°5 U.S.Deportment of » Heolth, Education, °t ond Welfare, Public ^ Health Service °i Bethesda, Md. » U S.Deparlment of ** Health, Education. » and Welfare, Public " Health Service NATIONAL LIBRARY OF MEDICINE ^ >/ NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE N 3NOia3w jo Aavaan ivnouvn 3nidio3w jo Aavaan ivnouvn 3noiq3w jo Aavaan ivnouvn /S^ ? v\ i f\¥ t >v^, s s/r r >. THE HUMAN EAR ITS DISEASES; A PRACTICAL TREATISE UI'ON THE EXAMINATION. RECOGNITION. AND TREATMENT OF AFFECTIONS OF THE EAR AND ASSOCIATE PARTS; PREPARED FOR THE INSTRUCTION OF STUDENTS AND THE GUIDANCE OF PHYSICIANS. BY W. H. WINSLOW, M.D., Ph.D., OCULIST AND AURIST TO THE PITTSBURGH HOMCEOPATHIC HOSPITAL ; FORMERLY CLINICAL ASSIST- ANT TO WILLS' OPHTHALMIC hospital; ASSISTANT SURGEON TO THE EYE AND EAR DEPT. OF THE CHILDREN'S HOSPITAL; OCULIST TO THE CHILDREN'S CEOPATHIC HOSPITAL, AND SURGEON TO BEDFORD ST. HOS- PITAL, OF PHILA. ; MEMBER OF THE HOMOEO- PATHIC OPHTHALMOLOGICAL AND OTOLOGICAL SOCIETY. ONE HUNDRED AND THIRTY-EIGHT ILLUSTRATIONS BOERICKE & TAFEL: NEW YORK: PHILADELPHIA 145 Cr\nd St. ioiiArchSt. 1882. Entered according to Act of Congress, in the year 1882, By W. H. WINSLOW, in the Office of the Librarian of Congress at Washington, D. C. All rights reserved. PREFACE. " Jam me vobis, judices, indicabo, et de meo quodam amore glorice, nimis acri fortasse, verum tamen honesto, vobis confitebor."—Cicero. Pittsburgh, Pa., January, 1882. CONTENTS. CHAPTER I. PAGE Anatomy of the P^ar,..........9 Comparative anatomy. The human ear. The auricle. The external au- ditory meatus. The tympanum. The tympanic membrane. The mastoid process. The ossicles of the ear. The Eustachian tube. The internal ear. The vestibule. The semicircular canals. The otoliths. The coch- lea. The organ of Corti. The internal auditory meatus. The infant's ear. CHAPTER II. Physiology of the Ear,........ .66 The external ear. The tympanic membrane. The ossicles. The mastoid cells. The Eustachian tube. The mucous membrane. The tympanic and tubal muscles. The oval and round windows. The internal ear. The auditory nerve. Definition of sound. Analogy of the eye and ear in structure and functions. CHAPTER III. Examination of the Ear, etc.,........78 Method of recording a case. Otoscopes. Ear specula. Testing the hear- ing. Cleansing the ear. Syringes. Syringing. Inflation and ausculta- tion. Examination of the throat. Examination of the naso-pharynx. Examination of the nose. Examination with the Eustachian catheter. Bougies. Entotic test of hearing. Symptoms. Causes. Diagnosis. Treatment. CHAPTER IV. Diseases of the External Ear,.......123 Malformations. Hypertrophy. Erythema. Erysipelas. Frostbitten auricles. Eczema. Skin diseases. Furuncles. Anthrax. Abscess. Vas- cular tumors. Simple angiomata. Cavernous angiomata. Othcematomata. Other tumors. Comedones. Sebaceous cysts. Enchondromata. Fibro- mata. Sarcomata. Epitheliomata. Injuries. Fracture of the auditory process. Foreign bodies. Ceruminosi.s. Acute dermatitis of the external canal. Chronic dermatitis. Chronic adenoid dermatitis. Phlegmonous inflammation of the canal. Osteoperiostitis and exostosis. viii CONTENTS. CHAPTER V. PAGE Injuries and Diseases of the Membrana Tympani, . • • 186 The membrana tympani. Injuries of the membrane. Hyperemia. My- ringitis. Atrophy. Hypertrophy. Projections. Hemorrhages. Epithe- lioma, etc. CHAPTER VI. Diseases of the Middle Ear,........207 Otalgia. Tinnitus. Acute inflammation. Chronic purulent inflammation. Artificial membrana tympani. CHAPTER VII. Complications of Chronic Purulent Inflammation of the Tym- panum, ...........280 Polypi. Other tumors. Exostoses. Paralysis of the facial nerve. Mas- toid disease. Phlebitis. Pyaemia. Meningitis. Cerebral abscess. Caries of the temporal bone. CHAPTER VIII. Diseases of the Middle Ear and Associate Parts, . . . 316 Catarrhal inflammation. Coryza. Acute pharyngitis. Chronic nasal catarrh. Nasal polypus. Adenoid tumors. Enlarged tonsils. Chronic pharyngitis. Post-pharyngeal abscess. Chronic inflammation of the Eus- tachian tube. Chronic inflammation of the tympanum. General treat- ment of chronic inflammation of the tube and tympanum. Treatment of coryza. Treatment of acute pharyngitis. Treatment of chronic nasal ca- tarrh. Treatment of nasal polypus. Treatment of adenoid tumors. Treat- ment of enlarged tonsils. Treatment of chronic pharyngitis. Treatment of chronic inflammation of the Eustachian tube. Treatment of chronic inflammation of the tympanum. Operations upon the membrana tympani. CHAPTER IX. Electricity in Aural Disease,........458 Dynamic electricity. A constant battery. An inconstant battery. A Galvano-Faradic apparatus. Electrodes. Qualities of the currents. Method of application. Symptoms of aural electrization. Brenner's for- mula. Electricity in disease. CHAPTER X. The Internal Ear,..........473 Anaemia. Treatment of anaemia. Hyperemia. Treatment of hyperemia. Inflammation of the labyrinth. Meniere's disease. Treatment, of inflam- mation of the labyrinth. Deaf-mutism. Treatment of deaf-mutism. In- struments to assist the hearing. THE HUMAN EAR AND ITS DISEASES. CHAPTER I. ANATOMY OF THE EAR. It is a fundamental law in Zoology, that the greater the division of functional labor, the higher is the degree of development, and the position of the individual in the animal kingdom. In the Protozoa, there is little or no division of labor. The amoeba lives, moves, and has its being, in fact, performs all the functional actions of life, with its jellylike, sarcode body. This undergoes temporary mutation for specialized work, fashions a mouth or an anus, a stomach or a limb, as circumstances require, and then changes again to a state of dignified inertia. The essential vital processes go on as harmoniously and per- fectly, in these microscopic mucous masses, as they do in man, with all his glorious endowment of elaborate and specialized parts. The keenest examination of these animalculae fails to reveal the presence of any nervous structure. There is sensation and motion, without sensory or motor nerves and ganglia; and one family of the amoeba possesses the remarkable power of select- ing, from the particles of different stones over which it moves, only those of a special kind of flint, of which each individual builds himself a house or shell. Can it be that, in these minute, unorganized wonders, a nervous fluid pervades the tissues, and performs the duties of nerves and ganglia? That taste, smell, sight, and hearing are decentralized, and their pleasures pass from cell to cell as a breeze moves, carrying exquisite delight to the innermost recesses of being? It is probable from recent researches, that repeated discharges 2 10 THE HUMAN EAR AND ITS DISEASES. of neural currents, in certain directions through connective tis- sues, may modify the nutrition of tracts so much, as to produce ultimately a nerve fibre along the course of least resistance. The ectocarp of some medusae contains multitudes of short dis- connected nerve fibres, yet nervous currents jump from one to another, and pass all around the fringe of cilia. There are so many mysteries of the nervous system, and our knowledge of nerve terminations is so defective, that we should not be dogmatic. There seems to be a correlation between spe- cialized sense organs in the higher animals, so that when one of them is destroyed, some or all the others become more acute, and prone to take on in some measure the functions of the lost one. This is readily conceived, when we reflect, that these special sense organs are united in the lower forms of animals; that in them nerve terminations, little or not at all specialized, and, per- haps, nervous fluids alone convey to the corporeal structure the various vibrations, which we denominate sensations. The senses of sight and hearing, so highly specialized and so dissimilar in the nobler animals, show this correlation as we de- scend the animal scale, until, in the lowest forms,- they become united and simplified to such a degree that it is difficult to say whether we have an eye or an ear under observation, and natu- ralists escape from a dilemma by the happy expedient of calling it a sense capsule. The first appearance of any special sense organs is in the Pro- tozoa, but in the coelenterate Radiates, they are more numerous and characteristic. The tentacles of these animals have numer- ous sf»cs upon the surface, each of which contains a coiled thread. When touched, the sacs rupture and the threads dart out in a straight line, causing a pricking sensation in the human skin where they come in contact with it. They are thought by natu- ralists to be allied to tactile corpuscles. They are present in less numbers in Articulata and Mollusca. Their analogy to the organ of the common stinging nettle is interesting. The echinoderm Radiates are the first animals which possess a true nervous system of ganglia and fibres. Some of the latter terminate in pigmented capsules, containing carbonate of lime crystals, situated at the distal extremity of certain tentacles, and ANATOMY OF THE EAR. 11 surrounded by movable spines called eyelids. There is no posi- tive evidence of the function of these curious structures, though naturalists are inclined to consider them eyes, as they call them ocelli. The crystals are freely movable in the sacs, and the cap- sules are thus homologous with the internal ear of higher animals. The presence of pigment might be considered an ocular analogue. They are probably foreshado wings of the eye, because imperfect seeing would be much more useful to the weak organisms, wan- dering along the surface, or crawling in the depths over the myriad skeletons. of their ancestors, than imperfect hearing, which at the best in such rudimentary organs would be of very little use. The lower forms of Mollusca and Articulata have similar pig- mented sacs, containing colored carbonate of lime lapelli, of in- determinate or combined auditory and ocular functions; but the higher forms have the organs so specialized as not to leave any doubt of their analogies. An organ of hearing consists essentially of an auditory cap- sule, or labyrinth, which receives sonorous vibrations upon its surface, that pass by means of its fluid contents across it and impress the terminal filaments of the auditory nerve. The vibra- tions are intensified by the presence of one or more freely movable, sclerous particles almost always present, called otoliths, otoconites, lapelli, ear-stones, ear-sand, etc. This general definition of an ear covers the representatives of the organ in all the Invertebrata, though various slight modifications obtain, in anatomical struc- ture and bodily position in the different orders. For instance, the ear-stones are of various shapes and colors, and there may be one or many in a capsule. The otic capsule may be smooth within, or lined by delicate cilia, upon which the lapelli vibrate; it may have an opening outwards {Homarus and Palcemon), or be a closed sac; it may be exposed upon the surface of the body [Crustacea and Insecta), inclosed within the cephalic cartilage (Cephalopoda), or within the calcareous skeleton (Lucifer). The organ of hearing of Vertebrata consists of an otic cap- sule and auditory nerve, corresponding to the invertebrate ear, and of certain appendages, which increase its complexity and functional power. Fishes have the capsule, with one, two or 12 THE HUMAN EAR AND ITS DISEASES. three semicircular canals, the whole inclosed in bony walls, and having generally no communication with the pharynx, or with the exterior surface of the body. In amphioxus, the otoliths are absent; in osseous fishes, a single large one nearly fills the vestibule. In some fishes, the vestibule of one side unites with its fellow, and communicates with the swim bladder by a chain of bones; or the swim bladder is prolonged into the cranium, and connects with the auditory capsule, which arrangement greatly intensifies the sound. Some Batrachians have a simple otic capsule, partially or en- tirely inclosed ; others have a middle ear added to this, with a tympanic membrane upon the side of the head, a single bone (columnella) extending from it to the membrane of the single vestibular opening, and Eustachian tubes, sometimes united in the middle line, communicating with the pharynx. Reptiles have the internal ear inclosed in bone; a rudimentary cochlea; a middle ear with columnella (stapes) from the vestibule to the tympanic membrane upon the surface of the head, and well-developed Eustachian tubes. Birds have the otic capsule inclosed in bone; a spiral cochlea; a columnella; a tympanic membrane on the side of the head, shielded by a fold of skin, and Eustachian tubes, which unite before reaching the pharynx. Large foramina extend from the middle ear to spaces between the tables of the skull. Mammalia have the internal ear inclosed in osseous tissue; the vestibule is proportionately small; the cochlea is much increased in size and complexity, and has part of the auditory nerve dis- tributed to it. Instead of a single bone, a chain of ossicles, con- nected with muscles, extends across the middle ear from the foramen ovale to .the tympanic membrane. This membrane forms the bottom of a canal that opens upon the surface of the head and is generally surrounded by an auricle. The auricle and canal constitute the external ear. Separate Eustachian tubes communicate with the pharynx, and there are foramina from the middle ear to the mastoid cells. There are a few modifications of this arrangement in the lower animals of the class. After this abridged sketch of the dawn and development of the organs of hearing in the animal kingdom, one may the better THE AURICLE. 13 appreciate the delicate anatomy and exquisite functions of the auditory apparatus in man. The Human Ear is divided for convenience of study into the external ear, the middle ear, and the internal ear. The first comprises the auricle and external auditory canal; the second, the tympanum with two diverticula, the mastoid cells and pro- cess behind, and the Eustachian tube in front; the third, the vestibule, semicircular canals and cochlea. Fig. 1. The Auricle (Leidy).*—1, Helix; 2, scaphoid fossa; 3, antihelix; 4, triangular fossa; 5, concha; 6, tragus; 7, antitragus; 8, external auditory meatus; 9, lobule. The dots in the depressions represent sebaceous glands. The Auricle, or pinna, is composed of reticular cartilage, muscles, and skin, with vessels, nerves, and glands. It varies in form, size, color, and angle of attachment, and joins the external auditory canal between the articulation of the lower jaw and the mastoid process. It resembles a shell, with ridges, depressions, scrolls, and promontory. The tragus is a curved prominence of cartilage, with its con- cavity backwards, situated in front of the external meatus, which * An Elementary Treatise on Human Anatomy. By Professor Joseph Leidy, University of Pennsylvania. J. B. Lippincott & Co., Philadelphia, Pa., 1861. 14 THE HUMAN EAR AND ITS DISEASES. opens inwards from the bottom of a deep depression called the concha. The concha is the largest and deepest depression in the auricle; it has a semi-spiral course towards the meatus. It is divided by a ridge of cartilage, which starts from its posterior border, curves forward, upward, backward, and downward, to end in a point above the lobule. This forms the outer rim of the upper half of the auricle, and is called the helix. Upon its anterior border is a little eminence called the process of the helix. There is another ridge inside the helix, which curves downward parallel with it, and becomes elevated into a nodule opposite the tragus, called the antitragus. The ridge is called the antihelix. It turns forward, divides into two limbs, and includes the triangular fossa, or fossa of the antihelix. The depression between the two helices is called the fossa of the helix, or scaphoid fossa. The curved outlet of the concha below the meatus, between the tragus and antitragus, is called the notch. The fibro-cartilage of the ear has several fissures, is covered by tough perichondrium and ligamentous bands which strengthen it, and has appended to it below, a mass of connective tissue and fat, covered by the skin, called the lobule. The seven intrinsic muscles of the ear are attached to different processes of the cartilage, and all but one run towards the audi- tory canal. They lie close upon the cartilage; are striated, thin, pale, and difficult to dissect. They are of little or no use in man, and have been denominated vestigia, vestiges of muscles, which in some mammals are well developed, and perform important offices in shaping the auricle in audition. The auricular cartilage is firmly attached to the skull by three ligaments. The anterior ligament extends from the process of the helix to the root of the zygomatic process. The posterior ligament attaches the convexity of the concha to the mastoid pro- cess. The annular ligament connects the cartilage with the osseous portion of the auditory canal. There are three extrinsic muscles of the auricle: the attollens aurem, or superior levator; the attrahens aurem or anterior auricular; and the retrahens aurem, or post auricular muscle. The attollens is large and fan-shaped. It arises from the border THE EXTERNAL AUDITORY MEATUS. 15 of the occipitofrontal aponeurosis, and is inserted into the carti- lage on the posterior surface of the fossa of the antihelix. It draws the auricle upward. The attrahens is a thin band of muscular fibres, which arises from the temporal fascia, and is inserted into the helix and concha. The retrahens arises from the mastoid process, and is inserted into the back of the concha. The auricle is covered by skin, which is very thin and adheres closely in the depressions, but is thicker, and separated from the cartilage in other parts by connective tissue containing considera- ble fat. The skin forms a sort of pouch for the lobule, which rarely has any cartilage extending into it. The skin extends into the auditory canal like the finger of a glove, and covers with a delicate layer the outer surface of the tympanic membrane. The External Auditory Meatus, or canal, extends from the bottom of the concha to the obliquely placed tympanic mem- brane, and is divided into two portions, the external fibro-carti- laginous, about 10 mm., and the internal osseous, about 20 mm. in length, thus making the whole canal in the adult about 30 mm. (1|- inches) long. Its average diameter is 6 mm.; it is nar- rowest in the middle of the bony portion, and expanded at both ends; is oval from above downward, and runs in a sinuous course something like the letter S, twisted a little in a spiral. It can be nearly straightened by drawing the auricle upward and a little backward. It is often straighter, especially in negroes, which may account for their musical talent. The fibro-cartilaginous portion has a few fissures filled with elastic tissue. It is joined to the osseous canal by the annular ligament, is covered by perichondrium, and is immediately sur- rounded by fat and connective tissue. The bony portion consists of thin plates which have become joined together, as they have developed outwards and laterally from the tympanic ring. The superior wall of the canal is surmounted by cells, which commu- nicate with the cells of the mastoid process, and it separates the canal from the middle cerebral fossa. The posterior wall is thick and honeycombed with large cellular spaces, some of which open into the middle ear. It separates the canal from the sigmoid 16 THE HUMAN EAR AND ITS DISEASES. fossa of the transverse sinus. The anterior superior wall forms the roof of the temporo-maxillary articulation;,the bone is here frequently very thin, and is separated from tlie condyle of the jaw by a thin interarticular cartilage. The bony canal is covered with periosteum, to which the thin skin is so tightly adherent that it looks pinkish like a mucous mem- brane. This is quite sensitive, becomes very thin at the deepest part, and passes as a delicate epithelial layer over the tympanic membrane, where there are no glands or hairs. The skin of the auricle and cartilaginous portion of the canal is separated from the cartilage by more or less connective tissue and fat, has hair follicles and hairs, sudoriferous and sebaceous glands. The latter are large and numerous in the concha, and the sudoriferous glands are very numerous upon the posterior surface of the auricle. The tragus is sometimes ornamented by a tuft of hair. The hair fol- licles and hairs, and the glands are like those of the skin of other parts, except that some of the sudoriferous glands within the canal, mostly limited to the cartilaginous portion, become altered in character, and take the name of ceruminous glands. The eoiled tube of a ceruminous gland is thick, and the excretory ducts are shorter than in its allied sweat gland. There are from one to two thousand ceruminous glands. They are most numer- ous at the junction of the cartilaginous and bony canal, and se- crete a light, reddish-yellow, bitter, sticky wax, or cerumen, which exudes like plum sap on the bark, and forms a covering for the surface of the cartilaginous portion of the canal. It is a kind of bog for venturesome insects, and an omnium gatherum for dust and dirt. Vessels.—In the connective tissue, beneath the skin covering the cartilage, and within the skin and periosteum of the osseous canal, run the lymphatics, bloodvessels, and nerves. The arteries and veins of the external auditory canal begin at the umbo, or about the centre of the tympanic membrane and form a capillary network, which passes to the periphery and forms a ring. This network communicates with another in the middle ear, through the periphery of the membrane, around the malleus handle, and through ShrapnelPs membrane. From the ring upon the outer surface vessels go along the auditory canal to the meatus THE EXTERNAL AUDITORY MEATUS. 17 where they receive branches from the anterior surface of the auricle; some of these then join the temporal vessels separately \ others unite into a single trunk and pass to it under the name of the anterior auricular artery or vein. A few branches pass through fissures in the auricular cartilage; others curve around its edge and join the posterior auricular. The arteries and veins of the posterior surface of the auricle, though a few above anastomose with the terminal capillaries of the occipital and posterior temporal, for the most part, unite to form larger vessels, which run towards the mastoid and join the posterior auricular. This is a branch of the external carotid in one case, and of the tCmporo-maxillary vein in the other. The artery lies in the sulcus, between the auricle and the mastoid, and the vein a little farther posterior. The posterior auricular re- ceives below the stylo-mastoid vessels, which come from the in- ternal and middle ear and the mastoid cells. The occipital vein receives the mastoid vein through the mastoid from its cells and the lateral sinus of the brain. Delicate lymphatics arise upon the surface of the tympanic membrane, pass out of the external canal, form trunks, unite with those from the anterior surface of the auricle, which are very .numerous, go forward and downward, and debouch into three or four parotid lymphatic glands on and beneath the paro- tid gland. Other lymphatics, from the posterior surface of the auricle and the region of the mastoid process, empty into three to five posterior auricular lymphatic glands upon the mastoid and upper end of the sterno-cleido-mastoid muscle. From these glands, lymphatics communicate below with the superficial cervi- cal glands in the posterior triangle of the neck, and, what is more important, with the chain of submaxillary lymphatic glands be- neath the angle of the jaw. These communicate with the deep cervical lymphatic glands; and, finally, the united currents pass by fewer and larger ducts into the right lymphatic duct, which empties into the subclavian vein. Thus an interrupted com- munication exists, like a canal with locks, from the external audi- tory canal to the venous system, which has a decided significance for the clinician. Anastomoses are frequent between the branches of the superfi- cial vessels and those lying deeper. 18 THE HUMAN EAR AND ITS DISEASES. The nerves of the auricle and external canal are derived prin- cipally from the auriculo-temporal, a branch of the inferior max- illary; the posterior auricular, a branch of the facial, and the auricularis magnus. The auriculo-temporal nerve arises by two roots from the inferior maxillary nerve, beneath the base of the skull, inside of and anterior to the articulation of the lower jaw. It gives off'immediately a branch to the otic ganglion; passes beneath the internal pterygoid muscle, backward and outward around the neck of the jawbone, where it gives a branch to the facial; an inferior auricular branch, distributed to the auricle below the meatus; a few filaments to the sympathetic plexus on the internal maxillary artery, and a superior auricular branch, which supplies the skin of the tragus and contiguous parts of the pinna. The main portion of the nerve, with the temporal artery, passes upward through the parotid gland, gives a few filaments to it and the articulation of the jaw, then passes in front of the tragus and divides into two branches: the anterior temporal, which takes the genera] course of the temporal artery, and communicates with the facial; and the posterior temporal, which supplies the attra- hens aurem muscle, and the skin of the upper anterior surface of the auricle and contiguous parts above. Filaments from the superior auricular, inferior auricular, and posterior temporal, are distributed to the auditory canal and tympanic membrane, where the filaments terminate in forked processes, and make the surface exquisitely sensitive. The posterior division of the inferior maxillary, th« auriculo-temporal, is most sensitive; and it is through the nerves, traced out, that most of the pain is felt from operations on the front of the auricle and in the external auditory canal. The auricles of moles are so sensitive that they serve as tactile organs. The posterior auricular nerve comes off from the facial just after it makes its exit at the stylo-mastoid foramen. It receives immediately a branch made by a union of one filament from the pneumogastric, one from the glosso-pharyngeal, and one from the auricularis magnus, and then passes up between the mastoid pro- cess and the auricle, and divides into two branches: an occipital which goes to the back of the head, and an auricular, which sup- ■THE TYMPANUM. 19 plies the retrahens aurem and the skin over the mastoid, and upon the posterior surface of the auricle. The auricularis magnus arises from the second and third cer- vical nerves, winds upwards around the posterior border of the sterno-cleido-mastoid muscle, passes into the parotid gland, sends filaments to the posterior auricular and pneumogastric, and di- vides into several branches. The auricular passes under the auricle, runs upward and backward, and supplies the integument of the mastoid process and the back of the auricle. The occipitalis minor arises from the second cervical, ascends along the posterior border of the sterno-cleido-mastoid muscle to the back and side of the head. It gives off an auricular branch, which passes upward and backward, and supplies the skin of the upper part of the auricle; that behind this part and above it goes to the attollens aurem muscle. Sympathetic nerves, not only, communicate with the other nerves that supply the auricle and external auditory canal, but, also, accompany the vessels to those parts. Galvanization of the superior sympathetic ganglion causes a marked hypersemia of the auricle. The Tympanum, or middle ear, is situated in the base of the temporal bone, and its cavity is very irregular in shape. The walls are covered by periosteum and mucous membrane. Its length is about 10 mm., the vertical depth 6 to 8 mm., and width 2 to 6 mm., and it contains the ossicles, or ear-bones. It may be described as. having six walls. The superior wall is a thin plate of compact bone, forming the roof, and it separates the cavity from the middle cerebral fossa. It has many cells and vessels in that part which joins the squamous portion of the temporal bone, and these are more abundant in infants than in adults. It is sometimes fissured, when the mucous membrane of the tympanum and the dura mater alone separate the cavity from the brain. The inferior wall, or floor, is generally thick enough, consid- erably inclined forward and inward, and its surface is a mere groove, lying below the openings of the Eustachian tube and mastoid antrum, and the lower border of the drum-head. It separates the tympanum from the internal jugular vein, which 20 THE HUMAN EAR AND ITS DISEASES. enters the skull beneath. In the floor close to the inner wall is a foramen for the entrance of Jacobson's nerve, the tympanic branch of the glosso-pharyngeal. The external wall comprises the annulus and frame of bone, which holds the tympanic membrane, and closes the inner end of the external canal. The membrane is attached firmly to the groove, which in the infant is situated in the inner surface of the processus auditorius. This is a ring of bone, deficient above, which closes and grows outward as development progresses, and forms the bony part of the external auditory canal. The portion of the external wall behind the membrane curves towards the posterior wall, and forms part of the boundary of the foramen of the chorda tympani nerve, or the iter chordce posterius. In the portion of bone in front of the membrane, is the anterior foramen, the iter chordce anterius. This is high up, and is the beginning of the canal of Huguier, which runs for- ward and downward through the bone, comes out inside the articulation of the jaw, and transmits the chorda tympani nerve. Parallel to it and just below is the Glaserian fissure, a mere slit, which goes from the tympanum through the bone and opens in- side the articulation of the jaw. It transmits some tympanic vessels and nerves, and the laxator tympani muscle. The long process of the malleus lies in its tympanic sulcus. The Tympanic Membrane, membrana tympani, or drum-head, is inclined somewhat forward, downward and inward, in adults; it is more slanted in early life, and so oblique in infants as to be seen with difficulty. It is oval in shape, its vertical diameter is about 10 mm., and its transverse 9 mm.; it is depressed inward like a funnel, and its external surface presents the concavity of a very short hollow cone, at the apex of which is seen the yellow clubbed end of the handle of the malleus. It is composed of an external dermic layer, without glands or hairs, an inner mucous, and a middle fibrous layer; the latter forms the skeleton of the membrane. It has an outer set of radial fibres next the skin, inserted into the handle of the malleus and the tendinous ring around the periphery of the membrane in the annulus, and continuous with the cellular tissue of the auditory canal; and an inner set of circular fibres next the THE TYMPANIC MEMBRANE. 21 mucous membrane, firmly united to the others, much thicker around the periphery, and few and thin near the centre of the drum-head. A few of these circular fibres are attached to the malleus; a few others go from the neck of the malleus to the posterior border of the membrane, within the fold of mucous membrane that is reflected over the chorda tympani nerve; and a perpendicular set runs along the handle of the malleus. Be- tween the two fibrous layers, in a sort of socket of fibro-cartilage, the long process, manubrium, or handle of the malleus, and the Fig. 2. Outer Surface of the Eight Tympanic Membrane (Burnett).*—A, Manubrium of malleus ; B, end of manubrium ; C, short process; D, posterior fold. The triangle of light is seen below. short process, are held in a position, running from above anterior, downward and backward. It is movable in the groove or socket like an enarthrodial joint. These fibrous layers make the membrane firm and resistant, so as not to rupture from ordinary shocks. When rupture does occur it is near the end of the malleus handle, generally anterior, or posterior, or around its central boss, leaving a margin around the periphery. The membrane is elastic, so that adhesions often take place with the inner wall of the middle ear without any rupture. In the upper segment, the fibrous layers are so thin that the skin and mucous membrane come together. The mucous membrane of the middle ear forms the inner layer of the tympanic membrane. It is thin and closely adhe- rent to the fibrous layer in the centre, and looser at the periphery, where it is reflected upon the bone. * The Ear; its Anatomy, Physiology, and Diseases. By C. H. Burnett, A.M., M.D., Philadelphia. Henry C. Lea's Sons & Co., Philadelphia, Pa., 1877. 22 THE HUMAN EAR AND ITS DISEASES. The chorda tympani nerve passes horizontally from behind forwards in the middle ear, near and inside the handle of the malleus, and the mucous membrane leaves the tympanic mem- brane, goes over the nerve, and returns again to it; this makes a sort of mucous shelf, divided into two pouches, where mucus and pus are likely to lodge. The posterior large pouch is be- tween the malleus and the border of the tympanic membrane, contains a few fibres of the middle layer of the latter, and is shaped like a tent with the point downwards. This may be seen with good illumination. The anterior smaller pouch is in front of the malleus and has no fibrous tissue; it is lower down than the other, and contains within the fold all the parts which enter Fig. 3. Inner Surface of the Eight iympanic Membrane (Burnett).—A, Manubrium ; B, end of manubrium; C, head of malleus; D, body of incus; E, short process of incus; F, lenticular process of incus ; G H, chorda tympani nerve; I, point of insertion of the tensor tympani muscle. the middle ear through the Glaserian fissure. There is another very small pouch above the short process of the malleus, with an opening posterior, and above the posterior pouch. ShrapnelPs membrane, or the flaccid membrane, is the part of the drum-head above the mucous shelf forming the first two pouches. It is freely movable, contains little fibrous tissue and the mucous and dermic layers are loose and come near together. It was once thought to contain an opening, the foramen of Ri- vinus, but this is not now believed. Externally the handle of the malleus forms a slight ridge run- ning from its depressed cartilaginous end, or umbo, to the yellow button-like projecting short process above, and divides the mem- brane into two portions, an anterior, and a larger, posterior see- THE TYMPANIC MEMBRANE. 