Exfoliation of the Cochlea. 
S. 0. Richey, 
Assistant Aural-Surgeon to the Illinois Charitable Eye and Ear Infirmary, etc. 
This process is a comparatively rare one, and is one of the re- 
sults of chronic suppurative inflammation, which in its course in- 
volves the labyrinth. 
The membrana tympani has generally been destroyed, and the 
ossicles of the middle ear have previously been lost. Sometimes 
it has been complicated with polypi and mastoid abscess. In 
many of the cases observed, the cochlea alone of the labyrinth 
has been thrown off, while in other cases the cochlea, vestibule, 
semi-circular canals, etc., have been exfoliated. 
It has been claimed that some power of audition has remained 
after the cochlea alone has been removed, but that when the whole 
labyrinth has been destroyed no hearing power has remained, 
while there has usually been facial paralysis. 
It is difficult to decide, without an autopsy, that no part of 
the labyrinth except the cochlea has been lost, unless the surgeon 
is present, each time the ear is syringed, so that he may know 
what is cast off by seeing it. It is well known that the ossicles 
are often washed out by the patient or his friends without being 
Reprinted from the Chicago Medical Journal and Examiner for April. 2 
seen by them. May not a sequestrum from the labyrinth as 
easily escape notice ? 
Facial paralysis accompanying chronic suppurative inflamma- 
tion of the tympanum, is not a reliable symptom of the destruc- 
tion of the entire labyrinth, though it be associated with com- 
plete deafness, as it may arise from other causes. 
I have known one case in which partial paralysis of the right 
portio dura seemed to be due to the pressure of accumulated pus 
in suppurative inflammation of the right middle ear. There was 
no reason to suppose the labyrinth was at all affected, as the 
hearing was improved by removing the pus from the middle ear, 
and the paralysis was relieved when the discharge ceased. It 
has been my good fortune to have under observation at the 
Illinois Charitable Eye and Ear Infirmary, two cases in which 
the cochlea became necrosed, and was extracted. 
The first case is that of Daniel Gubbins, aged 8 years, who 
came under care as a dispensary patient, May 30th, 1876. The 
statement of the mother of the boy is, that more than 8 months 
prior to this time, the boy had been sick with measles, and dur- 
ing his sickness, “ he had a bad ear ache ” in the right ear, which 
“ got very red and swelled up.” 
A day or two afterwards “ he had a gathering ” in that ear. 
She claimed to have washed several “ gravels ” from the right 
ear, which she thought might have been the cause of the inflam- 
mation. These were in all probability the ossicles of the middle 
ear. 
At the time of his application for relief, the tympanum con- 
tained fetid pus, which escaped from the external meatus, and 
through two other openings, one above, and the other behind the 
auricle. The pus escaping from the fistula above the auricle had 
burrowed under the retrahens muscle, and had formed a sinus at 
least an inch in length. Necrosis of the squamous portion of 
the temporal bone had occurred at the upper opening, about 
which, in consequence, there was unhealthy and excessive granu- 
lation. 
Several spiculae of dead bone were taken from this region, and 
the granulations were reduced bv the solid nitrate of silver. The 
membrana tympani was entirely destroyed, and the external 3 
meatus and middle ear contained numerous polypi, which were 
extracted, and their bases cauterized. Medicated solutions could 
then be forced into the meatus and out through the artificial 
openings, or into these openings and out through the meatus. 
The whole right side of the head seemed enlarged, and the 
child staggered if he attempted to walk alone; the mother 
steadied him by keeping her hand on his shoulder. 
Even after he had improved greatly, if he endeavored to cross 
the room alone to a chair on the opposite side, he would go to a 
point somewhat to the left of the chair, until he came near it, 
when he would stop, change his deviation and reach the chair. 
Instead of carrying his head erect, he leaned it very much 
towards the left shoulder. 
If he were asked a question, he wrould after some hesitation, 
answer in a quick jerking manner. He was pallid, slept badly, 
and had a poor appetite, but he did not complain of any pain at 
this time. 
Hearing distance, right ear=4°8. 
Profuse granulation took place in the sinus behind the auricle, 
and continued, regardless of the efforts made to control it, until 
it became necessary to open up the sinus. 
In doing this the retrahens muscle had to be cut across, and of 
course the auricle fell forwards and below the plane of the other 
auricle, giving to the patient a somewhat peculiar appearance. 
The cicatrix, by contraction, has restored the pinna almost to its 
former position. The improvement has been gradual, and 
although the suppuration has nearly ceased many times, it has 
been again brought on by inattention at home and by exposure. 
The treatment has been cleanliness, and the application of carbol- 
ized and astringent solutions, the astringent being changed from 
time to time. 
A strong solution of the nitrate of silver has been applied once 
a week. 
Sept. 15th, 1877.— The necrosed cochlea was removed from the 
middle ear in which it could be seen. It is nearly perfect in 
form. At no time has there been any evidence of facial paraly- 
sis, so far as has been observed, nor does there seem to be any 
power of audition on the right side. 4 
Every sound he recognizes he attributes to the left ear, even 
though the meatus of that side is closed. 
The second case is that of Mr. Bernhard Sturm, aged 40 years, 
a resident of Jefferson county, 111., who became an inmate of the 
Illinois Charitable Eye and Ear Infirmary, May 19th, 1877. 
His history, as given by himself, is as follows: 
“ He does not know that he had any trouble with his left ear 
prior to his tenth year. At that time, while standing on ice, 
he was thrown down and his head struck the ice with so much 
force that he was insensible for a day and a night afterward, and 
he does not think he has heard anything with his left ear since.” 
