wills Hospital,