23 ment. The short process of the malleus forms a slight antero- posterior ridge, which is the lower boundary of Shrapnell's flaccid membrane before mentioned. On the outer surface, a triangle, or cone of light, is seen with its apex at the end of the manubrium, and its base, 3 mm. wide, on the periphery of the membrane in the anterior inferior quadrant. It shines like a metallic mirror, and is caused by the funnel shape of the membrane and the re- flecting qualities of the dermic layer. It is the first thing to alter in appearance when there is disease in the middle ear. The membrane may be for practical purposes divided into three portions: an upper segment above the short process of the malleus and the transverse folds before mentioned, called Shrap- nell's membrane; an anterior lower segment in front of the mal- leus handle and the cone of light; and a posterior lower segment behind the handle and the cone; these last two are bounded above by the mucous folds within, and by the short process of the malleus. The color of a normal tympanic membrane is from a bluish to a yellowish-gray, differing at different ages, and by anatomical variations in and around it. It is lighter in infants, because the dermic layer is thicker, and generally shaded with pink. It has an amber-gray, translucent appearance near the centre, in front, and behind the malleus. The vessels of the dermic surface, the anterior and posterior auricular, pass into the auditory canal and form a ring around the periphery of the membrane ; this sends branches to a similar ring in the mucous layer within, and many branches towards the centre of the membrane in the derma, which unite freely into capillary meshes. The stylo-mastoid artery, a branch of the posterior auricular, passes through the stylo-mastoid foramen and the posterior wall into the middle ear; the tympanic, a branch of the maxillary portion of the internal maxillary, passes up behind the articula- tion of the jaw through the Glaserian fissure into the tympanum, supplying the laxator tympani muscle in its course; the Vidian, a branch of the spheno-maxillary portion of the internal maxil- lary, goes along the Vidian canal with the nerve, and sends a small branch into the tympanum. A branch of the stylo-mastoid 24 THE HUMAN EAR AND ITS DISEASES. artery and the tympanic branch of the internal maxillary unite to form a ring around the periphery, in the mucous membrane covering the tympanic membrane. This ring communicates with the external ring described above, and it forms a set of capillaries which ramify over the internal surface of the membrane. One vessel, quite large, called the tympanic trunk, runs downwards from the ring, along the anterior border of the manubrium, turns around its lower end, and communicates freely with the general capillary network of the mucous layer. The veins are fewer, but take the same general course. There is a capillary net of lymphatics in the mucous layer of the membrane, communicating with that found upon the other walls. Nerves.—There are no nerves to the fibrous layer of the drum- head ; the mucous layer is supplied by a few filaments from the common tympanic plexus. The posterior wall of the tympanum is wider above than be- low, and the floor of the tympanum rises towards and lessens its height. In the upper part, there is a large irregular opening called the mastoid antrum, which may be regarded as a vestibule leading from the middle ear to a suite of rooms, the mastoid cells, which lie above, behind, and below the antrum in the shell of compact bone that forms the mastoid process. The wall has a few smaller openings into the mastoid cells, a foramen for a branch of the facial nerve to the tympanic muscles, and just in the angle, low down, between the posterior wall and the rim of the outer wall around the membrane, are the foramina for the stylo-mastoid vessels and the chorda tympani nerve. The facial nerve, in its aqueductus Fallopii, passes downward near the angle of the posterior and the inner walls, gives off the chorda tympani nerve below the level of the middle eary and the filament above for the stapedius and laxator muscles. The Mastoid Process is like a crushed honeycomb; the cells are quite large and irregular in shape, and they lie very near the lateral sinus and the external surface. The external part of the mastoid process is behind the auricle, it extends below the level of the external meatus and the ear proper, and the auricle has firm attachment to its anterior surface. Behind and a little THE MASTOID PROCESS. 25 above the meatus, at the upper border of the mastoid, the tem- poral bone is quite thin, and an opening through would enter the upper arm of the sigmoid portion of the lateral sinus. A vein from the external surface enters the mastoid foramen and empties into the lateral sinus in this part of its course, thus making a free connection between the mastoid surface and the venous current, important to consider with post-auricular abscess. Fig. 4. Mastoid Spaces and Tympanum (Leidy).—1, Promontory; 2, pyramid; 3, ridge of Fallopian canal; 4, round window; 5, oval window; 6, Eustachian tube; 7, surface for Eustachian cartilage; 8, canal of tensor tympani muscle; 9, Fallopian canal exposed; 10, canal for great petrosal nerve; 11, mastoid cells; 12, mastoid antrum; 13, foramen for the tympanic branch of the facial nerve. The mastoid cells are lined with a delicate, quite vascular mu- cous membrane, continuous with that of the middle ear, and its vessels communicate freely with the diploic vessels of the cranial wall. The mastoid process does not reach the above-described devel- opment until the age of puberty. In the child, it is a thin double shell of bone, containing very small cells. It develops outwards 3 26 THE HUMAN EAR AND ITS DISEASES. with the tympanic ring, which forms the external auditory canal. A knowledge of this difference is of vast importance in the treat- ment of children afflicted with ear diseases, because all the walls about the ear are of about the consistency of pasteboard, and they may be easily perforated by careless or rough manipulation and cause fatal injury. The anterior wall of the tympanum is wider above than below, is smaller than the posterior wall, and consists of a thin plate of bone, separating the tympanum from the carotid canal, which is just inside of it. It has a foramen for the passage of lymphatics, and a small artery from the carotid. At the upper part of the wall, there is an opening surrounded by a conical rim of bone, which projects a little backward into the tympanum, and has been called the anterior pyramid. The foramen leads to a canal in the temporal bone, which extends forward, inward, and a little downward to the base of the temporal bone, and opens in the fis- sure between it and the great wing of the sphenoid, being a little farther prolonged by cartilage. It contains the tensor tympani muscle, which arises from the angular process of the great wing of the sphenoid just behind the foramen ovale, from the cartilage of the canal and of the Eustachian tube below, and the upper wall of the canal, and passes along this to the foramen, where its tendon enters the ear. This turns at right angles to its tubular course, outwards from the anterior pyramid, and is inserted into the anterior surface of the inner edge of the manubrium near its root. Just below the anterior pyramid, but considerably above the floor of the tympanum, is a larger opening for the Eustachian tube. The inner wall of the tympanum is vertical, and is seen through the external canal, when the drum-head is destroyed. The first thing to attract attention is a pale, pinkish prominence seen about the middle of the lumen, which is an elevation called the promontory, caused by the lower coil of the cochlea. This is nearer the tympanic membrane, in the normal ear, than any other part of the wall, and can often be seen through it as a pale- yellow spot. In the wall just anterior to this is a pitchfork- shaped groove, with tines downward, in which run branches of the tympanic plexus of nerves. THE INNER TYMP'ANIC WALL. 27 On a level with the lower border of the promontory, and be- hind it, is a rounded opening into the cochlea, 2 mm. in diameter, called the foramen rotundum, or round window. It is closed by a membrane, sometimes called the membrana secundaria, com- posed of three layers: an outer mucous, a middle fibrous, and an internal serous layer. The latter is bathed by the fluid that fills the tympanic scala of the cochlea. On a line with the* promontory, above and a little behind it, so that a vertical line along its posterior border would bisect it, the foramen ovale, or oval window, is found. Its shape is nearer reniform than oval, and the long diameter is antero-posterior, Eight Inner Tympanic Wall (Burnett).—Note the orifice for the tendon of the tensor tympani muscle, that for the stapedius, and the chorda tympani nerve. inclined a little downward and backward. It is 3 mm. long and 1.7 mm. wide. A perpendicular line dropped from its posterior end would make a chord of an anterior arc, representing nearly one-third of the round window. The foramen ovale opens into the vestibule and is closed by membrane; the vestibular surface of this membrane is serous, its middle layer is fibrous, and its tympanic surface is covered by the bony foot-plate of the stapes. It is opposite the tympanic membrane, and connected with it by the chain of ossicles. Sometimes parts of the anvil and stapes 28 THE HUMAN EAR AND ITS DISEASES. or the oval window can be seen through a perforated drum- head. The pyramid, or eminentia stapedii, lies behind the round window, and is curved so that its summit nearly reaches the oval window. A canal extends from its apex to its base and opens into the aqueduct of Fallopius. It contains the stapedius muscle, the tendon of which escapes at the apex and passes to the stapes. The base of the pyramid is partly in the posterior wall, and bor- ders the foramen for the chorda tympani nerve. Behind the pyramid, there is an elevation of the posterior wall into a ridge, that curves upward and forward along the inner wall, and forms its posterior and upper boundary. This is the bone covering the aqueduct of Fallopius containing the facial nerve. Sometimes the bone here is deficient, and the facial is exposed to the middle ear. The inner wall is covered by mucous membrane, continuous with that upon the other walls, and reflected over the muscles, ten- dons, and ossicles. The Ossicles of the Ear.—The middle ear contains three small bones, united by ligaments into a series, or chain, and moved Fig. 6. 4 S *¥.*¥*$ !F The Ossicles (Leidy).—1. Inner surface of malleus : a, head ; b, articular facet; c, manubrium ; d, slender process. 2. Outer surface of malleus • letters as above, but e, short process. 3. Posterior surface of malleus: a, head and facet; b, short process; c, slender process. 4. Inner surface of incus : a, body • b, articular facet; c, short process; d, long process; e, lenticular process. 5. Outer surface of incus; letters as above. 6. Lenticular process broken off. 7. Stapes: a, head; b, c, crura; d, base. 8. Base of stapes. 9. Stapes cut to show obturator groove, a, a. by muscles. They extend from the tympanic membrane to the membrane of the foramen ovale, and are called the malleus incus, and stapes. The orbicular, or lenticular bone once de- scribed as a sesamoid bone in the articulation of the incus and stapes, does not exist. THE OSSICLES OF THE EAR. 29 The malleus, or hammer, consists of a head, neck, two pro- cesses, and manubrium, or handle. It is 9 mm. long, and the neck divides it into two nearly equal parts. The head is club- shaped and rounded; it is 2| mm. thick, and its long diameter is nearly vertical in position. Its posterior, internal surface has a vertical, oval depression, or facet, for articulation with the incus. The neck is a constriction below the head. The head and neck project into the middle ear, are free from the tympanic mem- brane, and extend a little above its upper margin. Just below the neck there is a small protuberance, called the short process, which projects outward against the membrana tympani, and looks like a minute yellow pearl. The slender process, or processus gracilis, is long and slim, like the blade of a Catlin knife; it projects forward from the inner surface below the neck into the Glaserian fissure, where it is connected with the bone below by ligaments, which permit slight movement. Below these two processes the manubrium extends downward and backward; it is thick and rounded at first, then bayonet-shaped, with one edge outward, and gradually diminishes to terminate in a slightly clubbed extremity. The whole length of this process lies between the two fibrous layers of the tympanic membrane, as before described, and shows clearly through it. The malleus is held in position by ligaments. The anterior ligament extends from the neck of the malleus and root of the processus gracilis, through the Glaserian fissure, to the spine of the sphenoid, and is also attached to the frame of the tympanic membrane and the walls of the fissure. The fibres running to the sphenoid are mentioned in some anatomical works as the laxator tympani muscle, but later researches have proved them to be a ligament. The superior ligament passes from the roof of the tympanum downward and outward to the head of the malleus. The external ligament extends from the temporal bone, above and inside the segment of Rivinus, where the annulus is deficient, to the front of the neck of the malleus. The posterior ligament is the pos- terior fibres of the external; the two really constitute a fan-shaped 30 THE HUMAN EAR AND ITS DISEASES. ligament, extending from the contiguous bone to the malleus, and sometimes called the axial ligament. The neck of the malleus moves but little, the ossicle seeming to rock upon this part as a lever upon a fulcrum. The incus, or anvil, is so named on account of its resemblance to an anvil. It has a body and a short and long process ; the processes are nearly at right angles to each other. The length Fig. 7.—Two inches divided into lines (///). Fig. 8.—Five centimeters divided into millimeters (mm.). of the short process and body is about 5 mm., that of the long process and body, 7 mm.; the body is 2J mm. in diameter at its thickest part. The bone looks more like a bicuspid tooth than an anvil; the body has opposite the processus an oval facet, which looks for- ward and outward, and is articulated by a capsular ligament with the head of the malleus. The thick, pointed, short, or horizontal process extends backward and downward; this process and the body of the bone are very near the roof of the tympanum. The long process, or descending ramus, curves a little outward and downward, becomes slender, then turns abruptly inward, forms a button-like, or lenticular extremity, which articulates with the head of the stapes by a capsular ligament. A sesamoid bone is found rarely in the joint, which has been described as the lenticular bone, or os orbiculare. Anatomists now deny the existence of this formation, and consider it when found the len- ticular process that has been broken off during dissection. This process is said to exist as a separate bone in the foetus. The incus is held in position by its tympanic and articular ligaments. The superior ligament passes from the roof of the THE OSSICLES OF THE EAR. 31 tympanum to the middle of the short process; the posterior liga- ment fastens the point of the short process to a slight prominence upon the posterior wall of the ear just above the largest opening, the antrum, into the mastoid cells. The principal part of the incus is near the roof of the tym- panum, and hence above the inner end of the external canal, i. e., above the upper edge of the tympanic membrane, along with the head of the malleus. The stapes, or stirrup bone, is the smallest bone in the human skeleton. It consists of a head, neck, two arms, and a base. It is 4 mm. long from its head to the inner surface of the base. The base is 2J to 3 mm. long, 1 mm. wide, and about I mm. thick. It is shaped much like the old-fashioned iron stirrup, and extends horizontally from the lenticular process of the incus to the oval window. The head is a short horizontal cylinder; its outer surface has a cup-shaped depression, into which projects the lenticular process of the incus. A capsular ligament con- nects the two bones and forms a ball-and-socket joint. The junc- tion of the head with the arms is called the neck, though no de- pression exists. The crura, branches, or arms, spring from the neck, one from the anterior and one from the posterior portion, curve away from each other in a horizontal plane, and finally join opposite ends of the oval plate, which forms the base. The anterior arm is shorter and less curved than the posterior. They diminish in thickness as they approach the base, and are slightly furrowed upon their inner surfaces for insertion of the obturator ligament. The base, or foot-plate, of the stapes is a thin lamina of bone, dumb-bell or kidney shaped in a perpendicular plane, and like a concavo-convex lens in a horizontal one. It projects at each end a little beyond the junction of the crura. Its convex surface is towards the vestibule. The plate is smaller than the foramen ovale, into which it is held by an annular ligament from the bony margin, and by a fibrous connection with the membrane, which permits a slight in-and-out movement. The obturator ligament, or ligamentum obturatorium stapedis, is a thin plane of ligamentous tissue, that extends between the crura and the base of the stapes and closes the opening. 32 THE HUMAN EAR AND ITS DISEASES. The ossicles of the ear are covered by periosteum, and delicate cartilage is present upon the articular surfaces. The heavy heads of the malleus and incus are above the axial line of motion, and this greatly facilitates movement. Muscles.—The laxator stapedis is mentioned by some writers as a muscle, by others as a ligament. If it does not possess muscular fibres, it may act by elastic tension. Described as a muscle, it arises Fig. 9. Eight Articulated Ossicles (X 4 diam.) (Burnett).—k, Incus ; a, body; b, short process; c, long process; e, lenticular process; d, head of stapes, and malleo-stapedal articulation; I, crura; /, manubrium of malleus; g, slender process; h, neck; i, head ; j, malleo-incudal articulation. from the spine of the sphenoid and cartilage of the Eustachian tube, passes through the Glaserian fissure, and is inserted into the root of the processus gracilis and neck of the malleus. It is said to be supplied by the tympanic branch of the facial nerve. The tensor tympani muscle arises from the temporal and sphenoid bones at the end of the Eustachian tube, from the carti- lage of the tube, and from the walls of a bony canal above the Eustachian tube, passes along this to the ear, and terminates in a tendon, which turns outwards at a right angle over the processus cochleariformis, and is inserted into the anterior inner edge of the handle of the malleus, a little below the processus gracilis. It is supplied by a nerve filament from the otic ganglion. The stapedius muscle arises from a canal in the pyramid upon the inner tympanic wall behind and a little below the oval window • THE VESSELS OF THE TYMPANUM. 33 its tendon leaves the summit and runs upward and forward, and is inserted into the posterior edge of the articular surface of the head of the stapes. The muscle bends at an obtuse angle after it leaves the pyramid, and is supplied by a filament from the facial nerve and one from the otic ganglion. The fixator basis stapedis muscle arises from the inner wall, one millimeter above the posterior-superior border of the oval window, and is inserted into the junction of the posterior limb and foot-plate of the stapes. It receives a filament from the facial nerve. The middle ear is lined by periosteum and mucous membrane; the latter is reflected over the surfaces of the ligaments, muscles, Fig. 10. Eight Tympanum viewed from Above (x 2diam.) (Burnett).—a, Ante- rior ligament of the malleus; b, chorda tympani nerve ; c, head of malleus; d, posterior ligament of incus ; e, short process of incus; /, tensor tympani muscle. ossicles, and the chorda tympani nerve, forming folds, projections, shelves, and pockets, as before described. It is thin, delicate, and glistening, and upon the walls of the cavity is intimately connected with the periosteum, so that it has more the appearance of a serous than a mucous membrane. It contains no glands, except near the entrance of the Eustachiau tube, where racemose ones have been described. It is well supplied with vessels and nerves, and branches of both traverse its basement membrane and pass into its depressions and folds to supply the structures of the tympanum. Vessels of the Tympanum.—These are the stylo-mastoid, a 34 THE HUMAN EAR AND ITS DISEASES. branch of the posterior auricular, which enters the tympanum from the posterior wall; the external tympanic, a branch of the internal maxillary, which enters from the anterior wall; the (inner) tympanic, a branch from the Vidian, which enters from the inner wall; the inferior tympanic, a branch of the internal carotid, which enters from the anterior wall ; and the tubal tym- panic, a branch of the ascending pharyngeal, which enters from the anterior wall, having supplied the Eustachian tube and tensor tympani muscle. These vessels anastomose freely, form a rich capillary net, supply the bones, periosteum, ligaments, muscles, and mucous membrane of the tympanum and mastoid cells, and communicate through the tympanic membrane with the vessels of the external canal, as well, as with those of the petrous bone and contiguous structures. The veins of the tympanum communicate freely with the mas- toid vessels, the vessels of the surrounding bone, and those of the external canal; but the most important ones penetrate the inner and upper walls of the tympanum and join the middle menin- geal ; others, the Vidian, petrosal, and muscular branches, join the pharyngeal plexus; the former empty into the internal max- illary, and finally into the temporal, and the latter into the in- ternal jugular vein. The lymphatics of the middle ear pass through the petrous bone along the Eustachian and tensor tympani canals to join the pha- ryngeal plexus, as before described. Nerves.—The otic ganglion, having received its sensitive fibres from the inferior maxillary, its sympathetic fibres from the great meningeal plexus, and motor fibres from the internal pterygoid and from the facial through the small petrosal, sends a branch along the canal of the tensor tympani muscle and supplies it with motor influence. The tympanic branch of the glosso-pharyngeal (Jacobson's nerve), the most important nerve of the tympanum, enters it by a foramen between the jugular fossa and the carotid canal in the floor, near the inner wall, and receives filaments which have passed through the floor from the carotid plexus of the sympathetic system. It lies in grooves upon the inner tympanic wall breaks up into numerous branches, with which a large number of ganglia NERVES OF THE TYMPANUM. 35 cells are mingled, so that the mesh has been justly denominated the tympanic plexus. In-the distribution of filaments, one sup- plies the mucous membrane of the Eustachian tube, one goes upwards to the small petrosal and one to the large petrosal nerves, one to the oval window, one to the round window, and many others uniting with other nerves supply the mucous mem- brane of the tympanum and mastoid cells. The connection of the nerve by filaments to the petrosals, with the otic and spheno- Fig. 11. Nerves in the Aural Eegion (Burnett).—1, Fifth nerve and Gasserian ganglion; 2, tensor tympani muscle; 3, motor branch of fifth; 4, malleus; 5, small petrosal; 6, incus ; 7, otic ganglion ; 8, facial nerve in canal; 9, chorda tympani nerve; 10, membrana tympani ; 11, tensor palati muscle; 12, middle meningeal artery; 13, lingual nerve; 14, auriculo-temporal nerve; 15, inferior dental nerve; 16, external pterygoid muscle ; 17, internal pterygoid muscle ; 18, internal maxillary artery ; 20, mylo-hyoid aerve. palatine ganglia, makes a close sympathetic connection between the ear, throat, nose, teeth, and eyes, and explains many curious symptoms. Among the nerves of the middle ear before enumerated is a branch of the facial, which passes through -a foramen in the inner wall of the tympanum, sends one filament to the laxator tym- pani, one to the stapedius, and one to the fixator basis stapedis muscles. The chorda tympani nerve enters the tympanum at the lower, outer, posterior corner, curves up along the border of the tym- 36 THE HUMAN EAR AND ITS DISEASES. panic membrane, passes forwards above the tendon of the tensor tympani muscle and below the short process of the malleus, in the fold of mucous membrane, between the malleus and incus, and goes out of the tympanum through the canal of Huguier. It has no physiological office in connection with the ear. The Eustachian Tube, from its foramen in the middle of the anterior wall of the tympanum, runs beneath the canal of the tensor tympani muscle, downward, forward, and inward from the middle ear to the pharynx, and thus permits a free passage of the air from the throat to the ear. It passes from the tympanum at an angle of 135° with the external auditory canal, but from the external meatus through the ear to the pharyngeal end of the tube the direction often approximates to a curve. In an infant, the direction from the external meatus to the inner end of the tube is nearly transverse. The Eustachian tube is separated from the tensor tympani muscle by a thin scale of bone often incomplete, but with its de- ficiencies filled with cartilage and fibrous tissue; this is called the processus cochleariformis. The bony portion of the Eustachian tube is about 12 mm. long, and its inner aperture is in the fissure between the great wing of the sphenoid and the temporal bone. This end is rough; the cartilaginous portion is joined to it and prolongs it about 24 mm., making the whole length of the tube about 36 mm. (li inches). A triangular plate of cartilage is curled upon itself to form the cartilaginous portion, but its edges, which are below, do not meet, and the space is filled by fibrous and muscular tissue. The tube is lined with mucous membrane continuous with that of the mid- dle ear and the pharynx. Its canal is shaped like two truncated cones, flattened a little laterally and joined by the small ends • one part is in the osseous, and the other in the fibro-cartilaginous portion. The narrowest part of the tube is at the junction of the cones and is called the isthmus, where the vertical diameter is 2 mm. and the horizontal is 1 mm. The aural end has a diameter of 4 to 4.5 mm.; the pharyngeal, 4.5 to 9 mm. in height, and 4 to 5 mm. in width; the expanded pharyngeal end, or ostium, is 5 to 6.5 mm. deep. The cartilaginous portion is held in position by fibrous THE EUSTACHIAN TUBE. 37 tissue and the muscles surrounding it, and its inner end is some- what movable. The pharyngeal end has a decidedly elevated border, especially posterior, and is expanded like the mouth of a trumpet, with its sides pressed a little together, so that the open- ing is an irregular, perpendicular oval. It varies considerably in the shape of its lumen in different individuals, and upon the two sides in the same person, and corresponds in size with the external meatus; a large meatus accompanies a large-mouthed tube. The mouth is situated a very little below the angle formed by the posterior edge of the external wall of the nasal fossa and the inferior turbinated bone, and a little above the floor of the nose, and external to its outer wall. The two throat openings are about 25 to 30 mm. apart. If a broom straw be placed across, with an end in each Eustachian tube, its middle will nearly touch the pharynx. Some persons with very large throats, others with great breadth of the base of the skull, require Eustachian catheters with consid- erable curve. I noticed that the catheters used by Professors Miot and Desarenes, at their clinics in Paris, were much less curved than those used by Professor Gruber, at Vienna, and Professor Liitze, at Berlin. The French skulls, like those of the Latin races generally, have narrower bases than the Austrian and German. In very narrow skulls, sometimes a nearly straight catheter will go through the nasal fossa directly into the tube. Occasion- ally, the inferior turbinated bone of one side is so low down, or the vomer is so bent laterally, that one cannot introduce a cathe- ter, when resort must be had to a special one, applied through the other nasal fossa, or through the mouth. It is very frequently the case that the diseased ear is the one corresponding to the side of the nose deformed—too frequent to be accidental. When a catheter is in position, the mouth of the Eustachian tube can be moved nearly 6 mm. The point of a catheter in posi- tion may be turned upward and outward, exactly horizontal and sometimes even downward and outward. This depends on the position of the palate-bone, the width of the skull, and the shape of the temporal bone. The Eustachian tube is lined in its bony portion by periosteum, 38 THE HUMAN EAR AND ITS DISEASES. in its cartilaginous portion by perichondrium, both being covered by mucous membrane. The bones of the pharynx are covered by periosteum, connective tissue, and loosely applied mucous membrane. The mucous membrane of the tube and pharynx, as low as the palate, is furnished with ciliated epithelium, the cilia of which act from the tympanum downwards; ciliated epi- thelium also covers the mucous membrane of the respiratory portion of the nose. Below the palate-bone the pharynx is sup- plied with squamous epithelium. The mucous membrane of the * Eustachian tube, except its upper wall, is richly filled with aci- nous and follicular glands, which finally disappear towards the tympanic cavity. Muscles.—The Eustachian tube is surrounded by structures which influence its action decidedly. Beneath the mucous mem- brane of the pharynx, and upon and within the connective tissue beneath, there are numerous muscles, which contract with every act of swallowing, and thus affect the position of the Eustachian orifice and its patulency. The tensor palati muscle is the most important one in connec- tion with the Eustachian tube. It arises by a broad, thin, fan- shaped layer of fibres from the scaphoid fossa and spine of the sphenoid bone, and from the anterior lip of the Eustachian car- tilage, sometimes uniting with the tensor tympani, and becomes narrower as it passes downward into its tendon. This passes around the hamular process (hook) of the internal pterygoid plate, expands again into a ribbon of fibres, and is inserted into the posterior edge of the horizontal portion of the palate-bone as far as the middle line. Here it mingles its fibres with its fellow of the opposite side, and with the azygos uvular muscles, which extend from the nasal spine and aponeurosis down in the middle line and form the bulk of the uvula. The levator palati muscle arises from the under surface of the apex of the petrous portion of the temporal bone, and from the adjoining cartilaginous portion of the Eustachian tube; it passes over the upper concave edge of the superior constrictor of the pharynx, goes downward and inward, spreads out its fibres in the posterior part of the soft palate with the fibres of the tensor THE PALATOPHARYNGEAL MUSCLES. 39 palati, and extends to the middle line, mingling with those of its fellow, and of the uvula. The stylo-pharyngeus is a long, slender muscle, which arises from the styloid process, passes down between the superior and middle constrictor muscles, and, spreading out beneath the mucous membrane of the pharynx, is inserted into the middle constrictor muscle and the upper part of the thyroid cartilage. The palato-pharyngeus muscle forms the posterior pillar of the fauces; it arises from the fascia and is mingled with the muscles, Fig. 12. Muscles of Palate and Fauces (Leidy).—1, Levator palati muscle, left side removed ; 2, tensor palati muscle: 3, azygos uvular muscles; 4, Eustachian tube; 5, origin of palato-glossus and palato-pharyngeus muscles; 6, part of superior pharyngeal constrictor muscle ; 7, external pterygoid muscle. which form half of the soft palate and uvula; is perforated by the levator palati, passes outward and downward behind the ton- sil, and spreading out is inserted into the posterior border of the thyroid cartilage and the side of the pharynx, amongst the fibres of the middle constrictor muscle. The superior constrictor muscle of the pharynx, also, has rela- tion with the Eustachian tube. It is a thin, pale, quadrilateral muscle, which arises from the lower half of the internal plate of the pterygoid process and the hook of the sphenoid bone, and from the pterygo-maxillary ligament, aud curves backward and upward to join its fellow in the median line and be inserted into 40 THE HUMAN EAR AND ITS DISEASES. the pharyngeal spine on the basilar process of the occipital bone. The space above, between it and the levator palati and Eustachij n tube, is destitute of muscles and filled with fibrous tissue. The internal pterygoid is said to take its origin by some fibres from the under portion of the cartilage of the Eustachian tube, and this seems probable from sensations produced in the region by contracting strongly the muscles of mastication. The roof of the pharynx has such a number of large follicular and racemose glands, surrounded by spongy tissue so much like that of the tonsil, that it has been called the pharyngeal tonsil, or tonsilla pharyngea. The mucous membrane of the pharynx below the level of the palate-bone contains a great many follicular and racemose glands, which are very frequently hypertrophied and in a condition of inflammation; and the whole region of the throat above the larynx is richly supplied with glands, in a thick and quite vas- cular mucous membrane, loosely attached to the cellular tissue upon the muscles and bones. The tonsils proper, snugly ensconced between the pillars of the fauces, are compound follicular glands. They each have twelve to fifteen large follicular openings upon the surface, which lead into pouches having smaller follicles opening into them. They move with the superior constrictor and the palato-pharyngeus muscles, and when hypertrophied exercise a pernicious influence upon the pharynx and the orifice of the Eustachian tube. The Vessels of the Eustachian tube, upper pharynx and asso- ciate mucous membranes, muscles and glands are numerous and important. The external carotid artery supplies the entire region by its nu- merous branches, which are here enumerated. The lingual gives branches to the soft palate and tonsil. The ascending pharyngeal supplies the constrictor, tensor, and levator muscles; the mucous membrane of the soft palate, pharynx, Eustachian tube, and tym- panum ; the tonsil and posterior pillar of the fauces. The facial by its ascending palatine branch, supplies the superior constrictor tensor palati, levator palati, and internal pterygoid muscles • the mucous membrane of the soft palate, pharynx and Eustachian tube; the tonsil and deep cervical lymphatic glands. THE VESSELS. 