In the cranium at the junction of the sagittal with the lambdoi- 
dal suture, there is a depression so deep as to receive a finger, its 
length being in the direction of the lambdoidal suture. This he 
claims to be a result of the fall. Subsequent to the fall, he felt 
no inconvenience except as to the loss of hearing in the left ear, 
until eight years ago, when it began to have a disagreeable odor, 
and continued to do so, although no discharge was noticed until 
the middle of March, 1877. 
During the two winters preceding that of 1876-7, he had con- 
stant and severe pain in the left ear, which caused him much loss 
of sleep. This pain left him each spring when the weather 
became wrarm, until 1877. The left ear was unusually painful 
immediately before it began to discharge, March 1877. From 
the time suppuration began until he came to the infirmary, he 
could obtain only one or two hours’ sleep in the twenty-four. He 
claims to have been several times “out of his head ” with pain. 
For many weeks before he came into the infirmary, he could not 
walk alone because of dizziness, and if he attempted to turn 
around quickly, he would fall. Dr. J. H. Newton, his family 
physician, writes in regard to his case: “About March 12th, 
1877, after a few days’ exposure to a cold rain, he was taken 
with intense pain in his head and ear, accompanied with rapid 
pulse, vomiting and delirium. Upon the subsidence of the 
first fever, diplopia showed itself, and remained with him 
while he staid here, together with unsteady gait and confusion 
of ideas. Somewhere about May 1st, a small piece of bone, 5 
very much corroded, came out of his ear. I thought it a por- 
tion of the malleus.” 
The patient also mentioned this piece of bone, and compared 
it to a grain of wheat in size and shape. 
When he was admitted into the infirmary, he had severe pain 
all through his head, referable particularly to the left temporal 
region. Ilis appetite was poor, and he complained of constant 
nausea. His countenance was pallid, his gait unsteady, and he 
weighed 125 pounds. There Avas diplopia, due to the divergence 
of the left eye, and the vision of that eye was someAvhat confused. 
Nothing Avas done for this directly, but the difficulty disappeared 
in about one month, under the treatment to Avhich the ear Avas 
subjected. In the external meatus, near the membrane of the 
drum, groAving from the anterior and upper portion of the canal 
and nearly filling it, Avas a polypus. 
No portion of the membrane of the drum remained, the ossicles 
had been lost, and the middle ear contained several polypi, bathed 
in pus. These polypi Avere removed with forceps, and their bases 
destroyed with chlor-acetic acid. Hearing distance, left ear=4°8. 
Tavo days later the meatus Avas so SAvollen that it Avould admit 
only a small probe Avith a little cotton twisted tightly about it. 
By this means nitrate of silver Avas applied to the external meatus 
and the middle ear, and the swelling very gradually reduced. 
The pain in the head continued, except Avhen relieved by blisters 
over the mastoid process, by bromide of potassium, or by quinine, 
until the first sequestrum, a portion of the cochlea, was removed, 
Oct. 19th, 77. 
Suppuration also continued freely during this period, afte 
Avhich it immediately diminished, until it Avas almost impercep- 
tible, and the patient Avas free from pain. 
The external meatus slowly resumed its natural size, the patient 
slept comfortably, his appetite improved, and he gained in weight 
until Nov. 20th, when he Aveighed 153 pounds, three pounds 
more than his usual weight. 
Nov. 20th. A second sequestrum Avas taken from the middle 
ear. I had touched it and turned it over tAvo days before Avith a 
probe, and it seemed then to be buried in the soft tissue, in the 
posterior portion of the tympanum, near the mastoid cells. The 6 
day it was removed, it could be seen, beyond the middle ear, and 
wras withdrawn by a small hook. Its shape and structure indi- 
cate that it was thrown off from the mastoid cells. Since that 
time no suppuration has occurred in this ear, nor has there been 
any pain in it. 
Dec. 29th.—A new membrane of the drum was recognized by 
Dr. S. J. Jones, occupying the usual position of the membrana 
tympani, but lacking of course the support of the ossicles. It 
was less concave externally than is common. 
When the middle ear was inflated the membrane could be seen 
to move outward. It would resume its original shape and'posi- 
tion when the air was withdrawn from the middle ear. 
Bromide of potassium diminished the pain in the head for a short 
time, early in the treatment of the case, and afterwards seemed 
to be useless. Sulphate of quinine was substituted for it, and 
relieved this prominent symptom. The patient had lived in a mi- 
asmatic district, and the presence of a malarial element is prob- 
able. The watch cannot be heard when pressed upon the left 
auricle. If one tip of the diagnostic tube be placed in the left 
external meatus, and a vibrating tuning fork be placed in contact 
with the other end of the tube, he does not hear it. If a vibra- 
ting tuning fork be placed on any portion of the cranium, he al- 
ways attributes the sound to the right ear. The voice is heard 
with much more difficulty, if both meati are occluded, than if the 
right meatus alone be closed. Thus the evidence of power of 
audition in the left ear is entirely negative in its character. 
That there is hearing power in this ear may be possible, but if 
so, it is too small to be of any practical value. 
Each of these cases presents some points of special interest. 
They are similar in the unsteadiness of gait, having a tendency 
in direction toward the healthy side. 
The first sequestrum, in the case of the man, is smaller, more 
imperfect, and was more difficult of removal than that of the boy, 
whose cochlea is nearly normal in shape. The boy had mastoid 
abscess, with free communication between the mastoid abscess, 
the external meatus, and the pharynx. Parts of the temporal 
bone were lost by necrosis, and he leans his head toward the 
shoulder of the healthy side.  7 
In the case of the man, pain in the head existed for a period 
of several months, and there was diplopia, due probably to some 
interference with the healthy action of the third nerve, which 
supplies motion to the internal rectus, or of the sixth nerve, 
which performs the same office for the external rectus. 
The treatment has been much the same in each case, nitrate 
of silver being the chief application locally.