41 The internal maxillary gives a branch to the tympanum through the Glaserian fissure, a Vidian branch to the Eustachian tube and tympanum, and petrosal branches of the middle menin- geal to the tympanum. It supplies the constrictor, levator palati, tensor palati, and pterygoid muscles; the raucous membrane of the nasal fossa, soft and hard palate, pharynx, and Eustachian tube. All these arteries anastomose freely with each other. The internal carotid gives off, in its canal in the temporal bone, a small branch, which goes through the anterior wall into the tympanum. Lower down it lies in dangerous proximity, be- neath and outside of the tonsil. The veins of the tympanum, as they pass out through the fis- sures and foramina and along the Eustachian tube, take the same names as the corresponding arteries. Some unite with the middle meningeal of the internal maxillary, which receives the pterygoid, palatine, and others, and passes behind the neck of the jawbone to unite with the temporal vein. The Vidian, petrosal, and mus- cular branches join the pharyngeal plexus behind the pharynx, which receives branches from the pharynx, soft palate and tonsil, and unites with the internal jugular. The lingual receives branches from the soft palate, pillars of fauces, and tonsil, and goes to join the internal jugular. The facial receives the inferior branch from the plexus around the tonsil and soft palate. All the veins anas- tomose freely with each other and have no valves. The lymphatics form a capillary network in the ear and Eustachian tube, escape from its anterior orifice, and unite with a vast system of vessels from the nasal and pharyngeal mucous membranes and the interior of the cranium. These empty into the deep cervical glands, which receive ducts from the superior cervical glands, and extend as a chain along the carotid artery and internal jugular vein, to finally debouch into the right lym- phatic duct, thus forming a direct communication between the middle ear and the blood-current of the right subclavian vein. Quite a cluster of glands is situated just beneath the angle of the jaw, which receives ducts from the superficial and deep glands. These are especially prone to engorgement from external disease of the auricle, and from pharyngeal and tonsilar disease. 4 42 THE HUMAN EAR AND ITS DISEASES. The Nerves in and about the tympanum are numerous. The facial nerve, in the internal auditory meatus, sends several fila- ments to the auditory nerve. In the aqueduct of Fallopius it gives off the great petrosal branch, which joins with some sym- pathetic filaments from the carotid plexus, and a filament from the tympanic branch of the glosso-pharyngeal, takes the name of the Vidian nerve, goes through the canal in the temporal bone, through the foramen lacerum anterius and across the top of the pharynx to the spheno-palatine ganglion. This is located near the spheno-palatine foramen, in the spheno-maxillary fossa. The superior maxillary nerve, after its exit from the foramen rotun- dum, sends two small branches to this ganglion, and it thus re- ceives motor, sympathetic, and sensory fibres. The ganglion sends branches to the levator palati, azygos uvula?, palato-glossus and palato-pharyngeus muscles; to the mucous membrane of the nasal fossae, soft palate, hard palate, and gums; to the lateral and posterior pharynx, the orifice and canal of the Eustachian tube, and the tonsil. The facial, in the aqueduct, sends a fibre, the small petrosal nerve, augmented by a filament from the sympathetic branch of the glosso-pharyngeal, through a superficial canal in the temporal bone, and down through a foramen in the spine of the sphenoid to join the otic ganglion, which is situated inside the inferior maxillary nerve, just below the foramen ovale. The ganglion receives two or three sensitive filaments from the beginning of the auriculo-temporal, motor filaments from the in- ternal pterygoid of the internal maxillary, and sympathetic fila- ments from the sympathetic plexus upon the middle meningeal artery. It sends one branch to the tensor palati, and one to the tensor tympani muscle. The facial, in its aqueduct near the pyramid, gives off a branch that penetrates the inner wall of the tympanum and supplies the muscles therein. The internal maxillary gives off the internal pterygoid nerve which supplies the internal pterygoid muscle, and some think also, the tensor palati. The pneumogastric nerve in the jugular fossa gives off an THE INTERNAL EAR. 43 auricular branch (Arnold's), which receives a filament from the glosso-pharyngeal, enters the temporal bone near the styloid process, and joins the facial in the aqueduct. Just below the jugular fossa, the pharyngeal branch leaves the facial. It receives a filament from the spinal accessory, and, at the border of the middle constrictor muscle, unites with the glosso-pharyngeal, superior laryngeal, and sympathetic to form the pharyngeal plexus. This plexus sends branches to the levator palati, palato- pharyngeus, and constrictor muscles, and to the mucous membrane of the pharynx. By other portions of the pneumogastric, com- munication is made with the oesophagus, larynx, etc. The glosso-pharyngeal nerve from its petrous ganglion sends a nerve filament to the trunk of the pneumogastric; it gives off the auricular, to unite with a fibre from the pneumogastric, and this joins the posterior auricular of the facial before mentioned. A fine branch anastomoses with the superior cervical ganglion of the sympathetic. Another branch (Jacobson's) traverses a canal in the temporal bone between the carotid canal and the jugular fossa, enters the tympanum by a foramen in the floor near the inner wall, and divides into several branches which supply the tympanum and contiguous parts. The pharyngeal branches of the glosso-pharyngeal leave the trunk lower down. They are three or four filaments, that join with branches of the pneumogastric and sympathetic to form the pharyngeal plexus. This is distributed to the mucous membrane of the pharynx and larynx, and to the stylo-pharyngeus, salpingo- pharyngeus and constrictor muscles. Other filaments are dis- tributed to the tonsil, fauces, soft palate, and tongue. The Internal Ear, the most important portion of the auditory apparatus, includes the labyrinth, the internal auditory nerve, and the internal auditory meatus. It is situated deep within the temporal bone, and extends a little farther back than the tym- panic cavity. The bony labyrinth is separate and merely sur- rounded by the temporal bone in the infant, but it becomes united solidly with it in later years. There are two distinct parts: one composed of bone, called the 44 THE HUMAN EAR AND ITS DISEASES. bony labyrinth; and the other of membrane, called the mem- branous labyrinth. The bony labyrinth has three divisions: the vestibule, the semicircular canals, and the cochlea. The name labyrinth is frequently used by authors to signify only the vestibule and semicircular canals. The Vestibule is situated between the tympanum and internal auditory meatus; its bony wall is thin, and it lies imbedded in the petrous bone. The semicircular canals are situated posterior and external, and the cochlea anterior and internal to it. It is oval in perpendicular section ; pear-shaped with small end forward in horizontal sec- tion. It is about 5 mm. long and deep, and 3 to 4 mm. wide. Its outer wall is the inner wall of the tympanum, and contains, as before mentioned, the oval window, or fenestra ovalis, closed by the membrane and base of the stapes. Just behind this is the ampullar opening of the horizontal semicircular canal. Above it is the termination of a ridge of bone from the inner wall and roof, called the pyramis vestibuli of the crista vestibuli. There are several minute openings in this for the passage of nerves, and these constitute the superior macula cribrosa. The floor of the cavity is a mere groove with a few small foramina for vessels. The anterior wall has little surface and shows the oval opening of the scala vestibuli, or canal of the cochlea. The posterior wall has considerable surface and several open- ings. In the centre is the unexpanded opening of the horizontal semicircular canal. At the junction of the superior, posterior and inner walls is the straight opening common to the superior and posterior semicircular canals. The ampullar end of the posterior semicircular canal is at the junction of the inferior posterior, and inner walls. The ampullar end of the superior semicircular canal opens in the roof just behind the crista ves- tibuli. The crista vestibuli is a slight ridge of bone, which begins on the outer wall above the oval window, goes across the roof and down the inner wall, and separates into two limbs near the floor THE INTERNAL EAR. 45 of the vestibule, one curving forwards and one backwards. The inner wall is divided by the crista vestibuli into an anterior por- tion slightly concave, called the recessus sphericus, and a posterior upper portion, also somewhat depressed, called the recessus ellip- ticus, bounded below by a slight groove, the sinus sulciformis. Just below and behind this latter is a foramen, the aquaeductus vestibuli, through which the vestibular vein goes backward and inward through the bone, along with the funnel from the dura mater, which contains cerebro-spinal fluid. The space between the limbs of the crista is called the recessus cochlearis. In this, near the upper part, are several foramina, called the macula cribrosa (inferior). In the anterior inferior part of the recessus sphericus is the macula cribrosa media. Above and behind the recessus ellipticus, near the ampullar entrance of the posterior semicircular canal, is another group of foramina, the macula cribrosa posterior. The macula cribrosa superior is at the termination of the crista upon the external wall. These foramina all communicate with the internal auditory meatus, and receive filaments from the internal auditory nerve. The walls of the vestibule are so called for convenience. It is not correct to speak of the different walls of a cavity made by spherical surfaces. The ridge, described as projecting from two and part of the third wall, constricts the cavity around the middle like a belt around the waist, and thus makes a hemispherical space anterior, and a semi-elliptical space posterior. The anterior contains the sacculus rotundus, and the posterior the utriculus. The Semicircular Canals are bony, oval tubes of unequal length, irregularly curved more than a half circle, so that their openings come nearly together. They are named according to their position, the superior, the posterior, and the inferior, or horizontal. They are situated above the inner back part of the tympanum, behind and a little outside of the vestibule, with which they com- municate by five orifices. Two of these terminate in straight tubes, and three have ampullar dilatations. The latter have been called ampullae from their fancied resemblance to a wide-mouthed jug. The posterior semicircular canal is 22 mm., the superior 20 46 THE HUMAN EAR AND ITS DISEASES. mm., and the horizontal 15 mm. in length. Their general diameters vary from 1 to 1.7 mm., but the ampullae have a diameter of about 2.5 mm. The canals are of thin bone, strengthened by fibrous tissue, and much contorted. If a cube be placed just behind the vestibule, approximately, the horizontal semicircular canal would lie flat beneath the lower, the superior upon the inner, and the posterior upon the posterior surfaces of it respectively. The superior canal is vertical in position, at right angles to the other canals, and makes a rounded prominence on the anterior surface of the petrous bone. Its ampulla opens in the roof, Fig. 13. Fig. 14. Fig. 13.—The Labyrinth Exposed (Leidy). — 1, Vestibular branch of auditory nerve; 2, branch to the sacculus ; 3, branch to the utriculus; 4, branch to the ampulla of the posterior canal; 5, branch to the ampulla of the horizontal canal; 6, branch to the ampulla of the superior canal; 7, cochlear nerve; 8, cochlea showing scalse, modiolus, etc. Fig. 14.—The Nerves of the Vestibule and Ampulla (X 3 diam.), (Leidy).—1, Branch to vestibule ; 2, branch to sacculus; 3, branch to utriculus ; 4, branch to the posterior ampulla; 5, branch to horizontal ampulla; 6, branch to superior ampulla ; 7, branch to the cochlea. and its other end, after uniting with the undilated end of the pos- terior canal, opens by a straight tube 3 mm. long, into the inner posterior part of the vestibule. The posterior semicircular canal, the longest of the three is also placed vertically, and extends to the back part of the tem- poral bone. Its straight end opens in the inner posterior part of the vestibule, in union with the superior canal, as already de- scribed, and its ampulla opens at the lower inner part of the posterior wall. THE INTERNAL EAR. 47 The horizontal canal, the shortest of the three, extends back- wards at right angles to the other canals. Its unexpanded limb opens into the vestibule in the middle of the posterior wall, and its ampulla at the upper part of the external and posterior walls. Thus the three semicircular canals have five openings, two straight unexpanded tubes, and three expanded into the peculiar pear-shaped ampullae. The vestibule and semicircular canals are lined throughout by a fibro-serous membrane; the fibrous portion, like a periosteum, adheres closely to the inner surface; it sends a tubular process along the aquseductus vestibuli to the dura mater; it extends into and lines the scahe of the cochlea, and sends a tubular prolonga- tion along the aquaeductus cochleae to the dura mater. The serous surface consists of a basement membrane covered by tessellated epithelium. The fibro-serous membrane passes over the membranes of the round and oval windows. It secretes a bland, watery fluid, called the perilymph (aqua labyrinthi, or liquor Cotunnii), because it surrounds the membranous labyrinth. It is said to be received in some measure from the subarachnoid space through the foramen acustica, and to escape when in ex- cess through the aquaeductus cochleae. The perilymph is a weak alkaline fluid, containing a little albumen. This fluid surrounds the membranous semicircular canals and the saccules, and is con- tinuous through the oval opening in the anterior wall of the ves- tibule with that which fills the vestibular and tympanic scalae of the cochlea. The bony labyrinth incloses the membranous labyrinth, which consists of a sac constricted in the middle into two pouches, and of three canals communicating with it. These are counterparts in shape of the bony labyrinth, but are a little smaller. They do not float freely in the perilymph, because numerous vessels, nerves, lymphatics and fibrous bands hold them rather near to the osseous labyrinth. The fibrous bands have been called liga- menta labyrinthi canaliculorum. The vestibular portion is closer to the inner wall of the cavity, and is removed a little distance from the outer wall, so that it does not interfere with the oval window. The membranous ampullae lie close to the bony wall, but other parts of the labyrinth are more removed. 48 THE HUMAN EAR AND ITS DISEASES. The portion of the membranous labyrinth contained in the vestibule is constricted in the middle. The anterior lower por- tion is of globular form, is called the sacculus rotundus, and occu- pies the recessus sphaericus (fovea hemispherica). The posterior and upper portion is elliptical in shape, is called the utriculus, and occupies the recessus ellipticus (fovea semielliptica). This shows the five openings of the tubes and ampullae of the mem- branous semicircular canals, which occupy the bony semicircular canals, being held in position by ligaments at their convex por- tions. The membranous labyrinth is composed of several layers. The fibrous layer is a dense membrane showing connective tissue cells and nuclei. It is the thickest and most important layer, fur- nishing a firm support for the delicate structures within, for the attachment of external ligaments, and the passage of nerves and vessels. Next to this layer upon its inner surface there is a net- work that is supposed to consist of nerves and ganglia. The hyaloid layer, or tunica propria, covers this, and is closely united with the fibrous layer. It resembles the hyaloid membrane of the eye, but upon close examination shows longitudinal fibrilla- tion and elongated nuclei. Upon the inner surface of the hyaloid layer of the semicircular canals are found various sized papillary prominences, or minute elevations, which are most numerous near the middle portion of each arc, and do not extend into the utriculus. Over these and upon the whole internal surface of the canals, there is a layer of thick, nucleated pavement epithelium, which terminates at the ampullae, where ciliated epithelium is found. The vestibule, or saccules, and the ampullae are covered by a thin, yellowish ciliated epithelium. The hyaloid layer is thick- ened where it extends into the ampullae, and the short ciliated ridge is called the crista acustica. There is a similar projection of ciliated cells in the saccules, called the macula acustica. At the end of each crista acustica an elevation of ciliated epithelium called the planum semilunare, extends along each ampulla. Filaments of the auditory nerve from the network mentioned above extend into the cilia of these parts, and receive impressions from the vibrating lymph and dancing otoliths. THE COCHLEA. 49 Otoliths, otoconia, or ear stones, are composed of single and aggregated crystals of carbonate of lime of different sizes and angular shapes, which are found within the membranous laby- rinth. The minute ones are unattached here and there, and some writers state that they are found exceptionally in the semicircular canals and cochlea. There are two large, white, discoid masses of otoliths, having a fibrous, cartilaginous, or amorphous organic mesh, that holds the crystals together; these adhere to the epi- thelium, one in the utriculus and the other in the sacculus, near the cribriform spots, where the nerve filaments terminate in great numbers. That otoliths serve an important purpose in audition is evident from the fact, that they exist in the ears of many of the lower animals having excellent hearing. Fig. 15. Human Otoliths from the Vestibule. The membranous labyrinth is completely filled with a limpid serous fluid, alkaline and albuminous, called the endolymph (liquor Scarpae). Dr. Hasse states that an epicerebral lymph cavity sends a tubular membrane through the aquaeductus vesti- buli to communicate with the vestibule, and thus convey cerebro- spinal fluid to act as endolymph, or to relieve excess of endo- lymph at any unusual increase. The Cochlea consists of a conical axis of bone, surrounded by a bony canal wound spirally around it in decreasing turns from base to apex, and the whole is massed together and covered by the temporal bone. It takes its name from its resemblance to a snail shell. It forms the anterior portion of the labyrinth, and 50 THE HUMAN EAR AND ITS DISEASES. is situated almost horizontally, anterior to the vestibule. Its base is at the posterior, inner surface of the temporal bone, and its apex is directed outward, downward, and a little forward, coming near the upper anterior part of the inner wall of the tympanum. The axis, modiolus, or columella is a solid, acute, cone-shaped pyramid of bone perforated by five canals for the passage of ves- sels and nerves. Its length is 2J mm.; the diameter of its base is 2 mm., and its apex J mm. The spiral, or cochlear canal is a bony tube that winds closely around the axis from base to apex, and is divided by bone and membrane into three canals; they are the vestibular seal a, the tympanic scala, and the cochlear duct. The lower end of the tube begins between the tympanic and vestibular openings of the cochlea, at the outer lower corner of the vestibule, reaches the modiolus, and winds forwards and upwards, in the right ear from right to left, and in the left ear in a reverse direction, two and a half times around it. Each turn of the canal diminishes in Fig. 16. The Cochlea Unroofed (Leidy).—1, Osseous wall of the cochlea; 2, lamina spiralis ossea, above; 3, end of the osseous lamina; 4, 5, edge of the osseous lamina; 6, lamina spiralis membranacea; 7, end of the membranous lamina; 8, helicotrema, and passage to the scala tympani. diameter towards the apex, and it terminates by a closed extremity called the cupola, which lies near the front surface of the tem- poral bone, close to the canal of the tensor tympani muscle and above the ascending part of the carotid canal. The first turn of the canal is near the surface of the inner tympanic wall and makes a projection known as the promontory. The canal is 28 THE COCHLEA. 51 mm. long, and its greatest diameter 1 mm., and its last half turn diminishes gradually in calibre. The cochlea proper has a base 4 or 5 mm. in diameter, and its height is about the same. The canal in the bone varies in the shape of its transverse sec- tion. At some places, it is triangular, with the outer side convex; at others, it is semicircular, and again at others, oval. A thin bony shelf of two united plates projects from the modiolus about half way across the canal, and helps to divide it into two parallel canals, the scalae. This is the spiral lamina, or lamina spiralis ossea; it is 1.2 mm. wide and .3 mm. thick at the lower end, and .5 mm. wide and .15 mm. thick at the upper end. Fig. 17. The Cochlear Nerve (Leidy).—1, Trunk of the nerve; 2, membrana basilaris with membrane of Eeissner removed ; 3, filaments of the nerve pass- ing from the osseous lamina to organ of Corti; 4, helicotrema leading to the scala tympani. The lamina begins upon and curves gracefully away from the wall of the vestibule to the modiolus, winds spirally around this, like the threads of a screw, and terminates in the cupola by a sharp crescentic edge or hook, called the hamular process. The undivided space between this and the end of the cochlear canal is called the infundibulum, or helicotrema. Around the modiolus, in the base of the lamina, passes a canal called the canalis spiralis modioli. Between the two surfaces of the lamina are numerous radiating canals for the passage of nerves from the modiolus; 52 THE HUMAN EAR AND ITS DISEASES. these open upon the side next the base of the cochlea through perforations in the edge, called the habenula perforata. The fibro-serous, periosteal lining of the vestibule is continuous as the canalis reuniens, through the oval opening in its anterior wall into the cochlear canal, and is closely attached to its walls and to the lamina spiralis throughout their extent. Near the edge of the lamina spiralis, the membranous layers from its sur- faces approach each other. That covering the basal surface of the lamina, called the membrana basilaris, runs straight along and across to the opposite wall of the canal, where it is firmly attached to the bone. The place of attachment is thicker than elsewhere, owing to an extra development of connective tissue, and has been called the ligamentum spirale of Henle. This membrane completes the partition between the tympanic scala and the cochlear duct, but ends at the hamular process above, and forms the sharp border of the helicotrema. The membrane covering the apical surface of the lamina, the membrana vestibuli, becomes thickened by connective tissue and epithelium before it reaches the border of the osseous lamina, then gradually be- comes thinner, and finally terminates at the edge of the bone by irregular, cartilage-like, dentate processes, which are collectively named the lamina denticulata. The inner edge of these processes is called the crista spiralis, and the processes themselves the aural teeth. The membrana tectoria, or delicate roof-membrane, takes its origin here, extends parallel with the membrana basilaris, a little separated from it, as far as the beginning of the organ of Corti, where it terminates by a feather edge. The thickened portion of vestibular membrane behind the dentate processes gives off at an angle of 40° a delicate fibrous membrane, the membrane of Reissner, which goes to be attached to a cushion of connective tissue upon the outer wall of the cochlea, at some distance, of course, above the membrana basi- laris, thus leaving a space between them, called the ductus coch- learis. This duct is taken from the vestibular scala, lies between it and the tympanic scala, and incloses the organ of Corti. Its outer wall is covered by the fibro-serous lining common to the scalae. The membranes passing from the lamina spiralis ossea to the outer wall of the canal, and dividing it into three canals THE COCHLEA. 53 are mentioned collectively in general anatomy as the lamina spiralis membranacea. Fig. 18. First Cochlear Coil (Burnett)'(Transverse section X 100 diameters).— a, Vestibular lamella of lamina spiralis ossea; b, e, origin and attachment of Eeissner's membrane, middle portion cut away ; b, c, crista spiralis; c, process forming one of the auditory teeth ; d, membrana tectoria; /, p, cushion of con- nective tissue, called the ligamentum spirale of Kolliker; g, o, periosteum; h, n, osseous wall of the cochlea; i, stria vascularis;,/, vas prominens and liga- mentum accessorium spirale; k, sulcus spiralis externus; I, ligamentum spirale of Henle"; m, periosteum ; n, bone; o, union of connective tissue and periosteum; q, c, zona denticulata; q, u, organ of Corti; q, I, zona pectinata and epithelium above; r, region of outer ciliated cells; r, t, zona arcuata; s, thinnest part of membrana basilaris; t, region of inner ciliated cells; u, habenular perforata, or place of nerve entrance; u, I, membrana basilaris; v, sulcus spiralis internus; w, tympanic lamella of lamina spiralis ossea; x, cochlear nerve fibres; y, ductus cochlearis; SV, scala vestibuli; ST, scala tympani. 54 THE HUMAN EAR AND ITS DISEASES. The basilar membrane and membrane of Reissner have radi- ating lines, are covered by epithelium, and have a glassy, trans- parent appearance. They pass from the osseous spiral lamina to the opposite wall of the cochlear canal, and there become contin- uous with its fibro-serous lining. The spiral cochlear canal is thus subdivided into the hemispherical tympanic scala below, the imperfect obtuse triangular vestibular scala above, and the trian- gular cochlear duct between these. The three spiral canals run parallel to each other from the base to the cupola of the cochlea, where the scalae communicate by the helicotrema, and the cochlear duct ends at the hamular process in a blind extremity. The canal below the basal lamina, when the cochlea is placed upon its base, is the scala tympani, or tympanic scala. It is closed at its lower end by the membrane of the round window of the tympanum, the membrana tympani secundaria of the fenestra rotunda, situated behind and below the promontory. The fibro- serous membrane of the outer wall of the scala passes over the inner surface of this secondary membrane and adds to its thick- ness. A little distance from the lower end of this scala, and in its wall, there is a foramen of a canal, the aquaeductus cochleae, which passes down through the temporal bone and opens upon its base just inside the carotid canal. It transmits the cochlear vein to the inferior petrosal sinus, or in some cases to the internal jugular. There are several other openings in this part of the scala, through which vessels pass into the canals of the modiolus. The scala tympani passes by diminishing turns around the mo- diolus, towards the apex of the cochlea. Its basal wall is the cochlear wall proper, and that towards the apex is the lamina spiralis and membrana basilaris, until it reaches and ends in the infundibulum, or cupola. This is merely the rounded end of the cochlear canal common to both scalae, as the spiral lamina stops before it reaches the end and thus the two scalae are no farther divided. The space between the termination of the membranous spiral lamina and the cul-de-sac of the cupola may be regarded as the beginning of the vestibular scala. The base of the scala is made by the vestibular lamella of the spiral lamina, and by the mem- THE ORGAN OF CORTI. 55 brane of Reissner, and its roof by the wall of the cochlear canal proper. The scala passes by increasing turns around the modi- olus parallel to its companion towards the base, and opens directly into the vestibule by an oval opening in its anterior wall, and is hence called the scala vestibuli, vestibular scala. The fibro-serous membrane lining the scalae is periosteal in character, covered by pavement and peculiar epithelium, contin- uous with that of the vestibule. The scalae are filled by perilymph, which flows freely from the vestibule through the oval opening along the vestibular scala to the helicotrema, and then passing downwards over the hamular process and sickle-shaped edge of the dividing membrane in the cupola, goes backwards along the turns of the tympanic scala to the inner surface of the membrane of the round window of the middle ear. The triangular ductus cochlearis has its base formed by the membrana tectoria and membrana basilaris, its outer wall by the cochlear wall proper, and its roof by the membrane of Reissner. It diminishes the space that would otherwise be in the scala ves- tibuli. It follows a spiral course between the scalae, and is closed at both ends. It is lined by pavement epithelium and filled by a fluid similar to the perilymph. The outer wall of the duct has a vessel passing along it called the vas prominens, and between this and the external attachment of Reissner's membrane is found the striae vascularis. The sur- face or floor of the duct has near the edge of the bone a longitu- dinal space, the sulcus spiralis internus, or internal spiral groove; at the outer attachment of the membrana basilaris there is another longitudinal space, the mlcus spiralis externus, or the external spiral groove. It is further divided into three zones. From the crista spiralis to the outer end of Corti's organ is called the zona denticulata, from the inner to the outer ciliated cells, included in the former zone, is the zona arcuata, and from the outer border of the organ of Corti to the sulcus spiralis externus is the zona pec- tinata. These names are slightly descriptive of the appearance of the parts. The Organ of Corti is a peculiar ridge of connective tissue, nucleated and ciliated cells, granular matter, and nerve filaments, 56 THE HUMAN EAR AND ITS DISEASES. situated upon the membrana basilaris within the ductus coch- learis, between the edge of the lamina spiralis ossea and a line midway between it and the outer wall of the duct. It was first described by the Marquis of Corti, but our knowledge of it has been greatly increased by later studies with the microscope. Fig. 19. The Organ of Corti (Burnett) (Transverse section 800 diam.).—a, Co- lumnar epithelium in the sulcus spiralis internus ; b, entrance of cochlear nerve; c, basilar process of d, with granular matter about the nerve filaments ; d, inner ciliated cell; e, head of an inner pillar and location of cilia of inner ciliated cells; /, summit of the arch formed by union of the inner and outer pillars, the upper portion of one and the whole of another outer pillar ending above q ; g, i, j, outer ciliated cells ; h, a branch from g ; k, membrana reticularis extending to e / I, one of the support cells with base cut away; m, bases of two more outer ciliated cells ; n, vestibular layer of the membrana basilaris in the zona pecti- nata; o, y, homogeneous layer of membrana basilaris; p, transverse section of connective tissue fibrillse, nuclei, and granular protoplasm in membrane of scala tympani; r, vas spirale; s, nerve filament extending across the arch of Corti from the cochlear bundle to an outer ciliated nerve; t, base and granular pro- toplasm of an inner pillar; u, thick origin of the membrana basilaris ; v, blood- vessels ; w, periosteum of lamina spiralis ossea; x, a fasciculus of the cochlear nerve within the bone; y, tympanic lip of the crista spiralis. The surface of the membrana vestibuli, upon the edge of the bony lamina spiralis within the ductus, is covered by a layer of large, plump, columnar epithelial cells arranged vertically. The inner ciliated cells stand next to these outwards ; they consist of a single row of long large cells, with strong cilia in tufts above THE ORGAN OF CORTI. 57 and their lower ends terminating in a granular layer of inde- terminate strurture. The inner pillars come next. They are a row of still longer nucleated, non-ciliated cells, having their large bases fixed upon the membrana basilaris, and their upper ends, or heads massed with other cells from without, and with the mera- branous layer upon them. A triangular space, following the spiral direction of the duct, succeeds these, and is limited out- wards by a second row of long nucleated cells, the outer pillars.' The outer pillars rest upon the membrana basilaris, curve in- ward towards the spiral lamina, and their broad head-pieces fit into a depression between the heads and head-plates of the inner pillars, forming with these the pillars and arches of Corti. The inner and outer row of pillars and the membrana basilaris thus form a triangular tube, which runs the whole length of the ductus cochlearis, and makes a fourth duct in the cochlea. There are said to be three thousand of these pillars; the height of the triangle which they form increases towards the hamulus. The outer ciliated cells stand next to the outer pillars and parallel with them. They consist of five rows of large ciliated cells, arranged close together in rows. Their bases rest upon the membrana basilaris, and their ciliated ends are held in the roof of the organ, adjoining the heads of the external pillars. Out- side of these is still another row of cells parallel to these, but non-ciliated, and called support cells. The membrana reticularis is a netlike layer of connective tissue, which extends from the place where the two sets of pillars are joined together to the row of support cells, and covers over the intervening structures. The tufts of cilia of all the outer ciliated cells fit into and project through these meshes, and are bathed by the fluid of the ductus cochlearis. The parts of this membrane around the ciliated ends are called rings, and the spaces between, phalanges. The membrana tectoria is over the membrana reticularis and ciliated tufts, in light contact with them, and terminates in a thin free edge as far outward as the support cells. The ultimate fibres of the cochlear nerve pass out of the fora- mina in the lamina spiralis ossea, are distributed to the inner 5 58 THE HUMAN EAR AND ITS DISEASES. and outer ciliated cells, and lost in their granular matter and nuclei. Their number is estimated at 16,400 filaments. The organ of Corti consists simply of rows of ciliated cells, supplied by filaments from the cochlear nerve, and protected and held in proper relationship by membranes and bone. Fig. 20. Cast of Left Labyrinth (Burnett).—a, Fenestra ovalis; b, ampulla of superior semicircular canal; c, ampulla of horizontal semicircular canal; d, straight canal, formed by union of superior and posterior canals; e, ampulla of posterior semicircular canal; /, fenestra rotunda ; g, tractus spiralis foram- inosus. The Internal Auditory Meatus is situated in the posterior surface of the inner third of the petrous portion of the temporal bone, near its upper edge, and directly over the jugular foramen (fossa). It is a funnel-shaped opening looking directly inward, and towards its fellow opposite, so that a straw passing from one to the other would be about 12 mm. behind the basilar process of the occipital bone, and 18 mm. above the anterior border of the foramen magnum. The funnel-shaped meatus leads into a cylin- droid canal about 3 mm. in diameter, and 18 mm. in length, which leads downward, forward, and outward to the inner wall of the labyrinth ; this bottom, or cul-de-sac, is divided by a transverse crescentic ridge into a small upper and a large lower portion. The upper part is subdivided by a vertical ridge into two pits. The anterior one leads into a canal in the bone, the aquaeductus Fallopii, which is directed forward, then turns sharply backward and outward above the vestibule, and curves downward in the inner and posterior wall of the tympanum, to open upon the base of the skull just behind the styloid process, as the stylo-mastoid foramen. This devious canal transmits the facial nerve, or portio THE INTERNAL AUDITORY MEATUS. 59 dura of the seventh pair of nerves, and some of its branches through the temporal bone. The posterior pit of the upper division contains numerous foramina of canals, which pass into the vestibule, forming near the spine of the crista vestibuli the superior cribriform spot; they transmit the superior branch of the vestibular nerve, and some vessels. The lower and larger portion of the bottom of the canal, below the transverse septum, at its anterior (inner) side, is occupied by the base of the modiolus, and the beginning of the spiral tract. It is perforated by minute foramina of canals, which pass into the modiolus; some follow the lamina spiralis ossea around the axis; others bend out from the axis at different heights, penetrate be- tween the plates of the lamina, and open in the perforated place called the habenula. These canals transmit the cochlear nerve and vessels to the bony and membranous structures of the cochlea. One canal in the cul-de-sac passes through the wall of the vestibule into the upper part of the recessus cochlearis, and forms a lesser cribriform spot, through which a filament of the cochlear nerve goes to the septum of the saccules in the vestibule. The posterior (outer) portion of the lower division is perforated by foramina of canals, which pass into the vestibule in the reces- sus sphaericus, and form the middle cribriform spot for the middle (inferior) division of the vestibular nerve. In the posterior wall of the canal, there is a foramen of a small canal, which opens by several foramina in the ampulla of the pos- terior semicircular canal, and forms the inferior cribriform spot. The posterior division of the vestibular nerve passes by this means to its distribution. A tubular process of the dura mater, inclosing the facial and auditory nerves, goes to the bottom of the internal auditory canal, and is prolonged into the aquaeductus Fallopii, for the passage of lymph, and to supply the vestibule with perilymph. About 6 mm. outside of the internal meatus there is a slitlike depression in the temporal bone, at the bottom of which is the opening of the aquaeductus vestibuli, which leads into the vesti- bule. 60 THE HUMAN EAR AND ITS DISEASES. Vessels.—The internal auditory artery, a branch of the basilar, accompanies the auditory nerve to the bottom of the internal auditory canal, where it divides into the vestibular and cochlear branches. The vestibular vessel divides into several branches, which pass through numerous foramina and the inner wall of the vestibule, and are distributed in a fine capillary network to the bone, sacculus, utriculus, and semicircular canals. The cochlear vessel, also, immediately divides into about a dozen branches, which enter the foramina in the base of the mod- iolus and tractus spiralis, mingle with the nerve filaments, and proceed towards the apex of the cochlea, giving off branches, which bend outward in the lamina spiralis ossea, and supply the bone, the lamina spiralis membranacea, and all the soft tissues. Anastomoses exist between the capillary bloodvessels of the inter- nal and middle ear, so that disease may pass from one part to the other. The veins of the labyrinth are exceedingly irregular. The venous radicles of the soft structures of the vestibule and semi- circular canals mostly unite in one trunk, the vestibular vein, which passes out of the petrous bone through the aquaeductus vestibuli, and empties into the superior petrosal sinus. A tubu- lar process of membrane from the sacculus, and another from the utriculus unite and form a single membranous canal, which ac- companies the vestibular vein, and is said to terminate in a blind extremity, or cul-de-sac, within the dura mater. Some authors consider this an open process of the dura mater to the vestibule, through which the cerebro-spinal fluid flows freely in and out of the vestibule from the base of the brain. A few venous radicles from the vestibule pass through its walls into the base of the cochlea, and join the venous sinus in the spiral canal of the modiolus. Part of the venous radicles of the soft tissues of the cochlea enter the lamina spiralis ossea through the foramina upon its surfaces and in the habenular, and form the spiral venous sinus, which receives the branches from the vestibule, escapes from the base of the cochlea into the internal auditory canal, and, passing out of its meatus, joins the inferior petrosal sinus. A few other radicles from the soft tissues of the cochlea form a trunk, which passes out of the tympanic scala THE VESSELS. 61 through the aquaeductus cochleae, escapes from the little triangu- lar pit upon the base of the skull in front of the jugular foramen, and joins the inferior petrosal sinus, or the jugular. A tubular membrane accompanies this vessel from the tympanic scala to the base of the skull, and is said to furnish an outlet for the lymph of the cochlear canal. Thus the vestibule and cochlea have each two sets of efferent vessels, so that, should one set be obstructed, the other would probably be able to carry off the venous blood. Lymph spaces and lymphatics have been demonstrated in the internal ear. A tubular process of the dura mater passes through the aquaeductus vestibuli and divides into two branches; one communicates with the utriculus, and the other with the sacculus, as before described; so that the cerebro-spinal fluid can ebb and flow from the surface of the brain to the cavity of the vestibule. A tubular membrane is prolonged from the dura mater into the curved portion of the aquaeductus Fallopii, which is probably a lymph space of like character. The dura mater lines the internal auditory meatus, and is continuous, with the periosteal lining of the foramina in the bottom, and with that serous modification which covers the walls of the labyrinth, so that the cerebro- spinal fluid can flow into the internal auditory canal and the labyrinth, helping to supply the perilymph, which surrounds the saccules and semicircular canals, and fills the scalae of the coch- lea. From the lower end of the scala tympani, a tubular process of membrane leads downwards through the aquaeductus cochleae to the base of the skull, in front of the jugular foramen, and thus furnishes a channel of escape for an overflow of lymph. The discovery of perivascular lymph spaces around the cere- bral vessels, renders it probable that they extend into the internal ear with its bloodvessels; and the lymphatics found in the pia mater seem to indicate that the internal ear is well supplied with them, though few have been yet demonstrated with certainty. Nerves.—The facial nerve arises by a small root from the gray nucleus in the floor of the fourth ventricle in the medulla; it passes outward between the restiform and olivary bodies, and unites with a larger root from the restiform body. It crosses the medulla upon the upper side of the auditory nerve, lying in 62 THE HUMAN EAR AND ITS DISEASES. a depression, goes horizontally in a double sheath with the audi- tory to the internal auditory meatus, where it is anterior to its fellow, and, at the bottom of the canal, gets above it. A few nerve filaments connect the nerves in the canal; the facial now passes through the foramen in the anterior pit of the superior division of the bottom of the canal, and bends backward along the course of the aquaeductus Fallopii. Just here it is increased in size by the addition of several nervous ganglia, which form a reddish swelling that is called the intumescentia gangli- formis. This part of the nerve gives the large petrosal nerve to the spheno-palatine ganglion, and the small petrosal to the otic ganglion, and receives the external or superficial petrosal, a sym- pathetic branch from the sympathetic plexus of the great menin- geal artery. The facial nerve now passes backward, and follows its course down behind the tympanum. When it gets opposite the pyramid of the middle ear, it gives off a fibre that enters the tympanum through a foramen in its posterior wall, and divides into two branches, which are distributed to the stapedius and the laxator tympani muscles. This fibre is sometimes called the tympanic nerve. About 6 mm. above the stylo-mastoid foramen, the facial gives off the chorda tympani nerve, which passes upward in a separate canal parallel with the facial aqueduct, enters 'the tympanum through a foramen in the posterior wall, near the lower outer corner, and passes across the tympanic membrane, and out through the canal of Huguier. The external branches of the facial have already been considered. The internal auditory nerve arises by one root from the trans- verse white striae in the floor of the fourth ventricle, and from the gray matter of the medulla, and by another root from a gray nucleus in the cms cerebelli and the restiform body; this latter has a small ganglion upon it. The fibres unite, and the nerve passes outward between the restiform and olivary bodies, in the same groove with the.facial, but just below it; the two nerves are separated here by a small artery of the bulb. The two nerves soon come together, the facial resting in a groove upon the auditory, and pass in a double sheath nearly horizontally to THE NERVES. 63 enter the internal auditory meatus, where the auditory gets ex- ternal (posterior) to the facial. The auditory nerve has a very thin neurilemma, and is soft and gray. It divides at the bottom of the canal into the cochlear and vestibular nerves. The vestibular nerve presents a small ganglion upon its root, and then divides into three branches: a, a superior branch, the filaments of which pass through the superior group of foramina, behind the entrance of the aquaeductus Fallopii, and enter the vestibule through the superior cribriform spot, to be distributed to the utriculus and the membranous ampullae of the superior and horizontal semicircular canals; 6, a middle branch (inferior), which sends its filaments through the posterior group of foramina below, and through the middle cribriform spot to supply the sac- culus; c, an inferior branch (posterior), whose filaments enter the foramina in the posterior wall of the canal, escape from the in- ferior cribriform spot and are distributed to the membranous ampulla of the posterior semicircular canal. The terminations of these nerve filaments in the membranes have been already described. The nerves float in the perilymph in their passage from the bone to their distribution in the membranes, and their ends are soaked in the endolymph, which washes the epithelium within. The cochlear nerve, at the bottom of the canal, gives off a small branch, which enters a foramen, passes through the wall of the vestibule, and escapes at the lasser cribriform spot, to supply the membranous septum between the utriculus and sacculus. The main portion of the nerve enters the base of the modiolus and lamina spiralis ossea, and continues in canals around and through the axis to the hamular process, distributing filaments in a radi- ating manner outward, between the bony plates of the lamina spiralis ossea and through the habenula perforata, to pass into the ductus cochlearis and the organ of Corti. These fibres form a gangliated plexus just before passing out of the lamina spiralis, and are divided into an inner fasciculus for the inner ciliated cells of the organ, and an outer fasciculus for the outer cells. They pass from the habenula through the granular layer, then each filament goes into the interior of its cell, and the soft axis cylinder mingles its neural elements with the nucleus and protoplasm. 64 THE HUMAN EAR AND ITS DISEASES. Sympathetic nerve fibres from the superior cervical ganglion accompany the vessels into the vestibular and cochlear structures, and regulate the blood-supply. The cerebral surface of the petrous portion of the temporal bone is covered closely by the dura mater, and the tough fibres of the tentorium are firmly attached to its upper edge. The superior and inferior petrosal sinuses skirt the edge of the posterior surface above and below, and join the lateral sinus, Fig. 21. The Eight Ear Displayed (Leidy).—1, Auricle; 2, concha ; 3,4, external auditory canal and meatus; 5, ceruminous gland; 6, membrana tympani; 7 incus; 8, malleus; 9, manubrium of malleus; 10, tensor tympani muscle; 11 tympanum ; 12, Eustachian tube ; 13, superior semicircular canal; 14, posterior semicircular canal; 15, horizontal semicircular canal; 16, cochlea • 17 internal auditory meatus and canal; 18, facial nerve; 19, large petrosal nerve- 20 21 aquaeductus Fallopii. which curves deeply towards the mastoid, and then goes inward and downward to the jugular vein. The close proximity of these large vessels to the ear and mastoid must be remembered in order to appreciate the danger of disease in those parts. The middle lobe of the brain rests in front upon the petrous portion of the temporal bone; the posterior lobe is behind it THE INFANT'S EAR. 65 resting upon the tentorium, and the lobe of the cerebellum below and behind fills the posterior fossa, and is snugly covered over by the tentorium. The Infant's Ear differs considerably from that of the adult which has just been considered, and it is important to the aurist to know what these differences are. The younger the person is, the more cartilage there is in place of osseous structure, and the less developed are the cavities, tubes, and processes of the tem- poral bone. The tympanum is filled at birth by a gelatinous substance, which is said to disappear within the first twenty-four hours of life, and its absence is considered medico-legal evidence of live birth. The bony portion of the external auditory canal is short; the passage from the external auditory meatus to the pharyngeal end of the Eustachian tube is nearly a straight transverse line, and the membrana tympani is so oblique from above, inward, and forward, as to serve almost as a prolongation of the anterior superior wall of the canal. The tympanum lies much nearer the surface of the side of the head than in the adult, and the flakes of bone and cartilage that surround the ear, the mastoid, and the external canal are very thin and delicate and easily perforated. The mastoid process consists of a group of small cells with their long diameters antero-posterior, situated immediately behind the tympanum and the auditory canal, and extending a little above and below the walls of the latter. They are limited externally by the squamous portion of the temporal bone, anteriorly by the posterior wall of the auditory canal, and superiorly by a pro- longation of the thin scale of bone that forms the tympanic roof. The lower cells are a little below the level of the tympanum, and secretions are apt to collect in them and excite inflammation. This anatomical arrangement favors the development of caries, which is prone to excite cerebral irritation and disease by trans- mission upwards through the delicate tympanic roof. The great mastoid of adults is developed behind and below this portion, and is more liable in case of caries to affect the lateral sinus and the cerebellum. The ears of infants and children should be examined with extreme care, as serious results may follow rough or unskilful manipulation. 66 THE HUMAN EAR AND ITS DISEASES. CHAPTER II. PHYSIOLOGY OF THE EAR. The auditory apparatus in man is exquisitely adapted, like all things in nature, to the forces which act upon it. A funnel- shaped external part concentrates waves of sound, and conducts them to a vibratory membrane; this membrane transmits its vibrations by delicately adjusted osseous levers to another mem- brane, attached to the inner end of the chain of ossicles; these corresponding vibrations, like echoes of the first, set in motion fluid contained in a bony cavity beyond the membrane, which surrounds closed sacs, containing fluid, and having nerve termi- nations projecting in epithelium upon their inner surfaces. The fluid within the bone in front of the sacs moves by gentle wraves up one spiral tube in the cochlea and down the other, setting thousands of attuned keys that lie in the membranes between them into quavers, and beats and breaks like mimic surf against the second membrane of the internal ear, to exhaust its force, and to counteract other vibrations that come from the first membrane across the tympanum independent of the chain of bones, and thus to smother, after proper record, all the tones of sound. Delicately and correctly shaped auricles are a thing of beauty, and an attribute of culture and taste. Long, thin, coarse, thick, or misshapen ears generally accompany faulty development in other parts of the body, and are seen in the simple, the ignorant, and boorish. The position upon the head, whether close down or standing far out, has much to do with the impression they produce upon the observer. I have seen them stand out so far that the auricle was in a direction parallel with the face and again so flattened as to be barely visible from in front. The auricle is rarely movable at will in man. The muscles attached to the auricle, both extrinsic and intrinsic, are analogous to very useful ones in the lower animals. Whether civilization PHYSIOLOGY OF THE EAR. 67 has caused their partial atrophy in the genus homo, I leave lovers of speculative philosophy to determine. Man must turn his head instead of his ears to catch the direc- tion and character of slight sounds. The extrinsic muscles act involuntarily to a slight degree in all persons upon the applica- tion of a stimulus, such as an ear douche, or a passage of the electric current. The pinna is drawn upward and forward, and upon the stimulus ceasing, it goes back to its proper position. I have occasionally seen persons move the pinna voluntarily, and it always went upward strongly, a little forward, and then back to its position. It is probable that among the savage and coarsely developed races of men the muscles of the auricle may be so large, as to enable a voluntary movement of the pinna, shaping and di- recting its concavity towards the source of sound. The cartilage of the auricle gives it shape and character, and the auricle as a whole acts as a resonator of sound. Dr. Burnett says, " the region of the helix and its fossa resound to the deeper notes, the antihelix and its fossa to the intermediate notes, and the concha to the high partial tones." If the relations or shapes of the dif- ferent parts of the auricle are altered artificially, or by disease? the action of the organ is modified. He continues, " the auricle, in combination with the meatus auditorius, forms a resonator of a more or less conical shape, closed at the bottom by the membrana tympani, the special function of which is to strengthen by reso- nance those waves of sound which possess a short wave length."* The length of high note waves corresponds closely with the length of the meatus and canal, and of lower note waves with this length augmented by the depth from the border of the meatus to the outer edge of the helix. This depth of ear is increased and the vibrations condensed by pulling the auricle outward, by hold- ing the hand around the auricle, and by the use of a trumpet; thus the natural resonance is greatly increased by those who are deaf or who wish to catch feeble sounds. * The Ear, Its Anatomy, Physiology, and Diseases. By C. H. Burnett, A.M., M.D. H. C. Lea, Philadelphia, 1877. This is a standard work, to which I am indebted for many facts and some excellent illustrations embodied in my book, and I recommend it to all who desire an elaborate treatise. 68 THE HUMAN EAR AND ITS DISEASES. The hairs often seen about the mouth of the meatus serve to shield the canal from dust, and the cerumen always found in a limited amount in healthy ears lubricates the skin and protects the deeper parts from dirt, moisture, and rude winds. This dries and falls out usually, if let alone, as the canal from the place of its secretion slopes downward and outward, and the epithelium of the canal is supposed to move outward during its growth. The auditory canal is the small part of the auricular trumpet, and it aids in the condensation of sound as above described. The membrana tympani receives the vibrations of sound di- rected against it by the external ear and canal. Sound is an impression produced upon the auditory nerve by the vibrations of sonorous bodies. The atmospheric air is usually the medium of transmission for the vibrations, or waves of sound. Noise is a sensation produced by waves of unequal length ; music is one produced by those of equal length. All sounds have the same velocity in the same medium, but no sound is transmitted in a vacuum. Sound moves in the air at a temperature of 61° F. at the rate of 1118 feet per second. As the temperature is lowered, the velocity diminishes a foot and a tenth for every degree. The velocity of sound in liquid is increased over that in air about four and a half times, and in solids from four to sixteen times. Sound has three qualities: 1. Tone, or pitch, is high or low; the more rapid the vibra- tions, the higher will be the sound. 2. Intensity, or loudness, depends upon the height of the vibra- tions ; sounds may be of the same tone, but of different degrees of loudness. 3. Quality is a peculiarity in sound by which one can dis- tinguish between two sounds having the same tone and intensity. For instance, everybody can tell the notes of the flute from those of the clarionet. The number of vibrations, or waves of sound, in a second, that the human ear can appreciate, varies from eight to over forty thousand. The waves are from .029+ to 139.75 feet in length • the length of a wave, or sonorous vibration, is equal to 1118 feet the distance sound travels in a second, divided by the number of vibrations in a second. PHYSIOLOGY OF THE EAR. 69 Very rapid vibrations are very acute in tone, and painful to the ear. It is probable there are sounds in nature too acute for perception by human ears, yet, easily received by the peculiar auditory apparatus of insects and other animals. The waves of sound are conducted against the membrana tym- pani, and set it into rapid vibrations, consisting in rapid depres- sion and restoration. These in-and-out movements of the mem- brane occur regularly, and remind one of the ceaseless agitation of the surface of the ocean. The membrane holds the manu- brium of the malleus in position, and supports through it the entire chain of ossicles, which swing pendulum-like in the tym- panum, and transmit the vibrations received from the tympanic membrane to the membrane in the foramen ovale of the vestibule, to which the foot-plate of the stapes is attached. The tympanic membrane keeps the chain of bones in equilib- rium, and prevents them from being pushed too far in, or dragged too far out, in order, that vibrations may set them into to-and-fro motion with the greatest ease. The membrane protects the structures of the tympanum from foreign substances and the direct entrance of cold air, and transmits vibrations, also, to the air of the tympanum, to impinge against the membrane of the foramen rotundum in the cochlea. The ossicles of the ear receive vibrations from the membrana tympani, and transmit them to the oval window. Their articu- lations and ligaments hold them in position, and permit them to move with great ease through a limited space. They are partially enveloped by a delicate fold of the mucous membrane of the drum, which does not hinder their action. The tensor tympani muscle is caused to contract by irritation of the inferior maxillary, and the facial nerves, acting through the otic ganglion. It is probable that the muscle acts both involun- tarily and voluntarily. It draws the malleus inward and rotates it upon its long axis, so that its posterior border becomes prom- inent outward, and the posterior segment of the membrane ad- vanced, while the anterior border undergoes corresponding de- pression with the anterior portion of the membrane. The muscle steadies the malleus and membrane by its elastic tension, places the membrane in the best condition for vibrating 70 THE HUMAN EAR AND ITS DISEASES. to high notes, and, acting in unison with the palatal muscles which open the Eustachian tube, it assists probably in changing the air within the tympanum. Lucae thinks by contracting, it accom- modates the membrane for low musical notes. The stapedius muscle is the antagonist of the tensor tympani; it holds the stapes in position, and prevents its being forced into the oval window. It contracts with the laxator tympani when the facial nerve is irritated, and acts as a check upon the move- ments of the chain of ossicles, caused by the action of the tensor tympani. Besides the facial filament, it is said to receive another from the motor part of the inferior maxillary nerve. Traction on the stapedius draws the head of the malleus inward, and the lower part of the membrana tympani moves outward. The sta- pedius draws the head of the stapes backward and outward, so that the anterior end of the foot-plate moves outward a little, the long process of the incus is forced outward and its head in- ward, dragging the head of the malleus with it. This moves the malleus handle outward, and relaxes the membrane for low tones. Lucae believes that when it is contracted it accommodates for high unmusical sounds. The normal movement of the foot- plate of the stapes is from y^ to T\ mm. The fixator basis stapedis serves to antagonize the stapedius, and to prevent it from forcing the foot-plate too far into the oval window. The laxator tympani is said not to possess muscular fibres, but to act by elastic tension to hold the malleus in position, relax the tympanic membrane, and thus antagonize the tensor tympani. The membrane of the foramen ovale holds the stapes in posi- tion, limits its movements, prevents the escape of the perilymph of the vestibule, and transmits to the perilymph the vibrations received from the stapes. The membrane of the foramen rotundum, the membrana secundaria, closes the foramen of the tympanic scala and keeps the perilymph within it. It vibrates in unison with the oval membrane, through impulses received from the perilymph, which is continuous from the space around the saccules of the vestibule through the scalae, but its excursions of from T1^ to yff^ mm. are a little later in time. It vibrates, also, independentlv from PHYSIOLOGY OF THE EAR. 71 impulses received from the membrana tympani through the air of the tympanum. These may act directly upon the cochlear fluid and produce sound through Corti's organ. Each vibration in- wards may come between two vibrations outwards, produced by the fluid affected by the impulses from the oval membrane, be- cause the vibrations from the vestibule must come later, than those received directly through the tympanic air, though we must remember that fluids and solids conduct vibrations much faster than the air. Thus both sets of vibrations would be intensified, for a spring moving up or down will have its excursion increased by an added force in either direction, as we see when a buggy- spring breaks, when the carriage body bounds upwards after the wheels have gone suddenly into a deep hollow. If these vibra- tions do not thus alternate and fit together, then those that pass through the air of the tympanum probably act as dampeners to arrest the movements of the oval membrane, caused by the laby- rinthine agitations, in order, to permit a new set to have full effect upon the nervous apparatus. I have thought that, perhaps, the oval and round membranes acted in unison during the passage of the regular periodic vibrations of music, and in opposition during the irregular ones of noise. The mucous membrane of the tympanum covers the tympanic walls and contents, and keeps the cavity moist, and the parts movable. The chorda tympani nerve has nothing to do with the audi- tory functions, but merely passes through the ear to its place of distribution. The facial nerve supplies the motor filaments for the muscles of the tympanum, and sensibility resides in the tym- panic plexus before described. The vessels of the ear are devoted to the nutritive processes, as in other parts of the body. The mastoid cells, with their large, irregular spaces, and the tympanic cavity are filled with air, which is subjected to varia- tions of pressure from the vibrations of the membrana tympani. Low tones cause large movements of the membrana tympani, and considerable pressure in the air of the tympanum; and, as a large tympanum would cause too much resonance, the increase of ca- •72 THE HUMAN EAR AND ITS DISEASES. pacity necessary for the proper reception of such tones is made in such a way, as to interfere least with the vibrations. The Eustachian tube conveys air to the tympanum, and mucus out of it. The pharyngeal mouth of the Eustachian tube during regular respiration moves a little, but does not open by itself. When the vowels are pronounced the mouth of the tube opens downward and forms an oblique triangle. Some authors think the upper portion of the Eustachian tube in a normal condition remains slightly open, that air may escape from the tympanum, when the tympanic membrane is suddenly driven in by great pressure. This permits a slow interchange of air between the throat and the tympanum. Professor Moos believes the tube when at rest is closed for two-fifths its length at its narrower part, and this seems a reasonable state for the functional activity of the ear. The whole tube is opened at each act of swallowing, which per- mits mucus from the tympanum and tube to be worked out by ciliary and muscular action, insures a proper interchange of air be- tween the throat, tympanum, and mastoid cells, and exerts enough counter-pressure upon the inner surface of the tympanic membrane to keep it in equilibrium. The tube opens when great and sudden sounds strike the membrane, and thus prevents shock and injury to the apparatus. The stylo-pharyngeus, palato-pharyngeus, levator and tensor palati, salpingo-pharyngeus, superior pharyngeal constrictor, and the internal pterygoid, are all concerned in opening the Eustachian tube. In contraction, they raise the mouth of the tube upward, then draw the anterior wall forward, the inferior downward, and the posterior backward, and thus open wide the tube. Eminent authorities are in conflict in regard to the part of the process per- formed by each muscle. It seems probable they all have some part to play in opening the tube during swallowing, but the tensor and levator palati muscles are the most important. The tensor and levator palati, acting with the palato-pharyn- geus, perform a very important function in dragging the soft palate back against the pharynx, and then shutting off the naso- pharyngeal space from below, so that air may be driven into the ears through the nose and Eustachian tube. Sound waves are best heard when the tube is closed because PHYSIOLOGY OF THE EAR. 73 when they strike both sides of the membrana tympani they cause confusion and sometimes pain. The cochlear walls protect and contain the most elaborate por- tion of the organ of hearing. The organ of Corti is the aeolian harp, which responds to every vibration of the membrana tym- pani, and furnishes the music of the universe. The ciliated, or hair-cells, of the terminal fibres of the cochlear nerve are moved like the strings of a piano by the blows of sounds, which are transmitted through the membrana basilaris by the fluid of the labyrinth. The cells are grouped and protected by the three thousand arches of Corti, and each one is supposed to be attuned for the reception of a particular tone. The vibrations of music sweep over these hair-cells, as the wind sways the nodding plumes of a wheat field; as the pitch rises, contiguous groups of cells are excited, and there is a harmonious blending of impressions, like the melting of one tone into another, when the loud pedal of the piano is pressed. The cochlear nerve elements have such delicate sensibility, that expert musicians can distinguish a difference between two notes, whose rates of vibration are 1000 and 1001 in a second, only gV of a semitone. Every sound is composed of a number of partial tones, and their number and strength make the difference in notes. One of these tones is the fundamental, and the rest are overtones, or harmonics. Every note sets in vibration that part of the organ of Corti belonging to its fundamental tone, and the other parts corresponding to its partial tones. Noise consists of inharmonious tones, and its irregular vibra- tions act upon the hair-cells of this wonderful organ, as a child plays with piano-keys. The hair-cells deliver their tremblings of sound to the ultimate nerve filaments, that pass through the habenula perforata and down the modiolus to form the cochlear nerve, and this carries its precious messages to the consciousness. The membranous semicircular canals and vestibule undoubt- edly act as a transmitting apparatus of sound to the brain. The presence of fluid around and inside the saccules and canals, the large distribution of nerve filaments to the ciliated cells, the numerous otoliths adherent and lying free upon these, and the 6 74 THE HUMAN EAR AND ITS DISEASES. regular form and position of the canals would seem to indicate great and important auditory functions. In the higher Invertebrates, the organ of hearing generally consists of a simple capsule, with the auditory nerve distributed to1 ciliated epithelium upon its inner surface, and containing one or more otoliths; there are no signs of canals or cochlea. In the Vertebrates, one finds a similar capsule (vestibule) containing otoliths, corresponding to the entire ear of the Invertebrates; while the semicircular canals appear, and are developed more and more in the ascending scale. There are at first in fishes two imperfect semicircular canals (marsipobranchiates), then in higher fishes three (elasmobranchiates), but there are no signs of a cochlea either in fishes or batrachians. If the cochlea is necessary to appreciate musical notes, I would like to know how frogs are able to modulate their merry voices so harmoniously as they do. The cochlea first appears in reptiles as a slightly curved canal without any scalae, except in crocodilia; in birds, it begins to form a spiral, succeeds in the lowest of the mammals (ornithorynchus), and reaches its highest development in man. The semicircular canals are long and narrow in rapacious birds, and large and wide in singing birds,—very significant facts in this connection. All these facts make it certain, that the vestibule and semicircular canals are very necessary for audition, however vivisectionists may deduce the contrary from their mutilating experiments. The perilymph vibrates from impulses received from the mem- brane of the oval window, and sets the membranous saccules and canals, with their endolymph and otoliths, into responsive vibra- tions; these impress the terminal filaments of the vestibular nerve in the saccules and ampullae, and pass along its trunk to the brain. The vestibular nerve, also, transmits to the cerebral centres sensations of the equilibrium of the head and body. Experi- ments upon the lower animals and man indicate, that the endo- lymph moves in certain directions, according to the movements of the head, and impresses the terminations of the vestibular nerve, so that the individual is conscious of the correct position of his head, and mediately of his body, in space. Each semicircular canal has a definite direction, and the meas- PHYSIOLOGY OF THE EAR. 75 ure of the current of lymph depends upon the plane in which the head is turned, and its amount of rotation. Injury of one or more of the semicircular canals causes a loss of muscular co-ordi- nation, and the victim reels and tumbles about in a peculiar manner. Injury of a horizontal canal causes the body to turn around its long axis. Injury of a vertical canal excites a move- ment of the head in a vertical direction, i. e., around its trans- verse axis. These motions sometimes occur in man from disease of the internal ear. Authorities differ considerably in their ex- planations of the phenomena, but, until we have more definite knowledge, the vestibule and semicircular canals must be con- sidered auditory in function, as well as special organs of the new sense of equilibrium. The auditory nerve is composed of fibres much like those of other nerves, but irritation of them produces only sensations of sound. Hearing is the perception by the sensorium of vibrations as sound. The entire ear has for its object to render the propa- gation of sonorous vibrations more perfect, and to multiply them by resonance. We judge the direction of the source of sound by comparison, based upon experience of the intensity of the sound in one ear with that of the other. Judgment becomes difficult in impairment of hearing in both ears alike, and of one ear more than the other. The direction may be determined by one ear alone, if it be turned so that sonorous vibrations strike it at different angles consecutively. Estimation becomes difficult, when objects intervene between the hearer and the source of sound, and more difficult, when the objects are large and present many plane surfaces. The distance of the source is inferred from the intensity of the vibrations produced, but the imagina- tion modifies the effect of the sensations in a measure. Aribra- tions, or their molecular changes, continue awhile in the auditory nerve and its centre after a sound ceases, and persons subjected to a continuous sound for some time, will hear it awhile after the cause has ceased to operate. Different persons have the auditory apparatus attuned to notes of different pitch. One may be sensitive to feeble tones, and not be able to recognize the musical relation of sounds, while another, 76 THE HUMAN EAR AND ITS DISEASES. whose hearing for feeble tones is imperfect, may have a lively appreciation of discord and harmony. Objective sounds come from without, and pass to the auditory nerve through the ear, and, rarely, through the bones of the head. Subjective sounds arise from within, as a result of irritation of the nerve from other causes than sonorous vibrations. Ordinary sounds affect the nerve much like a common sensa- tion, and attract little attention; a musical rhythm causes pleas- ure; an intense tone, pain, and long-continued sounds produce paralysis. Hearing varies with the temperament of the individual; the condition ,of the body, whether fatigued or refreshed; the state of the abdominal viscera; and the different states of the atmosphere. It is influenced by reflex action from parts remote from the ear, and impressions made upon the auditory nerve through the usual channel may excite reflex action in other parts of the body. The auditory apparatus is more complex, even, than the eye, and its functions awaken admiration and astonishment. The ears are the portals of the mind through which much knowledge is gained, and the soul is stirred to deeds of valor and to songs of praise. ANALOGY OF THE EYE AND EAR. Structure.—There are certain parts of the ear and eye which, in structure and function, have a sort of correspondence. The properties of sound and light are analogous, and variations in the two great organs of special sense adapt them to the various requirements of the vibrations which act upon them. The concave surface of the auricle, and the external canal col- lect and direct the vibrations of sound to the drum-head as the expanded cornea, aqueous humor, and pupil gather the undula- tions of light, and transmit them to the lens. The auricular cartilage, tragus-hairs, and ceruminous and seba- ceous glands are comparable to the tarsal cartilage, the cilia the Meibomian and lachrymal glands. The similarity in the shape and functions of the drum-head and the lens is obvious; each concentrates and transmits aerial undulations; but the drum-head and its chain of bones must be ANALOGY OF THE EYE AND EAR. 77 taken together, as the analogue of the lens and its capsule, in order not to destroy the correspondence of deeper parts. Then the bony labyrinth and cochlea, with their inner periosteum, rep- resent the sclerotic and choroid coats; the peri- and endo-lymph, the vitreous; the membranous labyrinth and organ of Corti, the retina. The papillary terminations of the vestibular branch of the auditory nerve may represent the rods of the retina; and the delicate, ciliated cells of the organ of Corti, the cones. Functions.—Normal ears are generally capable of perceiving the distance and the source of sound, the direction from which it comes, and the position the sound occupies in the musical scale. It is well known that some persons are unable to recognize musical notes. In common parlance, " they do not know one note from another." So the ability to determine the distance, or the direc- tion of sound, may be absent, though the deficiency is not so readily recognized. Normal eyes have also a triple function. The retinae readily perceive the distance, the figure, and the color of objects; but any one of these functions may be deficient. Persons are some- times found with acute vision for objects, but deficient in color sense, so that they cannot recognize one or more of the primary colors. The analogy of function between the terminal filaments of the auditory and optic nerves is thus manifest, in the sensibility of the one to the notes of the musical scale, and of the other to the colors of the spectrum; and this throws some light upon the conception of the blind man, who said red was like the sound of a trumpet! Much may be detected in the correlation of nerves, in accord with the correlation of forces. 78 THE HUMAN EAR AND ITS DISEASES. CHAPTER III. EXAMINATION OF THE EAR. Diseases of the ear in general are so complicated by abnormal physical conditions, sometimes the cause, but oftener the conse- quence of the disease, that it is important to detect them, in order to institute those methods of mechanical and instrumental treat- ment, which long experience has demonstrated to be valuable. A moment's examination will often lead to a more rational treatment, and a more successful issue in aural disease, than the most painstaking collation of subjective symptoms. The objec- tive symptoms, found by a systematic examination of the ear from all sides, and all the subjective sensations, must be carefully correlated to get the best results from our therapeutic measures; for remedies are as important as medicines in the treatment of aural affections. A comprehensive knowledge of the pathological condition in aural diseases is acquired by certain methods of manipulation and instrumentation, which should be known by every physician who undertakes to treat diseases of the ear. These methods are simple and require few instruments, and a certain system of examination should be followed, in order, that everything essential may be elicited, and records of cases may be uniform and valuable for future reference. In addition to the record of the examination, the diagnosis ought to be written out sufficiently full to give a clear understanding of the case, and the prognosis should be made guardedly. Never promise too much, because experience teaches that, in treatment of so complex an organ as the ear, one falls short of the mark oftener than one reaches it. Every physician has cases drift back to him, which he has treated years before, and it is often of great im- portance to the patient and to science to have an accurate de- scription of just what was the matter, and what was done in the early treatment. From the case-books of educated, systematic EXAMINATION OF THE EAR. 79 practitioners must the experience of the centuries be gathered, and the advance of medical science signalized. It is well to have a card in the case-book (unless one gets a case-book printed with headings), with a skeleton like the one below, which can be followed in making the record—a plan which I have found convenient and useful. Date. Name. Age. Sponsor. Address. 1. History and subjective symptoms. 2. Hearing: Voice [low, medium, or high]. Watch : R. E. Hw. = L. E. Hw. = Tuning-fork: [meatus, vertex, glabella, mastoid]. 3. Objective symptoms. 4. Aural region. 5. Auricle and meatus. 6. External canal. 7. Membrane or middle ear. 8. Throat. 9. Nose. 10. Eustachian tube. 11. Diagnosis. 12. Prognosis. 13. Treatment. 14. Result. Many of these divisions may be left out in simple cases, as in recording attacks of eczema of the auricle, but I advise the sys- tematic method to be followed pretty closely, in order to get a complete knowledge of the pathological condition. It is convenient at the office to seat the patient in a revolving chair, with his back to a table upon which the light and instru- ments are arranged, or the chair may be placed so that daylight may be used, and the table be located between the patient and the window. A high chair is very convenient for young children. A large oil lamp, or gas with the argand burner, furnishes plenty of light, and I prefer the latter to all other apparatus, as sufficient for thorough examination, for correct appreciation of tissue 80 THE HUMAN EAR AND ITS DISEASES. changes, and little injurious to the surgeon's eyes. Daylight is very agreeable, and gives the true color of tissues when one uses a magnifying speculum, and, if one is inclined to display and luxury, a Tobold's lamp with its arm mirror and condensing lenses can be both ornamental and useful. Bright sunlight di- rected into the meatus is now seldom employed in aural practice. In visiting patients at their homes, one can find sources of illumi- nation enough for most purposes. It is better for the physician to sit during the examination, and the light should be behind and beyond the patient's head, so that it may pass to the mirror, and be reflected at a small angle back into the ear. The history and subjective symptoms as given by the patient should be recorded, and the physician should by leading ques- tions supply missing links in the chain of testimony. The tem- perament, condition of general health, and the presence of any dyscrasia should be noted before proceeding to the more par- ticular examination of the ear. Ask about sore throat, coryzas, and chronic catarrhs, the use of tobacco, and if deafness is hered- itary. Objective symptoms should next be gathered. Test the hear- ing of each ear by the voice, watch, and tuning-fork, and make a careful record as directed farther on. Then look carefully at the auricle, meatus, and region about the ear, and record any- thing that seems abnormal; push the hair a way from around the ear, then run the index and second finger around the attachment of the auricle, pressing firmly in front of the tragus, beneath the lobe, and over the mastoid to find if any soreness is present. If tumefaction is seen, the pressure should be delicate, and its outlines and relations to the meatus or mastoid process should be determined and recorded. The mastoid process must be carefully examined for tender- ness, redness, swelling, and scars, and sometimes it is well to percuss the part with one index finger for a plexor, and the other laid flat upon the bone as a pleximeter, as thereby deep-seated pain indicative of disease may be awakened. Some enthusiasts have claimed to be able to determine the condition of the mastoid cells by percussion sounds, but cases OTOSCOPES. 81 that would give any response to such striking questions are ex- ceedingly rare. It is instructive to take the auricle between the fingers and double the top and the lobe together closely, then move the whole pinna and meatus around by a rotary motion, as this often reveals a soreness not otherwise to be discovered. Sore- ness and pain may exist in and about the auricle from external affections, without there being any deeper trouble of the ear; but, conversely, deep disease of the ear is frequently accompanied by external soreness and pain. Take the auricle by the upper part and pull it upward and backward, which straightens the external canal considerably, then examine the meatus and canal by direct light, and then by re- flected light from a mirror. Otoscopes.—There are several kinds of reflecting mirrors, or otoscopes, in use. They are generally concave, from 1\ to 2>\ inches in diameter, with a central round perforation T3g to \ of an inch in diameter, and a focal length of 6 to 12 inches. The hand- mirrors are firmly set in a metal back, and attached to a wooden handle by a rod, screw, or hinge. I have one purchased in Berlin, such as is used by most medical men in Northern Germany, which has a hinge, and possesses some advantages over others. Another larger one, bought in Vienna, has the handle screwed firmly into the back. Fig. 22. Hand Mirror, or Otoscope. A piece of looking-glass, with a clear place scratched in the mercury, would serve well in an emergency. The ophthalmo- scopic mirror illuminates tolerably, but some kind of a hand otoscope is a necessity for every physician who treats ear disease. 82 THE HUMAN EAR AND ITS DISEASES. In some cases it is necessary to have both hands free for handling instruments and performing operations, and, yet, one must have a good illumination of the external canal, tympanic membrane, and, perhaps, of the tympanum. For this purpose, a similar mirror to that described above is attached by ball and socket joint, hinge, screw, clamp, or other contrivance, to a plate, fastened upon an elastic band, which fits around the head. Some of these are not perforated in the centre, and are to be placed in the middle of the forehead; others hang low over the brow, so that the central perforation is directly in front of the eye. Fig. 23. Forehead Mirror. A single mirror is now made to serve for both hand and head otoscope. A handle is screwed into a ball upon its back for hand use, and this is unscrewed and the ball slipped into a socket upon a plate, fastened to an elastic band, for head use. A man busy in aural practice will require both kinds as separate instruments. The use of an otoscope is simple. The best illumination will be had when the light is accurately focussed upon the part that one wishes to examine, and the observer's eye is placed behind the central hole, through which rays return from the object. There are several other otoscopes of use occasionally. Blake's otoscope has a large rubber speculum, fitted with a prism and condensing lens, which gives excellent illumination, and permits one to use both eyes in direct vision. Hassenstine's otoscope is a hard rubber cylinder, with three different sized tubes for the auditory canal. It has an opening OTOSCOPES. 83 in the side, through which the light enters, and is reflected by a mirror through the tube and lens, so that the eye, placed at the external end, receives an enlarged image of the object. Fig. 24. Hassenstine's Otoscope. Brunton's otoscope is upon the same principle. It is made of white metal, silver or nickel plated; has three funnel-shaped tubes of different sizes for the meatus, a magnifying eye-piece, and a large trumpet-mouthed projection upon one side, which con- centrates light upon an obliquely placed mirror that reflects it down the tube. It is a handsome and costly instrument, but it Fig. 25. Brunton's Otoscope. gives excellent magnified pictures of the membrana tympani or middle ear, and is very useful in studying minute changes in the membrana tympani and tympanum. For general use and practical purposes, however, the hand- head mirror and tubular specula will answer, since it is not so difficult to diagnose as to properly treat ear affections. The light from the mirror should be thrown into the external auditory meatus; and the presence of any extraneous bodies, 84 THE HUMAN EAR AND ITS DISEASES. matted hairs, and hardened cerumen, and the condition of the skin- lining of the canal should be noted. After examining the outer part of the canal, a conical silver speculum, warmed over the flame in cold weather, should be introduced into the meatus by turning it around and pressing it inward gently by a screw movement with the fingers, while the auricle is pulled upward and backward by the other hand to straighten the canal. If the canal is very nar- row, one may have to use a bivalve speculum. Any obstruction at the inner end should be examined, and, if abnormal, should be removed by syringe, ear-spoon, or forceps, or avoided by turning the speculum aside a little. The speculum should be held in position in the meatus between the thumb and forefinger, the latter pushed well into the concha Fig. 26. Illuminating the Ear. and the auricle pinched between the forefinger and the other fingers placed behind it. It can then be pulled upward and back- ward to straighten the canal, and moved about to favor different views through the speculum and canal, as the light is reflected deeply into the ear. It is recommended to use the left hand for the right ear, and the right hand for the left ear; the index finger fits thus very well into the concha, and the speculum and auricle can be handled to advantage, but this has the serious disadvantage sometimes of obstructing the light from behind, when the mirror EAR SPECULA. 85 is held in the other hand, but of course this need not occur when the head mirror is used. I use the right hand for the right ear, and the left for the left ear, when the hand mirror is em- ployed, and thus keep a clear course for the passage of light from the flame behind, and find it just as convenient to handle the speculum and auricle as by the old method. The auditory canal being illuminated, the state of the skin of the canal, the color, shape, and condition of the membrana tym- pani, the presence of perforations or polypi, the presence or ab- sence of the ossicles, and the amount of vascularity of the parts, should be ascertained and recorded, with a detailed description of the pathological changes visible. Ear Specula.—An ear speculum is needed to dilate the audi- tory canal, crowd hairs out of the lumen, and push the tragus for- wards. They are of a variety of shapes, sizes, and materials. Some are made of hard rubber, some of porcelain, and others of coin silver. The rubber and porcelain are not good illuminators, but are economical and useful when it is necessary to make me- dicinal applications to the deep parts of the ear. Fig. 27. Wilde's Tubular Ear Specula. The silver specula are the best illuminators, and are used for diagnostic purposes by all specialists. Specula are from an inch to an inch and a half in length, have an opening at the smaller end from 3 to 6 mm., and at the larger end from 12 to 18 mm. or more in diameter. They have the shape of a hollow cone, or of a funnel, and sometimes are compressed so that the lumen is oval instead of round. The small end is smooth, the large end is 86 THE HUMAN EAR AND ITS DISEASES. beaded, and both surfaces are bright, though Gruber has fostered a speculum with a blackened interior. " Wilde's tubular," or straight-sided, conical, silver specula, three in a set, and Knapp's funnel-shaped silver ones in three sizes are the best. Either set will be all that a general practitioner re- quires. They take up more room than a bivalve, are apt to wound the canal if pushed in roughly, often push a ring of cerumen ahead Fig. 28. Knapp's Funnel Ear Specula. of them, and are not suited for very crooked canals, or for those compressed from front to back. There are self-retaining specula, having two valves, a hinge and screw, which are very useful during operations, when one wishes to use both hands. Of these Spier's is the best. Fig. 29. Spier's Self-retaining Speculum. There are bivalve-dilating specula with handles, such as Kra- mer's and Tiemann's, used for opening and dilating very crooked EAR SPECULA. 87 or narrowed canals. The valves of these should be placed upon the anterior and posterior walls, and the handles compressed gently. These are not often required, and belong more to the outfit of a specialist than to that of the family doctor. Fig. 30. Kramer's Bivalve Speculum. Siegle's pneumatic speculum is a short hollow cylinder, having three sizes of graduated tubes for insertion in the auditory meatus, which screw on to one end. The other end is closed her- metically by a clear glass lens. From the side of the cylinder, projects a short tube, to which is attached a piece of rubber tubing, with a mouthpiece or an air-pump. Fig. 31. Siegle's Pneumatic Speculum. The proper graduated tube to fit the auditory canal under ex- amination is screwed on, and is introduced air-tight into the canal. When this is difficult, a perforated rubber cork fitting the canal may be slipped over the tube. The mouthpiece is placed in the mouth, or the air-pump held in the hands. The membrana tym- pani is now illuminated by throwing the light from a mirror through the lens closed canal, and the air is rarefied by suction of the 88 THE HUMAN EAR AND ITS DISEASES. mouth or pump. This causes the membrane, if free, to move out- wards, owing to the vacuum produced upon its surface. Sometimes it is well to inflate the tympanum before using the speculum. By alternately exhausting and condensing air in the canal, a to-and- fro movement may be produced in a part or the whole of the membrane. With exhaustion, the malleus handle goes forward, with condensation backward, and its free movement, with that of the membrane above the short process, will indicate free move- ment of the malleo-incudal articulation, and probably of the chain of ossicles. One can, also, get a tolerably accurate knowledge of the amount of depression of the membrane, and the adhesions present. Fig. 32. Blake's Middle Ear Mtrror. I have used this instrument with the mouthpiece, which I prefer, to produce the to-and-fro movement in the membrane for a minute or two—a kind of aural gymnastics—and am sat- isfied it has aided in breaking up adhesions and improving the nutrition of the membrane. The instrument should be used cautiously, when perforation of the membrane is suspected, in order to avoid drawing mucus or pus into the mouth. When the Eustachian tube is impervious, Siegle's speculum is very necessary in making a diagnosis of the pathological changes in the membrane and middle ear. Blake's middle ear mirror is another instrument recommended TESTING THE HEARING. 89 in the examination of diseased spots in the auditory canal and middle ear. It consists of a set of polished steel mirrors from \\ to 3 mm. in diameter, fastened at an obtuse angle to wires, which when needed are fixed into a handle and secured by a screw. The light from the head mirror is reflected into the small mir- ror and the deep parts of the ear examined, as is done by double reflection in other regions. The auditory canal must be large to permit the use of this refinement, but it may be useful in reveal- ing hidden granulations, the exact seat of a polypus, or a carious place behind a projection. Testing the Hearing— Voice.—The aurist tests the patient's hearing indirectly for the voice during conversation as the first step of the examination, though not designing to do so; but this way is not entirely reliable. It is best to stand a few feet away from the patient upon the side of the ear to be tested, so that he cannot see the lips move, then ask him questions in a low voice. If he cannot hear, address him in a medium tone, and if he is still unable to hear what is said, raise the voice even to a shout if necessary. There are various degrees of hearing for each tone, but low, medium, and high will be sufficiently exact for all practical purposes. Watch.—The watch test is the most generally used, because we can test a watch and learn how far a normal ear can hear its ticking, and thus get a basis for an accurate record. One may use a special stop-watch, or an ordinary time-keeper. The stop- watch can be stopped and set a going at will, and is valuable in testing children and others, who think they hear when they do not, from a sort of persistence of sensation, after the watch is cov- ered or removed. One can use the ordinary watch for detection by simply turning the back of the hand holding it to the ear tested. It must be remembered that the auditory nerve some- times ceases to respond—does not hear for a moment—owing to fatigue induced by constant repetition of the same sounds. The sensibility of the nerve is somewhat blunted in old people. The watch must always be held by the hand, in the same way, in making comparative tests. It makes considerable difference whether one hangs the watch by the finger, or holds it in the 7 90 THE HUMAN EAR AND ITS DISEASES. palm of the hand with the whole hand as a resonator. Hold the watch in the palm with its face towards the hearer's ear, say six feet distant, then approach slowly, and learn how far by actual measurement all your friends with normal ears can distinguish the ticking; take the average of these distances and remember it as the normal hearing distance for that watch, to be used as the denominator of a fraction, to express the hearing capacity of patients. In testing a patient, hold the watch six feet away from the ear, having the other ear closed by the finger, approach it gradually until the patient can catch the sound, then measure the distance from the ear by a tape-measure. Suppose a watch can be heard by most persons at sixty inches, and a patient hears it only at twelve; this gives the denominator and numerator of the fraction, and the hearing is |f, or \ of normal; or suppose the watch is heard only six inches; this gives g6^. Make a record R. E. Hw. (right ear, hearing of watch = s%, or L. E. Hw. gV In this way one can record the hearing at each visit, and get a mathematical demonstration of the progress made, when the patient makes any. Some deaf persons can hear the watch a foot away, and, yet, hear only medium tones of voice; others can hear the watch, per- haps, only six inches, yet, understand everything said in a low voice. This difference is due to temperament and close attention. It is not difficult to understand a sentence if we hear three words out of four, and know something about the subject; long words are equal to four or five short ones to a deaf person. Sometimes a person gets, however, " all at sea " lip-reading. I had an amusing instance of a deaf patient's prepossession of the greeting of an ac- quaintance. Two ladies met. The one not deaf said to the other: " Why, when did you return from the mountains ? " The deaf one replied: "Pretty well, I thank you; how do you do?" When the watch cannot be heard at any distance, it should be pressed against the auricle, and, if heard then, the record should be made, Hw. = B% (contact). If not heard at all, write = e°ecause obstructions to the passage of sound through the tym- panum inward, also, act to prevent its diffusion and loss outward. The fork must be on the middle antero-posterior line of the skull, because if moved to one side the sound may go partly into the meatus of the ear of that side. The vibrations will, also, act stronger upon the opposite more distant ear, because they then move nearer perpendicular to its membrane, than they do to the one upon the near side. Thus the increase of sound in the near ear from proximity, may be counterbalanced in the distant one by approach to perpendicularity in the direction of the vibrations. If the tuning-fork is heard distinctly when vibrating upon the skull, we may conclude that the labyrinth and auditory nerve are healthy. Just in proportion to the diminution in intensity of the sound from the osseous vibrations, is the departure from health of the internal ear or nerve. When the vibrations are not perceived at all on one side, we may be sure on that side the labyrinth or the auditory nerve is seriously diseased; and, in the absence of cerebral symptoms, and the absence or presence of middle ear disease, it is tolerably certain that the disease is in the labyrinth, affecting, of course, the terminal filaments of the nerve. Cerebral disturbance, and absence of aural symptoms, except deafness, indicate disease of the nerve, the medulla, or con- tiguous structures. Roosa says, " Cases of diseases of the middle ear that are con- nected with disease of the labyrinth, or cases in which the middle ear is sound on one side while the nerve is affected, and just the opposite state of things exists on the other side,—that is, the middle ear is diseased and the nerve sound,—will of course render the value of the tuning-fork less positive, and a differ- ential diagnosis difficult."* If one labyrinth or nerve only should be affected, of course, the vibrations would be heard in the other ear. If both labyrinths or nerves should be affected, they would be heard best in the ear least diseased, provided there were no middle ear or external canal * A Practical Treatise on the Diseases of the Ear, including the Anatomy of the Organ. By D. B. St. John Koosa, M.A., M.D., etc. William Wood & Co., New York City, N. Y., 1873. 94 THE HUMAN EAR AND ITS DISEASES. disease. Should both labyrinths or nerves be diseased, and the conducting apparatus of one side be affected, that side might re- spond best to the vibrations, even, when its labyrinthine structures were the most affected, for we know that obstruction outwards intensifies vibrations through the cranial bones. It is evident that one must have his wits about him, and be very careful in his use of the tuning-fork, if an examination is to cast light upon obscure cases. The Acumeter is an instrument constructed somewhat after the principle of the Blake fork, and designed to be used in its place for testing the reaction of the auditory nerve, both through the canal and by means of the cranial bones. It consists of a steel cylinder, 4 mm. in diameter and 28 mm. long, fastened at right angles to a vulcanite columnar body, Fig. 34. The Acumeter. which is held between the index finger and thumb. There is a slot in this body, a little removed from the foot of the cylinder, in which moves a wire handle of a steel hammer, that strikes the cylinder near its end. The movement of the hammer is arrested at a certain point by a shoulder, so that the blows and the sounds it makes are uniform. Another wire rod, having a disk upon one end, is fitted to the body at a right angle to the hammer. The disk is placed against the head to test the bone conduction • but without the disk the instrument serves as a producer of sound to test the tympanic apparatus. Cleansing the Ear.—The external canal frequently contains dirt, unhealthy cerumen, epidermic scales, projecting hairs, in- CLEANSING THE EAR. 95 spissated pus, etc. Sometimes the canal may be tolerably clean, and a perforated or partially destroyed membrane be covered by pus, which fills the tympanum and hides the parts. It is fre- Fig. 35. Q.1\t>fcMtH 6. CO Cotton Holders. quently necessary to remove much offensive matter before a spec- ulum can be used in the canal with any satisfaction, and there- Fig. 36. B.TIEMfiM a CO- Ear-spoon and Hook. fore cleansing measures are necessary. Particles and pieces cling- ing to the canal walls, and not too far within the meatus, may be removed under good illumination by twisting cotton around the Fig. 37. Angular Ear Forceps. roughened end of the cotton-holder, wetting it with glycerine and water, and turning it around in the canal. The ear-spoon and hook, the angular forceps, and Pomeroy's 96 THE HUMAN EAR AND ITS DISEASES. forceps, will prove very useful in the hands of a delicate manipu- lator. They must be used very gently within the meatus, and care be taken not to injure the epidermic and other tissues. When the canal is much occluded, particularly, if the tube con- Fig. 38. Pomeroy's Ear Forceps. tains hardened cerumen or pus in any quantity, a good syringing with warm water will be necessary. Any common syringe will do the work in the hands of an intelligent person, but there are several syringes of especial merit for the use of specialists and those who can afford them. Syringes.—The improved fountain syringe, No. 1, I have used with much satisfaction. It has no valves to get out of order, Fig. 39. Improved Fountain Syringe. is self-acting, the flow is unbroken and steady, and it injects Shut down a clamp upon the tube, then fill the bag and no air. SYRINGES. 97 hang it up, the higher the more force is required; slip in the proper nozzle, lift the clamp, and direct the stream at will. The difference between its action and that of the ordinary piston instrument, is similar to that between a placid brook in a meadow and the stream of an old town pump. It is especially suitable for children, who are so easily made frantic by any irregular and energetic movements about the ear. The cheap bulb syringe and the more expensive Davidson's are next to the fountain for mere cleaning purposes. At my clinic Fig. 40. Hard Rubber Ear Syringe. at the Children's Hospital (Twenty-second and Locust streets, Philadelphia), I used a bulb syringe, connected with another bulb by tubing, so that pressure upon the lower one kept up a steady flow from the nozzle; the combination sending a continuous stream of water, as the double bulb atomizers do of spray. The glass syringes are an abomination and a snare to the uninitiated. A Fig. 41. Kramer's Ear Syringe. hard rubber syringe, of one-half or one ounce capacity, is necessary for every well-regulated family, and is very useful in cleansing the ear. It is essential to have a small nozzle, so that a fine and forcible stream of water may be thrown close to the canal wall for the removal of hardened cerumen and foreign bodies. The 98 THE HUMAN EAR AND ITS DISEASES. one I prefer has a shoulder for the first two fingers, and a ring for the thumb, and can be easily managed by one hand. Kramer's syringe has two side rings for the first two fingers, a piston ring for the thumb, and a graduated nozzle for the catheter. It is easily handled, and a favorite with many aurists. One of the best hard rubber syringes for the ear is the Uni- versal, an ounce syringe, with a ring on the piston for the thumb, and a projecting shoulder at the bale for two fingers. It has a variety of rubber and German silver tubes, two of which fit the catheter; quite a forcible stream can be thrown with it, and it is the most useful instrument for syringing out foreign bodies, Universal Syringe. impacted cerumen, and scales of epidermis. The vulcanite syr- inges should have one blunt-shaped nozzle for general use. Syringing.—It makes a great deal of difference how one uses a syringe. Loose dirt, pus, scales, and pellets of cerumen are re- moved from the auditory canal by simply directing the stream from any common syringe into the meatus. When the contents are obstinate, and one has picked out with the spoon and forceps all that is easily removable, the syringing must be vigorous and the stream directed with care. For this purpose, the hard rubber syringe with a small nozzle is the best. The water had better be warm, and be kept in a special vessel; the first syringing should SYRINGING. 99 be very gentle, and the process not too long continued at one sit- ting. It is well to have a small gas-stove handy to heat water rapidly when needed, though not too cold water may be used without much risk of exciting inflammation. Put a clean towel around the neck and shoulder upon the side to be syringed, tuckr ing it in to protect the patient's clothes. Fig. 43. G. TI EM ANN & CO. Ear-bowl. Give the patient a finger-bowl, a common china bowl, or tin cup, to hold against the side of the neck, under the ear, to catch the escaping fluid; an assistant is needed to do this if the patient is a young child. There are special ear-pans recommended, but except the one figured above they are abominations. An ear-spout may sometimes be used to advantage. Fig. 44. Ear-spout. Introduce the nozzle about half an inch into the meatus, direct the stream of water into the canal, and continue injecting until the canal seems clear. It is best to examine with speculum and mirror every minute or two, so that should opposing material be removed, one may stop the syringing and prevent injury to the membrane. To in- sure thorough work, draw the auricle upward and backward to straighten the canal, and direct a strong stream close against the upper canal wall. This will be necessary, particularly, for very 100 THE HUMAN EAR AND ITS DISEASES. hard cerumen and foreign bodies. One may assist their exit occa- sionally with spoon and forceps; their careful use is frequently necessary and permissible, notwithstanding the strong counter- teaching of some authors, who condemn this manipulation, be- cause instruments in the hands of rough and injudicious men have done injury to the auditory canal. Patients frequently become vertiginous from the syringing, par- ticularly after the membrane or middle ear receives the stream unbroken by any intervening substance, and, rarely, a patient may vomit or faint away, so that one must be prepared for squalls, and have a basin and a reclining chair handy. I have had a few pa- tients who were obliged to recline during the operation. Fig. 45. No person can syringe his own ears well, and when cases must of necessity be treated at home, the operator must be carefully in- structed in the details of the procedure. Only the initiated suc- ceed well. After syringing, the ear should be wiped with the end of che towel, and a finger covered with it pressed well into the meatus the head being a little bent towards the affected ear, in order to absorb the surplus water. If the examination through the spec- ulum shows any remaining water, or there be shreds and particles of pus remaining in the canal or tympanum, they should be care- fully wiped out with pieces of cotton twisted around the cotton- holder. The absorbent cotton of the shops is an excellent article INFLATION AND AUSCULTATION. 101 it greatly facilitates thorough cleansing, and is now largely used in aural practice. After thorough cleansing of the canal, illumi- nate it well with the mirror and speculum, and examine it care- fully. When the membrana tympani is intact, note its color, trans- parency, translucency, vascularity, mobility, adhesions, and other conditions. The appearance, position, and mobility of the manu- brium of the malleus ought to be carefully observed. The Siegle speculum should be applied to determine the mobility of the mem- brane, and position and extent of adhesions. Other means and instruments are necessary to find out the condition of the middle ear and Eustachian tube. Inflation and Auscultation.—Aural patients owe a debt of gratitude to Dr. Politzer, who introduced a simple, painless method of opening the Eustachian tube and filling the middle ear with air. Fig. 46. Politzer's Air-bag. The Politzer Air-bag consists of a firm, compressible rubber bag, either oval or pear-shaped, with a small hole in the base, and a slender nozzle on the opposite end, which is attached by a short piece of rubber tubing to a tubular nose-piece of hard rubber, 8 cm. long and 5 mm. in diameter, and slightly curved at the distal end. This nozzle may be put in the inferior meatus of the nose, but patients do not like it, and I substitute for it an olive-shaped hard rubber nozzle, or a beak-shaped glass nose-piece, which just fits the anterior nares. Inflation is just as successful with them as with the original nose-piece, and there is no pain caused, as neither goes far enough into the meatus to press against the turbi- nated bone. Sometimes during inflation a little air goes through the lachrymal passage and makes a queer sensation, but I have 102 THE HUMAN EAR AND ITS DISEASES. never known any harm to be done by it. One patient said he felt as if his nose was growing, which led to the discovery that his left lachrymal sac was considerably distended at each infla- tion. An auscultation tube, for use with the air-bag, or any other method of inflation, consists of a piece of soft rubber tubing from eighteen to thirty-six inches long, with a small bone, or hard rubber perforated tip at each end. One end is placed in the patient's and the other in the surgeon's ear. The tips are usually straight, but the one for the surgeon's ear should be bent a little, so that it may be better retained in position. Dr. Burnett recom- mends a tube a yard long, so that one end may be inserted in Fio. 47. Auscultation Tube. one ear of the doctor, and the tube go around back of his neck to the opposite side, and then direct to the patient's ear. A tube applied in this way is more liable to remain in position, than when entirely upon one side. Cover the patient's chest by a towel tucked under the chin, fix the auscultation tube in proper position in the ears, give him a mouthful of water, and tell him to hold it and swallow at the word. Now push the nose-piece of the air-bag into one of the patient's nostrils, in the direction of the inferior meatus and a little away from the septum, hold it firmly in position and close the other nostril with the thumb, or press the ala? of the nose firmly with the thumb and index finger. Grasp the bag firmly, with the thumb placed over the hole in its base, say, " Swallow!" and the next moment compress the air-bag vigorously and notice the sounds which come from the auscultation tube; then take the INFLATION AND AUSCULTATION. 103 thumb from the hole and remove the nose-piece. When inflation succeeds, there is often a clucking sound mixed with various rales, heard by both patient and physician, and the former experiences a fulness in the ears. I explain that I wish to blow a little air through the nose, and it will not hurt, but only feel peculiar. It is well to blow gently the first time, especially with children, in order to insure confi- dence. Both ears will usually be inflated by this method. To diminish action upon one ear, stop its meatus firmly with the finger. This seems to have some effect by reflex action in hinder- ing opening of the Eustachian tube. Turning the head towards the shoulder of the side you wish to protect will sometimes do it. Fig. 48. Inflating the Ear. A certain way of limiting the action to one ear is to inflate through the Eustachian catheter, and this will be desirable when the other ear is in a normal condition. When a person swallows, the palatine and pharyngeal muscles, not only open the mouth of the tube, but they draw the soft palate back against the posterior part of the pharynx, and shut off the naso-pharyngeal space above from the throat. In a normal condition, air enters the ear with each act of swallowing. The air from the bag is condensed in the nasal fossse and the superior portion of the pharynx, and, stretching the walls, forces apart the lips of the Eustachian tubes and rushes through them " 104 THE HUMAN EAR AND ITS DISEASES. to fill the tympanum. A blast of air in one nostril is likely to affect one ear more than the other. Often this is on the same side as the nostril used, occasionally on the opposite side. I have found dry deglutition, or the swallowing of a little saliva, some- times to insure inflation when swallowing water did not, probably owing to a closer contraction of the throat muscles. Instead of swallowing, one may use what I call the educational method. In this the patient keeps the mouth wide open and the head back, and as the bag is compressed he ejaculates in a guttural manner the words, hie, haec, hoc, hunc, hanc, hoc (hick, hank, hunk were the words recommended by the physician who first suggested this method). Each method may be tried until success crowns the effort. Occasionally a patient will not be able to keep the soft palate back against the pharynx, but it will yield, burst open, and air will distend the cheeks and escape from the mouth, or go down the throat. Then there is usually a failure to inflate. To obviate this, I make the patient bend the head far backwards during the use of the bag. If this fails, I have him turn his head sharply over one shoulder, and give him a blast in both nostrils as he swallows; then let him turn his head over the other shoulder, and give him another double blast. These positions change the relations of the trumpet ends of the tubes with reference to the posterior nares. By these manoeuvres I have often succeeded when simpler measures failed, and thus avoided the use of the catheter, which is so much dreaded by most patients. The Valsalvian method is another way of inflating the middle ears, which many ear patients will be found to know all about. The patient takes a deep inspiration, closes the mouth, puffs out the cheeks, holds his nostrils closed, and forces air upwards from the lungs to fill the mouth, throat, and nose. This is a convenient method for the doctor, who should observe the motion and appear- ance of the membrana tympani during the experiment. The air does not go so directly and forcibly, and the manoeuvre is not so beneficial in removing mucus, dilating the tubes, and airing the middle ear, as when the air-bag fills by a sudden blast the naso- pharangeal chamber and tympana. The congestion of head and ears, owing to the suspension of respiration, sometimes really injures INFLATION AND AUSCULTATION. 105 the ear. It may be used moderately, however, under the physi- cian's directions, but the patient should be warned that he may increase his deafness, if he persists in the measure by himself. The operation by the air-bag should be repeated several times until it is certain the ears have been inflated. One must judge of this by the patient's sensations, by the auscultation tube, and by the increased vascularity and improved position of the mem- brane. He may say he heard a cracking, and that his ears feel stuffed up ; this sensation disappears usually after swallowing. When the membrane is perforated, there is usually a bubbling, hissing, or whistling sound, as the air escapes through the open- ing and out of the external meatus. Deafness to the voice, subjective noises, stuffiness or pain may cease immediately after a successful inflation. The surgeon should inspect the membrane, which, if the opera- tion has succeeded, will show less depression, a more prominent umbo, and a reddening of the vessels along the manubrium of the malleus. The auscultation tube when used during inflation will often determine the question about the opening of the tube, and give one an idea of the size and condition of the tympanum. When the patient swallows, the air-bag is compressed quietly, or the Valsalvian method is employed, the operator listens for any sounds that may come to his ear from the ear of the patient. He will sometimes distinguish a soft hiss, moist crepitation or bub- bling, or a soft dry cracking, both near and distant. When the parts are healthy there is a sound like whoo in a whisper. If no sound is heard the Eustachian tube is obstructed in some way. The soft hiss indicates mucous adhesion of the Eustachian tube and may be followed by whoo, if the tympanum is nearly normal, or by moist crepitation if there is exudation in the tym- panum. If sounds are clear and come quickly, the exudation is thin ; if duller and slower, it is thick and probably in the tube. When there is a dryness of the tympanum, anchylosis of the ossicles, and some movement of the membrana tympani, cracking is produced by inflation. In the open tubes and dry tympana of old persons the sounds 8 106 THE HUMAN EAR AND ITS DISEASES. are rough and rasping. Patients of acute sensibility frequently hear these sounds during inflation, after they get a little used to the shock. The auscultation tube is rather more reliable when the inflation is made through the catheter. Vertigo is not uncommon after inflation. Shocks may occur when adhesions in the tympanum give way, as air is foreed vio- lently into it for the first time. A patient once fainted in my office from such a cause. She heard a tearing sound .and felt sharp pain in the ear. In treating infants, the ear may be inflated easily. A simple rubber tube with a mouth-piece in one end and a perforated tip in the other, much like the diagnostic tube, should be used in- stead of the air-bag apparatus. Have the child held, take the mouth-piece in the mouth and put the tip in the patient's nostril, compress both nostrils with tip retained and blow steadily. The child will cry, inhale, choke a little, draw the soft palate back, then swallow and the peculiar gurgle will indicate that the deed is done. One may verify the operation by examining the mem- brane when possible. Older children will readily submit to the air-bag after a little coaxing and gentleness on the part of the physician. The air-bag alone should not be used in acute rhinitis, acute angina, ulceration of the nasal fossse or in cleft palate. It is a blessing to the aurist, at least, that young children are not brought in crowds to be treated for ear diseases, because un- less they are anaesthetized, it requires about three persons to put each one through an ordinary examination. It is a curse to them, however, not to be treated, as older patients in clinics and deaf and dumb asylums show. Examination of the Throat.—The Eustachian tube, nose, pharynx and throat should be inspected in every case of aural disease. Have the light stream over the shoulder of the patient from behind, put on the head mirror, reflect the light into the throat, hold the tongue down with a tongue depressor in the left hand, and look at every part of the post-oral region. The size and condition of the tonsils, the position and action of the palato- pharyngeal and palato-tubal muscles, and the appearance of the EXAMINATION OF THE NASO-PHARYNX. 107 mucous membrane and glands of the throat and pharynx should be noticed. Tell the patient to say aye, and a little higher view of the pharynx may be obtained, but to see the upper portion of the pharynx, the mouths of the tubes, and the posterior parts of the nasal fossae, a rhinoscopic mirror must be used. A set of round or oval silvered glass mirrors backed by metal and from \ to li inches in diameter is desirable. Each mirror is attached Fig. 49. Rhinoscopic Mirrors. at an angle of about 120° to a strong wire stem, and when one is needed it is slipped into a universal handle and fastened by a set- screw. Examination of the Naso-Pharynx.—Seat the patient back to the light, with the head bent backwards, and reflect it into his Turck's Tongue Depressor. throat by hand or head mirror. Select the mirror to suit the case, by estimating the space between the velum and the pharynx, and fix it in the handle by the screw. Take it in the right hand, as the pen is held, warm it slightly by holding the glass surface over the burner, so that the vapor of the patient's breath will 108 THE HUMAN EAR AND ITS DISEASES. not cloud it, and introduce it into the throat with the angle hori- zontal. Have the patient hold the tongue by the tip, or with a Fig. 51. Tongue Depressors. tongue depressor, or the surgeon may hold it with the depressor, or the handle of the mirror. When the mirror reaches the phar- Fig. 52. Examination of the Pharynx. ynx, hold it close to the pharyngeal wall, but not touching, re- flect the light into it from the large mirror, turn it upwards EXAMINATION OF THE N ASO - PHARYNX. 109 and around in different positions, and observe the pictures therein. The mirror should be held steadily and not titillate the parts or gagging will result. If the uvula is too long, a slip noose should be passed around it, then draw it forwards and fasten the thread between the incisor teeth; in some cases it may be cut off. If the tonsils obstruct the round mirror, use a small oval one. If the palate goes back too much, have the patient breathe only through Fig. 53. Examination with Tobold's Apparatus. the nose. This is difficult, but is facilitated by keeping the jaws very wide open. Some throats are so small as to make such an examination impossible, but generally a tolerably good view may be obtained of the posterior nares and palate, the roof and sides of the pharynx, the mouths of the Eustachian tubes, and the larynx. The mucous membrane should be carefully examined for mu- cous masses, thickenings, rugose swellings, enlarged glands, ad- hesions, false membrane, ulcerations and morbid growths. The patulency and condition of the mouths of the tubes should receive 110 THE HUMAN EAR AND ITS DISEASES. careful attention, in order to judge whether the disorder of hear- ing is due to tubular disease, arising primarily in the pharynx* or to disease of the tympanum. Examination of the Nose.—The nasal fossae may be in such Fig. 54. Frankel's Nasal Speculum. a condition as to demand treatment, and should be thoroughly explored. The rhinoscopic mirror will generally reveal the state of the tissues in the posterior nares and nasal fossae, and a specu- Fig. 55. Thudichum's Nasal Speculum. lum should be introduced into the anterior nares to facilitate further examination. The head or hand mirror may be used to illuminate. There are several specula necessary. Frankel's is a useful and convenient one. It is of nickel or silver-plated steel, works EXAMINATION WITH THE EUSTACHIAN CATHETER. Ill with a screw, and leaves plenty of room between its branches for surgical work. Thudichum's consists of two. bivalves connected by a wire, and is a favorite with many specialists. Elsberg's is more of a dilating instrument, it has three branches and is convenient. Zaufal's long tubular specula may be useful in determining the state of the naso-pharyngeal space, and become a necessity in examining cases in which it is impossible to get a view of the parts with the throat mirror, on account of narrowness of the space between the palate and the posterior surface of the pharynx. Careful exploration by the index finger passed through the mouth to the roof of the pharynx and, even, into the choanae, should confirm the presence of morbid growths in this region, Fig. 56. Zaufal's Tubular Speculum. before operation, as recommended by Loewenberg. The state of the mucous membrane, size of the passages, deformities of the septum and turbinated bones, and the presence of ulcerations, swellings and tumors, should be noticed and recorded. The teeth should be examined in all cases of pain in the ear, when other symptoms of aural disease are absent or insignificant, as odontalgia occasionally causes violent earache and even in- flammation of the middle ear through the otic ganglion and the auricular branches of the fifth nerve. There is no doubt in my mind that numerous cases of subacute and chronic disease of the tympanum are caused by diseased teeth and the various metallic fillings put in them, as stated by Dr. Sexton. I have seen plenty of cases in which the evidence of this connection was irrefutable. Examination with the Eustachian Catheter.—This is an- other means of diagnosis of naso-pharyngeal, tubal, and tym- panic disorders. 112 THE HUMAN EAR AND ITS DISEASES. Eustachian catheters are tapering tubes about six inches long, with a slight curve at the small end and a ring upon the large end, in the same plane as the curve, to show the position of the latter when out of sight in the nose. Some catheters have the ring upon the same side as the curved beak, others upon the opposite side. The small end should be a little rounded like a silver probe, not left sharp as some are, and the diameter of the large end should be sufficient to take a syringe nozzle, and a tapering tip from the air-bag. They are made generally of hard Fig. 57. Eustachian Catheters.—a, Hard rubber catheter; catheter; c, Silver catheter. 6, Sexton's velvet-eyed rubber, and of coin silver, which materials are well adapted to the purpose they have so long served. Every aurist knows the frequency with which slight bleeding is caused by the most care- ful introduction of these instruments, and I have had occasion many times to file off the sharp edges of the beak in new sets, in order to save the feelings of hypersensitive patients, and to avoid abrasions of the tender naso-pharyngeal mucous membrane. It occurred to me that a catheter of soft rubber, sufficiently firm to answer most purposes, might be manufactured, and owing to its soft beak and easy flexibility, be inserted without any of the dis- comfort and damage incident to the unyielding ones. I communicated with Messrs. G. Tiemann & Co., the eminent EXAMINATION WITH THE EUSTACHIAN CATHETER. 113 and ingenious surgical instrument makers of New York city, who set immediately to work and produced the instrument de- sired. This corresponds in shape and dimensions with the medium size catheter furnished in sets, is stiff enough to be handled easily, and to retain the nozzle of the syringe, or the tip of Politzer's air-bag, yet, is so soft and yielding as to glide over obstacles, and do no damage to a tender, granular mucous mem- brane. It works well, can be made stiffer in its straight part by slipping in a wire if thought necessary, and its merits will commend it to every one engaged in aural practice. The manufacturers will keep it in stock and designate it " The Flexible Eustachian Catheter." Dr. Sexton, of New York, has invented a catheter, which is made of soft rubber and silver. It is indicated by b, Fig. 57. The base consists of a silver tube, with a ring similar to the outer half of the ordinary silver catheter. The other half, re- ceiving the distal end of the silver tube and ending in a tapering curved beak, is made of soft rubber, and resembles mine in its delicate touch and uses. The base is so heavy that the instru- ment is troublesome to keep in position, and it slips out of the nose and separates from the rubber part too easily. The hard rubber catheter should be used generally, when steam or medicines are applied to the Eustachian tube and ear, as the silver ones become heated or corroded. Catheters come in sets of three in each material, the sizes are small, medium, and large; but one should have a number of sets, so as to have clean ones always ready, and to be able to fit odd cases. They should be washed after use in boiling water containing a little carbolic acid, in order to prevent carrying disease from one patient to another. Occasionally quite a small catheter may be needed for a child, but the hard rubber ones may be heated and bent to any curve to fit special cases. It is better to avoid the use of the catheter in children, and to rely upon other measures. Persons with a wide brain case often require a much greater curve in the catheter, than those with a narrow one; not always, 114 THE HUMAN EAR AND ITS DISEASES. however, because with the wide brain, one may have great mus- cular development and a close throat; and with the narrow, atrophic muscles and a capacious cavern of a pharynx. Anglo-Saxons have broad cerebral bases and require, gener- ally, stronger curved catheters than the Latins who have narrower ones. I usually estimate the curve of the catheter necessary, by noticing the width of the head on a line with and behind the eyes, and succeed in selecting the proper instrument in most cases the first time. Short thick noses take catheters of large size; long slim noses require small ones; the inferior meatus varies much in size. A child's catheter is slender and little curved. The catheter which can enter the Eustachian tube easily, of course, shows approxi- mately the size of its lumen. Select the proper catheter, blow through it to be sure it is per- vious, warm it in a bowl of hot water or over the gas-jet, espe- cially, if it is of metal and it is winter weather, and take it be- tween the thumb and first two fingers, as most persons hold a pen. Have the patient clean his nose well and hold his head steady and erect. Now take hold of his nose with the left hand, raise the tip a little and introduce the beak of the instrument into the nostril half an inch or more, with the curve directed downward and a little inward. Direct the patient to breathe en- tirely through the nose in order to keep the velum immediately away from the posterior pharyngeal wall. Raise the catheter to nearly a horizontal position with the beak resting upon the floor of the nose near the septum, and push gently backwards until the back of the pharynx is reached. One can tell this by the length of the catheter inserted, the obstruction to further progress, the coughing or gagging, and the grimaces of the patient. The in- strument should be held loosely and moved in gently, so that no injury may be done, and the instrument may follow a crooked passage if such be present. I usually put the index finger upon the outer end, after starting the instrument in, and push gently and firmly onward, allowing free lateral play, and when the back of the pharynx is reached turn the ring so that the curve within shall be downward. EXAMINATION WITH THE EUSTACHIAN CATHETER. 115 After reaching the pharyngeal wall, hold the catheter horizontal against the septum, withdraw it about half an inch and turn its ring about a quarter of a circle (90°), to insure the turning of the inner curved portion outwards to the same extent, then push a little backwards and the beak will enter the mouth of the Eustachian tube or else the fossa of Rosenmuller. In the latter case, the catheter can be rotated largely and will not retain its position long. One should then draw it a little forward, keep the ring down a little and the beak turned outward, push the outer end against the septum and the instrument backwards, and the beak will slip into the mouth of the Eustachian tube. Sometimes a sensation as if breaking threads is felt and a little bleeding is caused, from the giving way of granulations as the beak is pushed home. The palate muscles may lift the beak into place very easily, but contact of the catheter with the velum often causes considerable pain and some bleeding. In difficult cases, ask the patient to swallow and this action will frequently assist in lifting the catheter into the tube. After it is in position, swal- lowing will in most cases move it slightly. It may be necessary to turn the catheter and repeat the manipulation several times before it will get into the proper place. It may be advantageous in some cases to turn it in an opposite direction, make three- quarters of a revolution, and drop the beak into the mouth of the tube from above. When this is done, some writers direct to hug the septum with the curved beak, but the space for operation is so small that this direction is superfluous. Occasionally the catheter will be turned during insertion by the walls of the in- ferior meatus and go directly into the mouth of the tube. The palato-pharyngeal muscles frequently contract upon the catheter and hinder its insertion. One should wait till the patient breathes calmly through the nose and the spasm yields. A little patience only is necessary, the velum will become pendulous and the course clear. No decided force should be used in introducing a catheter, as serious injury may be done to the mucous membrane. If after insertion the catheter can be rotated but a little, and a cartilaginous grip is felt at the inner end, one may be sure it is in proper posi- tion. Introduction of the catheter may cause tickling, or itching 116 THE HUMAN EAR AND ITS DISEASES. in the auditory canal, a stopped feeling in the ear, sneezing, cough, epistaxis, swallowing, gagging, nausea, vomiting, burning pain in the throat, neuralgia of branches of the fifth nerve, and injury of the tube. The catheter can be used before it is fixed in position, as an explorer for thickening of the mucous mem- brane, and the detection of morbid growths. Knowledge gained in this way, however, is not very reliable. One can tell the catheter is in position by the elastic cartilag- inous feel, an inability to rotate it far, by the position of its ring, by the ability to inflate the tympanum through it, and by ocular inspection with the rhinoscopic mirror. I must mention that the position of the ring when the catheter is in situ is variable. The rule is horizontal or a little downward, but it points as frequently upward and outward; in such cases, one will notice that the auri- cle and external auditory meatus are a little below the plane of the nasal floor. There are some fancy methods of introducing the ordinary catheter that I will not allude to. There are cases of total obstruction of one side of the nose to the introduction of the catheter, which are caused by irregular and deformed turbinated bones, lateral displacement of the sep- tum, swollen mucous membrane, adhesions between its surfaces, and the presence of adenoid, polypoid and osseous tumors in the inferior meatus and pharynx. These obstructions should be re- moved when possible; and operations upon the nasal septum and turbinated bones are justifiable and proper. The Eustachian tube of one side may be reached, however, through the other side of the nose. Dr. Noyes has invented a pair of double-curved catheters for this purpose. The curves are in planes at right angles to each other, and the beak is con- siderably prolonged. Auscultation. — It is premised that the catheter is now in position; it may be retained by Bonnafont's nose clamp; the patient may keep it in place by pinching the nose and breathing through the mouth; or the surgeon may hold it between his thumb and forefinger, the other fingers resting upon the forehead. One tip of the auscultation tube should now be pushed firmly into the corresponding auditory meatus of the patient and the other into the surgeon's ear. The surgeon may then place his EXAMINATION WITH THE EUSTACHIAN CATHETER. 117 mouth to the catheter, blow quickly, and listen to the sounds that come to his attentive ear. Instead of this method of inflating, a tapering tip in the air-bag may be fitted into the catheter, and air forced through by quick compression of the air-bag. Another Fig. 58. G.T1EMANN = CO. Bonnafont's Catheter Holder. way is to use Toyubee's explorer, a rubber tube, fitted with a tip for the catheter and a mouth-piece for the surgeon, the breath is blown through it and the catheter. This method makes much less noise and permits the sounds through the auscultation tube Fig. 59. Auscultatory Catheterization.—1, The patient; 2, the catheter; 3, the physician; 4, the auscultation tube. to be more readily appreciated, than when the air-bagx is used. If the Eustachian tube is pervious, air will be forced into the tympanum, and certain sounds will come through the ausculta- 118 THE HUMAN EAR AND ITS DISEASES. tion tube to the surgeon's ear, which he may interpret according to hints previously given. If air cannot be heard rushing or bubbling through the Eus- tachian tube and the tympanum, and the patient does not feel any fulness or improvement in his ear after several trials, the tube is impervious. Redness along the handle of the malleus is occasioned by examination of the auditory canal, and by the use of instruments in the throat and about the mouth of the tube, and must not be considered sufficient evidence of air having reached the tympanum. When inflation is made as a therapeutic measure, two or three blasts are sufficient to change the air of the tympanum, but half a dozen may be made without injury, when much stimulation is Fig. 60. Toynbee's Explorer. needed for diseased conditions, and it is desirable to expel mucus, and, especially, when one wishes to stretch and dilate a contracted tube. Bougies.—When obstructions are found in the Eustachian tube, they are usually at the isthmus or junction of the cartilaginous with the bony portion. Several kinds of bougies are used for their removal. They are made of catgut or soft metal, are longer than the catheter, and should be marked at just the length of the catheter, and then have another mark outside of this to indicate the average length of the Eustachian tube. One may know then just how near the tympanum the instrument is approaching, as it is pushed through the catheter. The bougie is introduced through the catheter in position and used like a sound to dilate actively but little force should be employed. The laminaria bougies are SYMPTOMS. 119 designed to dilate strictures and the tubes passively, by the swell- ing which they undergo when moistened. They are made of laminaria digitata, are considerably longer than the Eustachian catheter, and should be marked like those of catgut. The catheter being in position, a bougie of this kind is intro- duced through it beyond the stricture and allowed to remain some time. After it swells somewhat, the catheter may be removed and the bougie left as long as considered desirable. Sometimes they have been broken off, and pieces have finally escaped from the tube with benefit to its calibre, but this seems a hazardous and undesirable sequel. Entotic Test of Hearing.—Dr. Bing proposed a comical test of the ear. He connected by means of rubber tubing, an Eus- tachian catheter in situ with a bell-shaped collector of sound, and then spoke through it directly into the tympanum. The external meatus should be closed tightly, the patient should not be per- mitted to watch the aurist's lips, and should repeat what he hears. The results from this method are of little value, and I present it here merely to show the versatility of the Teutonic mind. Symptoms.—Diseases of the auditory apparatus have a variety of common symptoms. The most frequent and noticeable is deafness, and the patient is not conscious of this until it has reached a certain degree, when he perhaps notices it by accident. A person with normal auditory apparatus can hear an ordinary watch four or five feet, yet, his hearing may decline until he can only hear it a foot or less, and he may still hear the voice well enough. One's friends notice the demand the moderately deaf person makes for a repetition of sentences for his understanding before he does himself, and brusque ones may tell him that he is getting deaf, while polite ones will say nothing, but set him down as stupid. There are many children and adults credited with dul- ness who are simply deaf, and it is cruel to reprimand and abuse them, when an examination will reveal their affliction, and save them much misunderstanding and mortification. Deaf persons learn to watch the lips of the speaker, and thus gather in sense, when they cannot altogether compass the sounds, and their defect becomes manifest when circumstances prevent 120 THE HUMAN EAR AND ITS DISEASES. their lip-reading. The wistful look in the face, the anxiety to hear what is said by friends, and the morose dulness and discon- tent manifested by many deaf persons are distressing to behold. Causes.—It is self-evident that, though congenital deafness may result from defective development or deformity, acquired deafness is caused by disease and degeneration of the auditory apparatus. Late autumn, winter, and early spring are pregnant with changes of temperature and humidity, and are fruitful in acute inflammations of the ear, and acute exacerbations of old affections. In this six months of the year in the temperate zone, catarrhal and erythematous diseases hold high carnival, and numerous are the cases of aural mischief in every community. In all damp and changeable climates ear diseases are much more prevalent, than in warm equable ones. Temperament exercises a marked influence upon the genesis of aural disease. The lymphatic temperament is seen in three- fourths of the cases of disease of the middle ear, and in many of the external ones. It is the temperament of catarrhs, and both the sallow-faced and the blooming blonde are victims of fluxes from the mucous membranes from almost inappreciable changes. The sanguineous are afflicted next in frequency, but adults are more subject than youths; the ear disease is frequently phlegmon- ous and violent in its nature, and causes great suffering and some danger. The nervous are attacked in moderate numbers; the disease is mild and manageable, the patients exaggerate their sufferings and make loud complaints. The bilious suffer least from serious disease of the ear; they are prone to subacute and painless disorders, which advance slowly and seem of little importance, until they begin to diminish the auditory power. Heredity is another cause of deafness, and aural disease can often be traced through several generations. Deafness affects the young more than the old, though each period has some diseases peculiar to it; it is found in males oftener than in females, owing to their greater exposure; it attacks those of impoverished blood and afflicted by some dyscrasia; it occurs in those devoted to a life of great cerebral activity and hence DIAGNOSIS. 121 hyperaemia, and those exposed to the shocks of sea-diving, the foul air of mines and sewers, the whizzing and clanging of ma- chinery and tools, and the roaring of artillery. Among exciting causes are: chilling some part of the head or neck, as by a draft or exposure to cold air; chilling the body as a whole, especially, after having been in a warm room, and, per- haps, perspiring; suddenly cooling the ear; irritating the mem- brana tympani, and shocking the apparatus by swimming and diving in salt water; the abuse of tobacco in chewing and smok- ing ; attacks of tonsillitis, pharyngitis, diphtheritis, nasal catarrh, mumps, measles, and scarlatina; the introduction of foreign bodies, and vegetable and animal parasites into the external mea- tus ; and traumatic injuries, from the digging with a hairpin, to fracture of the temporal bone. These are the most common ex- citors of aural disease; but, in many instances, struma, the rheu- matic and gouty diatheses, or the syphilitic contamination of the system have prepared the ears for an explosive inflammation. Diagnosis.—The diagnosis of aural disease must be based upon an accurate knowledge of the normal appearances and physio- logical action of the auditory apparatus, and this, so easy of acquirement, is just what many physicians neglect. Every oppor- tunity should be taken to examine the membrana tympani, its color and movements during inflation, and phonation, the appear- ance of the ossicles if visible, and the hue of the middle ear. The naso-pharyngeal space, the mouth of the Eustachian tube, and the movements of the palato-pharyngeal muscles should be studied closely by methods and instruments already described. When a patient complains of some functional disturbance of the ear, a knowledge of the natural conditions will enable one to determine with accuracy the cause, consequence, lesion, and treat- ment. Without this analysis of a case, treatment must be irra- tional, unscientific, and hazardous. The pathology of the ear has been so well worked up that a special volume is required to contain it. Very much of inesti- mable value has been garnered from uninviting fields by the patient labors of devoted physicians, but I do not hesitate to say, that, in several directions, the advances are useless and soul- 9 122 THE HUMAN EAR AND ITS DISEASES. vexing—mere curiosities of science, and monuments of mis-spent energy. Histology has been a fashionable pursuit during the past de- cade, as was once the South Sea craze and the Tulip mania, and therapeutics has been left to the druggist's apprentice, and the fossilized grandmothers of medicine. With a few exceptions, the talent of both schools has been led captive by the charms of microscopic histology and medical physics, and the full value of medicines in the treatment of aural diseases remains in an unde- veloped state, a reproach to the science of medicine, and to our common humanity. Treatment.—The treatment of ear disease consists in certain measures, which experience has proved to be beneficial; in a careful use of such medicines as correspond in their characteristic symptoms to those of the disease, and in such others as experi- ence has proved of value in the morbid conditions. The paucity and unreliability of ear symptoms in our patho- geneses of medicines make it imperatively necessary to resort occasionally to remedies, which have only a clinical record to authorize and indicate their uses. A medicine having a pathogenesis corresponding very nearly with the totality of constitutional symptoms may be the very best remedy for an ear affection, but frequently the symptoms in the aural region constitute nearly the entire totality, and a resort to the materia medica will show little to correspond. In such cases, I hold it fraudulent to ignore the important symptoms of the ear, and to abstract and use a pretentious and deceiving totality from the recorded fancies and follies of imaginative provers. Ear diseases cannot be cured in this manner, and much better is it to rely upon clinical experience for the treatment of these cases, than to waste time in following Will o'the Wisps into the bogs. Ad- herence to the principles of treatment presented in this book will enable the physician to treat aural diseases with a fair measure of success, as the experience of many eminent aurists has been epitomized for a foundation for my own practical contributions. DISEASES OF THE EXTERNAL EAR. 123 CHAPTER IV. DISEASES OF THE EXTERNAL EAR. Malformations.—Congenital, imperfectly formed auricles are exceedingly rare, and usually accompany deformities of the tem- poral bone. The auricle may be entirely absent or represented by a small nodule, several nodules, a flap, a crumpled distorted mass, an hypertrophied and enlarged appendage, or by several rudimentary auricles. The meatus is sometimes filled by soft tissue, cartilage Ftg. 61. Microtia and Stenosis of the Meatus (Schwartze).* or bone, leaving a minute canal or none at all. Over these the skin passes smoothly or shows a slight depression. Among many thousand cases of ear disease, I have seen but one unfor- tunate, a girl of six years, with the right ear malformed. There was a slight wall of cartilage representing the antihelix, concha, and spine of the helix, with a nodule projecting outwards from * The Pathological Anatomy of the Ear. By Hermann Schwartze, M.D., Professor in the University of Halle; Translated by J. Orne Green, A.M., M.D., Aural Surgeon, Boston City Hospital, etc. Houghton, Osgood & Co., Cambridge, Mass., 1878. This classical treatise upon aural pathology, to which [ am under obligations for several beautiful plates and valuable notes, ought to be in the library of every physician. 124 THE HUMAN EAR AND ITS DISEASES. the latter. The lower and posterior portion merged gradually into the neck, and the position of the meatus was covered by a thick tight skin, which yielded very little to pressure. The ap- pendage occupied the normal position, the rest of the body was well formed, and the child intelligent. Defective development of the auricle usually corresponds with malformations of the external canal and other parts of the ear, Fig. 62. Malformed Auricle and Atresia of Meatus (Schwartze). and operative measures are advisable only in very exceptional instances. Dr. F. H. Schell, of Cincinnati, Ohio, reports a case of hyper- trophy of the auricle in a boy, the other auricle being of normal Fig. 63. Cats-ear of Left and Hypertrophy of Right Auricle (Schwartze). size. This is so rare, that I append the substance of the Doctor's report. MALFORMATIONS OF THE EXTERNAL EAR. 125 " Charlie L., aged five years, presented the singular deformity of different sized auricles. The left one was much the larger and thicker of the two; was very red and vascular, and became more so and puffy in cold weather and after manipulation; it lopped over, which made it only the more conspicuous. The boys called the poor little fellow ' lop ear,' and ' muley.' " A day or two after the child's birth, his parents noticed a dif- ference in the size of the ears, and discovered, also, a couple of Fig. 64. Hypertrophy of the Auricle (Schell). tumors in the scalp above the larger, one. The larger one grew rapidly, till at five years, it was 3| inches long, 2^ inches wide, and proportionately thick. "The anxious parents had consulted many physicians and surgeons, who had resorted to all kinds ^)f treatment, cutting, blistering, injections, setons, etc., which did no good, but de- stroyed the attollens muscle (accounting partly for the lopping), set 126 THE HUMAN EAR AND ITS DISEASES. up violent inflammation and erysipelas, to which the child had twice nearly succumbed, and left the ear covered with unsightly scars. " The little tumors in the scalp had been extirpated, but other- wise, as might have been expected, there was no improvement in the hypertrophied organ. At this stage of the case I was con- sulted, and I decided upon an operation to reduce the size of the auricle, though with some misgivings on account of the intoler- ance of manipulation previously manifested. At the first opera- tion, the patient having been chloroformed, I excised a portion of Fig. 65. The Hypertrophied Auricle After the Operation (Schell). the auricle, brought down the rim, and secured the edges firmly and evenly with half a dozen wire sutures on each side. The hemorrhage was quite copious, but easily checked by twisting the cut ends of the arteries. " I used Calendula water for sponging, and gave Aconite for several days after the operation. The wound healed promptly without suppuration, or leaving any conspicuous cicatrix behind. " The ear after recovery still looked thick and stumpy, and stood out too much from the head, to relieve which, I performed a second operation. I made an incision in the cuticle of the pos- ERYTHEMA OF THE AURICLE. 127 terior surface of the auricle nearly its whole length, and as near the line of junction with the scalp as possible. I then joined the two ends of this incision with another incision, enclosing an ellip- tical piece of integument, which was excised. I dissected up the whole of the integument of the back of the ear as far as the ex- ternal border, and removed a thick layer of dense cellular tissue, then brought the cut surfaces of the integument together, secured them with sutures, applied a cotton dressing and bandages, and prescribed Aconite. The wound healed again very kindly by first intention, and the final result of the operation was excellent. The ear was still somewhat thicker than the other one, not quite so translucent, but otherwise so nearly like it as not to attract any special attention." Another malformation rarely seen is the existence of a sinus more or less deep, situated just in front of the tragus, and called a fistula. They are mere cul-de-sacs, or may communicate with the tympanum, and are thought to result from non-closure of the first visceral cleft of early fcetal development. If thought de- sirable, they may be obliterated by cauterizing the lumen. There are acquired deformities of the auricle from faulty ways of wearing the hair, veils, bonnets, and caps, which should be a warning to mothers and doctors. I saw a gentleman with large sized auricles, which projected directly outward from the side of the head, so that the anterior surfaces looked directly forward. The effect in both front and back view was very ludicrous. The auricles may be made to stand out more from the head or to lie closer to it, by the judicious use of elastic pressure and a proper arrangement of the head dressing, during the early plastic period of infancy. Erythema of the Auricle.—This condition lies between the ruddy hue of the auricle, which is said to result from a person's talking about you, and that of true dermatitis, and is caused by cold, pressure, friction, and injury. It is a simple hyperaemia of the organ without pain or swelling. Restoration to a normal condition may soon succeed, or it may develope into a more se- rious affection, as eczema or erysipelas. When it occurs upon the posterior surface of the auricle and the mastoid, it runs into Intertrigo, which may depend upon local irritation, constitutional 128 THE HUMAN EAR AND ITS DISEASES. disturbance, or temporary paresis of the cervical sympathetic ganglia. Treatment.—The physician is rarely called to treat such a trifling affection ; the diet should be regulated, and the proper per- formance of the vegetative functions secured by appropriate medi- cation. A soothing local application may be required, as sweet al- mond oil (Ol. Amygdaloz dulcis), cold cream (Ung. Aquoe Rosas) or quince seed mucilage (Mucilago Cydonii). Apis, Arnica, Arsenic, Belladonna, Lachesis, Pulsatilla, Rhus, and Sulphur should be compared for internal medication. Erysipelas of the Auricle.—Erysipelas is dangerous when it occurs about the head, and in the auricle it is no exception, as it may extend into the meatus and thus reach the brain. It is caused by cold, bites and stings of insects, traumatic injuries, and extension from contiguous tissues. There are the usual symptoms of chill, fever, headache, and constitutional disturb- ance. The auricle becomes stiff, deep-red, shining, and swollen ; there is itching and burning, with exfoliation of cuticle, and, sometimes, crops of vesicles and small blisters. In severe cases, abscess may form in the subcutaneous cellular tissue of the au- ricle, as in the phlegmonous erysipelas of other parts, and the pus must be evacuated early to prevent distortion of the organ. The hearing is generally somewhat impaired. If the disease extends into the canal, it may leave a chronic dermatitis. If the membrana tympani and tympanum are invaded, an acute inflam- mation results in considerable damage to the auditory apparatus, and it is not without danger to the brain. Treatment.—The patient should have good nourishing food ; a moderate quantity of wine, if much depressed, and be kept quiet and comfortable. Notwithstanding the warning of some authors against cold applications to the ear, I would recommend the em- ployment of cold slippery elm (Ulmus fulva contusa) poultices to the auditory region in erysipelas, as the mass soon becomes warm ; but the meatus should be closed by cotton. If the cold poultice causes more than momentary chilliness, apply a warm one, and renew it as often as necessary to keep the auricle moist and comfortable. Another application that has proved beneficial is the blue-clay ERYSIPELAS OF THE AURICLE. 129 dressing of Dr. Hewson. Common blue clay is baked in an oven, pulverized, and passed through a fine sieve. Make a soft pultaceous mud of this by stirring in water, spread it upon strips of muslin, and apply all around and over the auricle. Renew the dressing as often as it becomes dry. I have seen this appli- cation have wonderfully good effects, not only in erysipelas, but in many other cutaneous diseases, during my walks with the dis- tinguished surgeon in the Pennsylvania Hospital. AVhen the dressings are renewed, the parts should be washed with warm water, and the meatus carefully cleaned of foreign particles. Some few cases will not tolerate these dressings, but are im- proved by the application of cold cream, or by dusting with fine starch. Every case is a law unto itself. If an abscess forms, it should be opened freely, care being exercised not to cut the auricular cartilage. There are no special symptoms about erysipelas of the auricle to call for a different treatment, than for the disease elsewhere. If it occurs with headache at the climacteric, Apis and Lachesis may prove valuable. Apis is indicated by sharp pains and oedema. Aconite is sometimes appropriate in the early stages, but Belladonna suits most cases better. Arsenicum, Rhus, and Sulphur are among the most valuable remedies, and Bryonia, Cinchona, Ferrum, Graphites, Hepar, Pulsatilla, and Phosphorus are occasionally indicated. The action of Apis and Rhus is some- times very gratifying. When the erysipelatous inflammation extends into the auditory canal or the tympanum, other measures may become necessary. Pain should be combatted by syringing the ear gently with hot water for some time, and by inflating the middle ear with the air-bag. The canal must be kept clear of pus, crusts, and scales, and the dressings may extend iuto it. It may be necessary to incise the soft tissues of the canal, to relieve tension and evacuate pus. Effusion in the middle ear may call for paracentesis of the membrane and other proceedings, described under acute inflammation of the tympanum. In ery- sipelas it is desirable to be very conservative in surgical opera- tions. 130 THE HUMAN EAR AND ITS DISEASE3. Frost Bitten Auricles.—The auricles get frozen frequently in our Northern latitudes, and must be treated carefully to avoid sphacelus. They are pale, stiff, cold, and insensible, and the patient may not at first be conscious there is anything the matter with his ears. The pathological condition varies with the se- verity of the freezing, from dermatitis to gangrene and sloughing. Treatment.—The auricles should be rubbed gently with ice- water, and then the temperature of the water gradually raised until warm, and the parts become thawed. Then apply a lotion of carbonate of sodium (Sodii bicarbonas), §ss. to a pint of water, for a few hours, and give Aconite for a time. Spirits of cam- phor (Spts. Camphoroi), may be applied to the auricle about three times, at intervals of several hours, and then the parts painted with tincture of benzoin (Tr. Benzoini). If there is severe pain, Belladonna may be useful. If vesicles form, and portions of the pinna look purple and slough, the parts. should be covered by vaseline ointment on soft linen, and Arsen- icum or Rhus given internally. Nitric acid is serviceable when the skin inflames, cracks, and bleeds, showing its impaired vitality. Agaricus is said to relieve itching, and cure the dry scaly condi- tion of the chronic stage. Other symptoms must be met according to general principles. Sometimes cartilaginous nodules form in the pinna, along with new cartilage, and are quite sensitive to the touch. When gan- grene supervenes, charcoal poultices and surgical operations may be necessary. In order to diminish the sensibility of the frosted ear to cold, it is recommended to bathe it daily, during the sum- mer, in a solution of alum (Alumen), §ss. to a pint of water. Eczema of the Auricle.—This is a common disease of the skin, and is seen occasionally in the auricle and meatus, where its appearance and course are somewhat modified. It is seen most frequently in children and females; in those suffering from gen- eral debility, faulty nutrition, and innervation, and having a strumous diathesis. Among those thin, pale, half-famished chil- dren of the poor, who fill our sunless alleys and crowded tene- ments, the disease is most prevalent; but indolent and overfed persons living in luxury are liable to attacks from irritation of the alimentary canal, and subjection to local injuries. Some ECZEMA OF THE AURICLE. 131 writers think menstrual disorders, and the approach of the meno- pause are potent predisposing causes. The exciting causes of the affection in the auricle are: too warm covering; uncleanliness; rubbing, scratching or picking the meatus; and using irritating remedies for ear-ache. Acute attacks begin with heat, redness, a burning sensation, itching, and swelling. The inflammation spreads slowly, and may pass down the canal to the tympanum, and even along the Eus- tachian tube to the throat, where its character becomes changed. An eruption of vesicles soon appears upon the auricle; these break early and pour out their sticky contents over the surface, where it dries and forms unsightly scales and crusts. If a crust is removed, the surface beneath will be moist, raw, and covered with bloody sero-pus, and this condition distinguishes eczema from many other skin diseases. As the disease advances, the crusts break and serum is poured out freely to thicken the disgusting covering, which shows deep cracks, or else friction and accident rub them off and leave a raw, wet surface with bloody points. We must be careful to diagnose this condition from syphilis, which it somewhat resembles. The auricle upon its anterior surface is very richly supplied with sudoriferous glands, and here the eczema is always more succulent and severe. The posterior surface of the auricle is liable to affect the con- tiguous surface of the mastoid by friction and contact of the dis- charge, the skin becomes raw, and, unless great care be exercised to keep the parts separated by a cloth or powder, the two surfaces will unite. I operated upon a case of this kind in a little girl, in 1879, where the attachment was so complete, that there was merely a trace of a sulcus between the helix and the side of the head. When eczema auris has become chronic, the pinna is stiff, thicks and misshapen from various cicatrices, and hypertrophy of the fibrous tissue. Should the, disease extend into the auditory canal, the inflam- matory symptoms will be more decided. The skin of the canal is reddened, the periphery of the membrana tympani and borders of the manubrium of the malleus show increased vascularity, and 132 THE HUMAN EAR AND ITS DISEASES. tinnitus, and slight deafness ensue. The epidermis of the parts is rapidly formed, elevated in vesicles, and exfoliated; the rete of the skin, and the periosteum covering the bone are thickened, and dermatitis blends with periostitis. The epidermic cells accu- mulate in the canal, the walls are" covered by shreds and scabs, the membrane becomes dirty white and opaque, and the exuda- tion of serum converts the debris into a cheesy fetid mass, which gradually fills the whole passage, and does considerable damage, if not removed frequently. The tympanum sympathizes by hyperaemia and pain with the contiguous disease; the membrane may rupture, and the inflam- mation extend to the middle ear, Eustachian tube, and pharynx. Fortunately these complications of the auricular disease are rare. Treatment.—The hygiene of the patient must be regulated, and any errors of diet corrected. The food should be light and easily digested, and acid fruits will prove salutary. In the acute stage, the parts should be bathed with warm water and wrapped in cotton. When the parts become moist and exco- riated, remove the crusts by picking, and washing with warm water, or apply a flaxseed poultice. Then bathe in diluted tar water (Aqua Picis liquidce); in a solution of borax (Sodii bi- boras), 5'j to a pint of water, or in one of German green soap (Sapo viridis), §ss. to the pint. Should these measures fail to ameliorate, or should there be an excessive exudation of serum, making the side of the head filthy, in spite of the care exercised; it will be beneficial to dust over the parts with a powder of one part of oxide of zinc (Zinci oxidum) to seven of fine starch or powdered rice (Oryza). Lotions of tar water, diluted tincture of arnica, diluted tincture of cautharides, solutions of carbonate of potassium or sodium ; glycerine, cod- liver oil, castor oil, vaseline, and oxide of zinc ointment have been extolled by different authors. I have used tar water, vase- line, and the zinc ointment in obstinate cases with much satisfac- tion, but I prefer the Hewson earth dressing to all other external applications. Clinical experience proves, that very many cases are made worse by oleaginous preparations. In a very severe case, in the practice of Dr. L. H. Willard of Allegheny City, Pa., where the disease covered the side of the SKIN DISEASES. 133 head and neck, after many external and internal remedies had failed to improve the condition, a solution of nitrate of silver (Argent, nitras gr. x, Aqua dest. fSj), was pencilled over the raw surface every day, and brought about a speedy cure. This experience accords with that of Dr. Knapp, of New York City, who has reported a severe case cured with the silver solution, and extols it above every other remedy. Whatever is done externally, the internal treatment must be persistent and thorough. Aconite, Apis, Belladonna, Cantharis, or Rhus will suit acute symptoms of certain cases. Conium is excellent for women with chronic eczema and menstrual difficul- ties. In my practice, Arsenicum, Calcarea phos., Graphites, Hepar, Mercurius, Rhus, and Sulphur have been beneficial and often curative in appropriate cases. Other medicines worth look- ing up are, Croton tig., Calcarea carb., Iris vers., Iodine, Kali hydriod., Lycopodium, Muriatic acid, Petroleum, and Pulsatilla. When the disease extends into the auditory canal, the daily attention of the physician is necessary to remove the crusts and dirt by syringing and the use of instruments, in order, to relieve from irritation, and the obstruction to hearing. The warm douche will allay the itching and inflammation, and should be used several times a day. Push a strip of cloth wet with glycerine and water, or smeared with vaseline or zinc ointment, a little way into the canal, to soothe the raw surface. If the affection extends deeper, the complications must be treated according to principles laid down elsewhere. Skin Diseases.—The external ear is subject to various other skin diseases. Pemphigus, Herpes, and syphilitic Roseola are frequent, and Condylomata of the auditory meatus have been seen occasionally. I had a case of syphilitic Psoriasis upon the outer surface of the auricle of a woman, which disappeared after a course of Mercurius corrosivus. These affections should be treated by the appropriate medicines, as they are when seen in other parts of the body, and complications met by the usual measures. One should be exceedingly careful to cleanse instru- ments in hot carbolized water, after dressing any purulent ear disease. 134 THE HUMAN EAR AND ITS DISEASES. Furuncles.—Circumscribed inflammations of the subcutaneous cellular tissue of the auricle or canal are denominated boils. They are usually indicative of improper diet, and imperfect assimila- tion. They occur upon the auricle or in the cartilaginous portion of the canal, upon the posterior and anterior walls; sometimes one follows another in rapid succession, and so-called epidemics have been recorded. They are frequently excited by pus coming from middle ear disease, and by astringent and irritating washes, and are occasional complications of eczema. The most common kind met with in practice are small, hard, red, and painful, especially, if they occur in the canal. The pain is dull, with occasional throbbings and sharp dartings, and is made worse by moving the auricle and the lower jaw. The tumors ripen slowly, and may undergo resolution by absorption; but usually they form a dull gray apex, break and discharge pus and mortified cellular tissue called a core; they disappear without leaving much trace. Others are large, cause considerable swell- ing and great pain, and destroy the symmetry of the parts. They may be distinguished from osseous tumors by the acute symptoms, the location, and rapid increase in size. Sometimes the membrana tympani becomes very red and swollen, but the history will differentiate this from idiopathic myringitis. Upon the auricle, furuncles are manageable, but in the canal they often close the opening, induce deafness and noises, cause sympa- thetic swelling in the tissues and glands outside, and are accompa- nied by long, heavy, lasting pain. There is some febrile reaction, and there may be headache and grave cerebral disturbance. I have known swelling just inside the meatus to close it, a furuncle to break inside this, and the confined pus to press inwards upon the membrana tympani, so that severe pain, tinnitus, and vertigo persisted, in spite of the use of hot douches and poultices, at- tempts to dilate the canal, active inflation, and the administra- tion of Aconite, Belladonna, and Hepar. A free incision of the canal over the seat of the phlegmon relieved greatly, and Kali hy- driod. brought about a cure. Sinuses sometimes remain in the wall of the canal, and granulations spring up at the opening and form polypi. Treatment.—Belladonna aborts boils if given early. Touching them with a drop of pure Carbolic acid often does the same. FURUNCLES. 135 Hepar will sometimes repercuss a threatened swelling, or failing in this, will promote ripening. Mercury is useful for very hard sluggish swelling with considerable pain. Silicea may be needed later. Carbo veg. is valuable in gross habit of body with glut- tony. A poultice of flaxseed meal (Lini Farina) should be applied over the auricle when it alone is affected, and a conical poultice in cloth pushed in the canal, if the canal is the seat of the swelling. In either case, the whole aural region may be covered with a poultice, as the danger of injuring the membrana tympani, or promoting the formation of polypi by their use is exaggerated. I have em- ployed them for six or seven days together, and have never yet seen a membrane injured, nor a polypus formed by their use. Warm douches are very agreeable, and cleansing the canal with cotton on the holder, if there is discharge, may be necessary. The pus must not be permitted to remain deep in the canal and upon the membrane, but all the white shreds and epidermic scales must Fig. 66. —->" '............. ' S>.~\ *£.ain, threatening acute exacerbation ; a great deal of painful sen- sibility on contact, and, especially, cases that do not improve under other applications, require nitrate of silver. There are aurists, who use this remedy for any and every case of purulent inflammation of the tympanum; but as some other medicines already mentioned cure easily, and this is liable to stain the auricle of the patient and the hands of the operator, it should only be resorted to, when its special symptoms are present or other agents fail. The fused stick nitrate is impure, and the crystals should be employed, dissolved for obvious reasons in pure distilled water. In ordinary cases, a solution of five to ten grains of the salt to a fluid ounce of water is sufficiently strong, but when the disease has existed a long time, and the tissues are profoundly altered, twenty to forty grains to the ounce or a saturated solution may be necessary. Very favorable reports of the action of the stronger solutions have been made by reliable physicians. There is dan- ger of paralysis of the facial nerve with these strong solutions when caries exists, and they should then be used cautiously upon cotton or not at all. The application should not be intrusted to the patient or his friends, but be made by the physician himself, every day for the mild solutions, and every second or third day for the stronger ones. After cleansing thoroughly, the solution should be put in the ear with a dropper, and neutralized in a few minutes by a syringe stream of mild salt (sodium chloridum) and water, so that the auricle will not become stained. This need not be thrown into the tympanum, but played upon the meatus, so as to unite with the silver solution, as the head is inclined and it flows into a bowl or other receptacle. Unless 254 THE HUMAN EAR AND ITS DISEASES. this is done,»the sulcus and lobe of the auricle will be stained brown in a few hours, and the patient will be justly indignant, especially if a lady. At the time of application, the patient will experience a warm smarting sensation in the ear, and if the Eustachian tube is per- vious, may have an acrid taste from leakage into the pharynx. I have had a patient immediately drop the head forward and blow a drop or two from the nose, getting thereby a disagreeable olfactory sensation and a stained handkerchief. If the tympanum be examined after instillation of the remedy, it will show a white coat of the chloride or albuminate of silver- This turns brown and then black in a few hours from the forma- tion of oxide of silver, and must not be mistaken for carious pro- ducts, or an accumulation of cerumen. Permanganate of Potassium is a remedy of much value in chronic suppuration of the ear. It dissolves purulent masses, deodorizes and disinfects fetid discharges, cleanses and soothes the mucous membrane, stimulates ulcerated surfaces and favors and hastens a cure. It is equally applicable to catarrh of the nose and pharynx, and is excellent in ozaena. In ordinary cases of suppuration in the tympanum, a solution of ten to twenty grains to the fluid ounce of water is required, once or twice daily. A tendency of the discharge to form gelat- inous lumps and stringy adhesive masses, and the presence of a foul odor call for this salt once or twice a day. Iodoform has won a deserved reputation for ill-conditioned ulcers in other parts of the body, and is somewhat beneficial in the disease under consideration. It is non-irritant, anaesthetic, anodyne, alterative and disinfecting, and may be tried in obsti- nate cases, where other agents have failed. The symptoms demanding it are, pale mucous membrane with granulations; weak, indolent gray ulceration ; a fetid discharge or light-colored pus, and a scrofulous constitution. The crude pow- der or a mixture of equal parts of iodoform and tannic acid may be blown upon the diseased surface once a day, and permitted to remain until the next syringing. Tannic Acid is a vegetable astringent, sometimes recommended for suppurating ears. It is irritating, bulky, dirty, and, some CHRONIC PURULENT INFLAMMATION OF TYMPANUM. 255 say, nearly inert for purulent cases. It might be used as an inter- current remedy, in obstinate cases, in solutions of ten to twenty grains to a fluid ounce of water. In powder or saturated solu- tion, it is an excellent styptic, preferable to iron to arrest hemor- rhage after polypus extraction, caries of the temporal bone, and other lesions. Hamamelis and Hydrastis owe their astringent virtues to the tannic acid they contain ; they are inferior to the pure sub- stance, and I would not recommend them for local applications. Alcohol is antiseptic, astringent and stimulating, and exercises a curative influence upon flabby granulations and ulcerative pro- cesses. It whitens the granulations, constringes the tissues and vessels, coagulates the blood, and interrupts the morbid process. Granulations and mucous polypi soon shrink and disappear under its application, and fibrous growths, though more obstinate, are frequently destroyed. Several weeks or months will be ne- cessary to restore the mucous membrane to a healthy condition and to effect a cure. It is applied diluted and even pure. Iodine is sometimes useful in a granular, inactive state of the tym- panic membrane, accompanied by swollen lymphatic glands, and a strumous constitution. I use a solution, containing iodine twenty grains, iodide of potassium twenty grains, and glycerine forty grains. This is caustic, and should be applied to granulations by a camel- hair brush or a cottoned holder, and washed away in five minutes by a syringeful of water. Add an equal quantity of water to this formula, and the fluid will be suitable for instillation, and stimu- lation of the mucous lining of the tympanum, Eustachian tube, and throat. Iodine solution should be used cautiously in the tympanum, as the vapor is very penetrating and stimulating and may excite acute exacerbations. I sometimes spray the middle ear with twenty drops of the un- diluted mixture to a fluid ounce of water, and think I have seen benefit from its use. Every other day is often enough to make use of any of these iodine solutions. Spirits of Turpentine is a representative of the balsams, and like all of them has an antiseptic, stimulating, and sanitary influence upon the mucous membranes. Ten to twenty minims in a fluid ounce of water, instilled into a cleansed but chronically suppu- 256 THE HUMAN EAR AND ITS DISEASES. rating tympanum, Avith bluish venous congestion, will destroy the fetor, diminish the purulent discharge, and stimulate the surfaces to healthier action. Fernel wrote, " Tercbinthina calefacit, mollit, discutit, tergit, expurgat; obstructions tollit, et angustos meatus aperitP Salicylic acid, salicylate of sodium, chlorine-water, glycerine and many other remedies are praised for their virtues in purulent otitis, but their qualities are known by all physicians, their value is secondary to the agents already enumerated, and I shall not consider them further in this connection. The tympanum and auditory canal having been cleansed by injections and absorbent cotton upon the holder, and the Eus- tachian tube cleared by a strong inflation, the remedies I have just mentioned may be introduced, if fluid by the syringe, a tea- spoon or a dropper. Tuck a towel close around the neck of the patient, over the shoulder of the side that is being treated, incline the patient's head towards the opposite shoulder and put in the solution. Let the patient keep quiet and retain the remedy for five minutes at least, and practice Valsalva's inflation once or twice to favor the passage of the fluid into and through the Eustachian tube. If the patient cannot open the tube, use the air-bag without or with the catheter. Then at the expiration of the time, place a cup under the af- fected ear, bend the patient's head towards it, catch the outward flow, and dry the meatus, auricle and neck with the towel. When one uses nitrate of silver, the neutralizing salt solution is to be thrown upon the lower wall of the meatus, as the pa- tient alters the position of the head, and a warm douche ought to be used afterwards to remove the white coagulum of chloride of silver. This treatment, except that with nitrate of silver and the air-bag, should be taught to the patient's assistant or nurse, and be followed closely at home. Inflation by Valsalva's method should be insisted upon every time the instillation of the astringent is made, as it cleanses the Eustachian tube, drives the pus outwards, and permits the medicine to reach the disease more thoroughly. CHRONIC PURULENT INFLAMMATION OF TYMPANUM. 257 One or two dressings daily will accomplish all the good of half a dozen, because reaction in the tissues must be established be- tween times. The use of powders has been described under alu- men, et seq. The syringing, cleansing, and medication must di- minish pari passu with the disease, until one treatment a day, one in two days, and finally dropping in the medicine alone every other day will be sufficient. Another method of treatment has come into favor of late for those cases, which can visit the aurist once or twice a day. It may be called the dry treatment, and consists in cleansing the ear thoroughly with tuft after tuft of absorbent cotton, and the application of medicated cotton, or the usual medicated solutions or powders afterwards. This makes much work for the physician and larger fees, but in my opinion has no advantage over the wet method. It is very difficult, not to say impossible, to clean a suppurating ear thoroughly with cotton pledgets, and few patients can endure the necessarily close wiping of the hypersensitive tympanum. I have tried the innovation and abandoned it, .except in peculiar cases, as of doubtful utility, and throw the burden of proof of its superiority upon its enthusiastic votaries. There is no proof that moderate syringing of a suppurating ear to get rid of the pus and debris increases the disease one iota; on the contrary, long experience approves this method of cleans- ing, and it is certainly less irritating to the mucous membrane than dry wiping. Probably the rigidly dry method will in the future be mentioned as a curiosity, as are now the aural douches of a pailful of water at a time, recommended by Itard. When the secretion of the tympanic mucous lining has been restored to nearly a normal condition, efforts must be made to close the perforation, as detailed under injuries of the membrana tympani; or failing in this, an artificial drum-head may be ad- justed to the peripheric remains of the membrane, or to the inner end of the canal, as directed under artificial membrana tympani, to which the reader is referred. When suppuration has been arrested, the ear will present one of the three following conditions : , 258 THE HUMAN EAR AND ITS DISEASES. 1. The membrane may be closed by a cicatrix, and the mucous membrane of the tympanum be healthy. 2. The membrane may show a small or medium perforation, and the mucous membrane be a little hyperaemic and moister than usual. 3. There may be a large perforation, and the mucous membrane look pale, thick, and dry from an extension of the epidermis of the canal into the tympanum, so that the lining is very much like the skin. This dermic transformation is considerable protection against future attacks of suppurative inflammation, and lately attempts have been made to induce this change by placing grafts of skin upon the granular mucous membrane. There are several acids employed for cauterizing purposes, which may as well be mentioned in this place. They are acetic, chromic, carbolic, chloro-acetic and nitric acids. Acetic Acid is cooling, astringent, stimulating, and caustic; it has a destructive action upon morbid tissues, and an affinity for the cellular structures of malignant growths. It does not cause much pain, but is not used as much as formerly. Nitric Acid is a severe caustic, causing deep, persistent ulcera- tion and severe pain. It destroys granulations and polypi rapidly, is thought to exercise a tonic influence upon surrounding tissues, but must be used sparingly, and should always be neutralized by a solution of the hydrate or carbonate of potassium. Chloro-acetic Acid has all the virtues of acetic acid, is rather more antiseptic, and causes only slight and transient pain, quickly removed by an injection of warm water. It is a favorite agent for the destruction of granulations and soft polypi in the ear. Carbolic Acid has not been employed in tympanic suppuration as much as its merit demands. It is stimulating, strongly anti- septic and disinfectant, causes local anaesthesia, and is, in my opinion, the very best of this group of remedies for cauterizing fungous granulations and soft polypi. I use the pure deliquesced crystals on cotton for this purpose, inject warm water afterwards; and dry out the ear carefully. It should have the preference in all cases accompanied by a foul odor, and by caries or necrosis, and may be employed with CHRONIC PURULENT INFLAMMATION OF TYMPANUM. 259 advantage as a daily cleansing injection, in the proportion of five minims to a fluid ounce of water. The pure acid is, also, an agreeable, manageable, efficient agent with which to irritate or blister the surface of the mastoid process, if an exigency should arise to demand this procedure. Chromic Acid is a more powerful escharotic than any of those mentioned. It is slow, deep, and persistent in action, and justly has the preference for the destruction of dense, fibroid polypi, or their roots remaining after abscission. A few crystals and a few drops of water, or about one part of the acid to four of water, give a suitable solution for cauterization. The morbid growths alone should receive the caustic; the action must be watched and the acid neutralized by a hydrate of potassium or carbonate of sodium solution, when.it has gone far enough. Burnett says, " Under no other application does the remnant of the pedicle of a polypus disappear so surely and so rapidly." The method of applying these powerful remedies is to twist a small tuft of absorbent cotton upon the end of a roughened silver probe, and make a miniature brush ; the brush part should be about four millimeters in length and diameter. Dip this into the acid and press the surplus out upon the neck of the bottle, or upon a tiny dish, then under good illumination with the head mirror and rubber speculum, touch the diseased place firmly and remove the probe. This should be done twice or three times a week for granulations, but in case of polypi or their remains, the operation should be performed every day. Between times, a pledget of cotton should be kept in the meatus to catch the drain, and a simple warm douche employed to remove pus and debris. When the caustic is no longer necessary, the astringent stimu- lants should be commenced and continued till a cure results. Tissues get accustomed to a remedy after prolonged use, and it is well to change to another and another, till the proper one cures. The state of the tissues will be a guide to the selection. The touching and medication should be diminished gradually as the disease disappears. The presence of granulations of moderate size upon the mucous membrane of the diseased tympanum is not a complication of the 260 THE HUMAN EAR AND ITS DISEASES. disease, but an ordinary concomitant, and will not be given a special division. These granulations vary in density and size, and predispose to the formation of polypi by increasing the quan- tity of discharge. They may be so solid, that wiping them with a hard cottoned probe will merely redden them; or so soft, succulent, and vas- cular, that they will bleed freely from mere touching. The former will require the stronger applications and the latter the weaker. Sometimes one application will destroy them, but gen- erally considerable treatment with both a caustic application and an astringent wash will be necessary. The clearer the tympanum is kept of pus the sooner they will vanish. I have insisted upon inflation before and during the dressings of the ear by the physician and by the patient, in order to drive all of the pus out of the Eustachian tube and tympanum, and to permit the flow of the medicated solution into the tube and pharynx. This happens in a majority of the cases, though the flow of pus through to the throat is rare. When the air passes through the tube with difficulty, or not at all, the medicine ought to reach the tubal lining. To effect this, clean the tympanum, introduce a rubber stopper closely into the meatus, having a perforation in the centre for the nozzle of the hand syringe; fill the syringe with salt water, press it tightly into the perforation, incline the head forwards, and with firm pressure send the piston home. The water may spray all over the patient and the operator unless he is careful, but it may go through the tube to the throat and drop or flow from the nose. Then use a little of the medicated solution in the same way, but do not try nitrate of silver for obvious reasons, unless the tube is very free, when it should be dropped into the canal inside the stopper, and forced through by a plain water injection. Another method of cleaning and medicating the tubal mucous membrane is by injecting through a Eustachian catheter in situ, but though apparently easy, this is really difficult, and not so comfortable for the patient, who swallows the leakage from the inner end of the catheter. Both methods should be employed when the tube is obstructed, and both ends thus medicated. Most of the medicated solutions may be used for the Eusta- CHRONIC PURULENT INFLAMMATION OF TYMPANUM. 261 chian tube, that are recommended for the tympanum. In some cases, I have been able to force fluid from the tympanum through the tube, and unable to reverse the process through the catheter, though the position of the latter in the tube was verified by the usual tests, and an inspection of its inner end by means of a throat mirror. ' It is probable that a relaxed mucous mem- brane closed the tube, or the force of injecting into the catheter pressed its inner end too hard against the side of the tube. The local measures outlined above should be continued persist- ently by the physician, assisted by the patient and attendant, no matter what the seeming discouragement. It will be difficult to get the home treatment done systemati- cally, and the physician must be vigilant in finding out how his orders are executed, and insist upon thorough work. A careful diagnosis of the morbid state, good judgment in ref- erence to the selection of the local applications, and the intelli- gent co-operation of the patient will do wonders in purulent otitis. The hygiene of the patient and internal medication must not be neglected. The surgical treatment in a given case will depend upon the complications. Affections of the auditory canal and tympanic membrane have been already discussed. Operative proceedings for polypi, exostoses, caries, necrosis and mastoid disease will be considered in a separate chapter, under complications of purulent inflammation of the tympanum. The hygienic and medical treatment must now engage the at- tention. The patient ought to live in a dry non-malarial region, have good nutritious food, and clothing appropriate to the sea- son. Home, river, and sea baths may be taken in moderation, but reaction must be established by wiping the body dry and red; the hair should be kept as dry as possible, and the ears should be closed temporarily by bits of cotton. This may pre- vent hearing ' what the wild waves are saying,' but it will pre- vent earache. Water in the ear is likely to increase the irrita- tion, especially sea-water, and exposure may give the most care- ful bather a coryza or sore throat, which may aggravate the tym- panic disease. Baths are quite beneficial to the general health, but should be indulged in with caution, especially, if the patient 262 THE HUMAN EAR AND ITS DISEASES. is anaemic and possessed of little reactive power. Warm brine baths are more suitable to this class of patients. Scrofulous persons, well rounded by fat and muscle, and hav- ing good appetite and digestion, improve their aural affections by a short summer visit to the sea-shore ; but the pale, thin, weak- ling finds the water too cold, the winds too strong, the dampness too great, and very often comes home with health unimproved, and the ear disease, if not worse, at least no better. This latter class do best in the dry, rarefied atmosphere of the mountains, where bal- samic airs and deep fragrant woods soothe the nervous system, and stimulate the mucous membranes to healthy activity. Cresson Springs, Pa., is a very salubrious place for these pa- tients, but the chalybeate water should be taken, if at all, only in small doses. The calcic sulphur water of the Yellow Sulphur Springs, the iron and alum water of Rockbridge Alum Springs, Va., and the sulphur water of Bedford, Pa., are appropriate for strumous ear cases. Syphilitic, rheumatic, and gouty patients often derive much benefit from short visits to some of the numerous springs with which our country is favored. It is fashionable and proper to take a vacation in the summer, and those patients who can get away should not wander aimlessly about, but by physician's di- rection seek the place most favorable to their cure. The Hot Springs of Arkansas have a deserved reputation in syphilitic cachexia, which must be removed and the blood puri- fied before a permanent cure of specific aural disease can be ex- pected. The rheumatic and gouty diatheses are favorably modified by the waters of Bedford Spring proper, of the Congress and Gey- ser, at Saratoga, N. Y., and of Saint Catherine's Wells, Canada; and the pleasures of a two weeks sojourn at any of these charm- ing places will do more than the waters to invigorate a jaded and depressed vitality, and thus promote healthier action in a diseased mucous membrane. Most of these mineral waters can be procured on draught or bottled at the pharmacies, so that they may be employed, if thought desirable, without going away from home. The medicines of value in purulent inflammation of the ear CHRONIC PURULENT INFLAMMATION OF TYMPANUM. 263 are few, and I shall not devote much space to their consideration. In acute exacerbations, Aconite, Belladonna, Chamomilla, Pulsa- tilla, and others mentioned under acute inflammation of the tym- panum, should be reviewed, and douches, gargles and inflations made as usual, until active symptoms subside. The canal and tympanum are to be cleaned out thoroughly, as obstruction to the outward flow of pus is oftener the cause of pain, than acute in- flammation. Most of the mild cases mentioned under number one and two, in my division at the beginning of this article, may require Ar- senicum, China, Hepar, Kali bichrom., Kali hydriod., Mercurius, Rhus or Silicea. Some few of number two, with those of num- ber three and varieties, are best treated by Aurum, Calc. phos., Calc. carb., Calc. iod., Ferrum iod. and Terebinthina. This is a general statement, subject to many exceptions, as will be seen from the symptoms under individual medicines. Arsenicum Album is indicated, when there is anaemia, localized oedema, weakness, and renal irritation from erythematous dis- ease. Persons of robust health, except in the ear, having a ten- dency to vesicular, pustular or phlegmonous eruptions, especially, in and about the ear, are greatly benefited by the remedy. I have not been satisfied with its action in those cases of intense struma, where the drum-head and ossicles melt away in the pro- fuse suppuration. When the throat is rough, dry and granular, there is burning and soreness during swallowing, the expectoration is slight and viscid, inflation is easily, almost noiselessly accomplished, and the cervical glands are a little hardened by infiltration, Arsenic is very useful. The special ear symptoms calling for it are: purulent inflam- mation of the tympanum of moderate degree; the pus is ichorous and irritates parts with which it comes in contact; the canal is rough and scaly; the mucous membrane is red, shining and dry in places, has small dense granulations or polypi not inclined to bleed; there is much sensitiveness to contact, and a tendency to hypertrophic processes in the mucous membrane, fibrous tissue, and intrinsic muscles. 264 THE HUMAN EAR AND ITS DISEASES. Aurum.—The pathogenesis of gold is remarkably diluted, and reliable indications for its administration scarce. It was long ago recommended highly for scrofulous and syphilitic diseases, but abandoned because other medicines were superior to it. The pa- tient requiring it is peevish, depressed and melancholy; feels weary and worn; is over-sensitive to touch and motion ; the bones ache and the joints are sore and stiff; the skin may show some slight eruption, or the subcutaneous tissue of the lower limbs be oedematous. The digestive and urinary tracts are irri- tated and disordered; the urine and insensible perspiration are increased; the heart's action is augmented and disturbed, and fitful feverish symptoms may ensue. The eyes are sometimes in a condition of chronic conjunctivitis, neuralgia shoots about the face, the orbital and cranial bones are sore to the touch, and may be affected by caries or nodes. There may be coryza, sneezing, and mucous discharge; chronic nasal catarrh with an excessively fetid and offensive discharge of crusts and pus; ulceration, pain and closure of the nose; caries of the nasal bones, tenderness of the nose and forehead, with severe headache between and over the eyes. The throat is rough and granular, the tonsils are swollen and hypertrophied, swallowing may cause pain, and the palatine bones be carious. The cervical glands below the ear are enlarged; offensive, yel- lowish-white pus flows from the auditory canal; the membrana tympani is largely perforated; the ossicles have mostly disap- peared; a polypus may fill the middle ear; the tympanic mem- brane is generally pale and flabby, and may show to the probe one or two sinuses, or there may be exostoses beneath it. Caries of the roof and posterior external portion of the tym- panic wall, extending to the mastoid, with a sinus discharging dark pus behind the ear, is a common condition. The pus of caries, whether from the sinus or from the meatus, is generally of mahogany color, owing to the admixture of blood and little particles of dead bone. It is not infrequent to have a light pus from the meatus, and a dark pus from the mastoid sinus, or vice versa; the foul odor of the darker is almost pathognomonic of necrosis and grave disease. There is generally some tension and pain in CHRONIC PURULENT INFLAMMATION OF TYMPANUM. 265 the mastoid and around the auditory canal; the overlying tissues are red, boggy and cedematous from inflammation, and there is great sensitiveness to cold. Such are the leading symptoms accredited to Aurum. Let them not lead away from other medicines, that have been better proved and have rarely disappointed. Cinchona is sometimes required in purulent otitis. It is de- manded by torpor of the vegetative functions, confusion of the mind, debility, great sensibility to cold, and fitful feverish symp- toms ; by rough sore throat, pain on swallowing, swollen sub- maxillary glands, and heat and sensitiveness in the aural region. The ear symptoms demanding Cinchona are, intermissions in the severity of the symptoms; ringing, roaring or rumbling tin- nitus ; a stopped, full feeling in the ear; neuralgic paroxysms in the ear, side of the head, and occiput; a moderate suppuration of the tympanum, the pus sometimes mixed with blood; consid- erable bright redness and heat of the auditory canal; a smooth crimson inflammation of the mucous membrane, without granu- lations or polypi, but with excessive sensibility to touch. Occasionally the discharge diminishes, the patient has a light chill followed by red cheeks and slight fever, which disappears when the discharge becomes free again. As an intercurrent remedy in hectic, caused by caries of the temporal bone, this medicine has no rival. Calcarea Phosphorica is a nutritive stimulant, which exercises marked influence over cellular processes, and has a decided af- finity for glandular and osseous tissues, so that it is very applica- cable to purulent otorrhoea in scrofulous subjects. In anaemic and cachectic patients, with long-standing profuse suppuration, much debility, and feeble circulation, it sometimes does wonders. The particular symptoms demanding the medicine are, coryza and dry sore throat, considerable mucous secretion, and pain when swallowing; the Eustachian tube is full of mucus and inflates with difficulty. There is dulness of hearing, tinnitus of varying quality, coldness of the auricles, sensibility of the ears to cold air and drafts, soreness on pressure in front of the tragus and under the auricle, and a copious flow of straw-colored offensive pus. 18 266 THE HUMAN EAR AND ITS DISEASES. The mucous membrane of the tympanum is light red, spongy, covered by large succulent granulations, and, perhaps, shows ulcer- ation ; the ossicles are generally gone; the tympanic membrane has a large perforation, and caries of the temporal bone may exist; a sinus may be open upon the mastoid, and discharge the same kind of pus, containing little particles of bone, as in caries of the meatus; the facial nerve may be paralyzed, and the face distorted. Destructive ulceration is likely to exist, and the constitution to show the effects of the disease by well-marked hectic fever. Calcarea Carbonica is like the phosphate a nutritive agent, but does not stimulate in the true sense of the word. It aids the organic processes, and has affinities for the glands, ligaments and bones. These properties make it an important agent in the mal- nutrition of scrofula, and eminently fit it for cases of chronic suppuration of the ear in strumous persons. It is suitable for these, when the patient chills and sweats easily; there is hyperaesthesia of the skin, eczematous eruptions, swollen lymphatic glands and, perhaps, parotids, irritable sensi- tive eyes, sore ulcerated nose either very dry or swollen and plugged by decomposing mucus, impaired sense of smell, and occasional epistaxis. The mucous membrane of the throat and naso-pharynx is con- gested, cedematous, and relaxed, and secretes a large quantity of dirty white mucus. There is burning in the throat, a sensation of a lump with feeling of constriction; swallowing is sometimes painful, pains shoot through the Eustachian tube, the neck is stiff, and on inflation loose mucous r&les are heard. There may be a coarse sounding tinnitus of a rhythmic variety, owing to the pulsations of congested vessels in the tympanum and adjacent to it; the profuse discharge from the ear is white, flaky, and caseous, of a cheesy odor, and the walls of the canal are white and macerated. The membrane usually presents a large perforation ; the ossicles are carious or absent; the tympanic mucous membrane when cleaned looks pink and flabby, and presents large pale granula- tions or polypi, which bleed easily when touched; there is consider- able sensitiveness to contact, but little soreness around the auri- CHRONIC PURULENT INFLAMMATION OF TYMPANUM. 267 cle; ulceration of the mucosa, and caries are frequently present, and the patient presents the appearance of marked dyscrasia. Calcarea Iodida is another lime medicine, which is appropriate for the same class of cases as the phosphate and carbonate. I have used it after a long trial with the latter, when the disease seemed to be at a standstill, and the mucous lining of the tympanum was indolent. A more acrid pus and greater swell- ing of the lymphatic glands, occurring in a thin, dark patient, have led me to employ it, and it has frequently proved its cura- tive power. Capsicum has pathogenetic outlines closely resembling the more acute symptoms of the disease under treatment. Symp- toms demanding its employment are, neuralgic pains, lateral headache of great severity, and chilly sensations followed by fever. There is nasal catarrh, acute or chronic; a dark red, inflamed throat, which burns and stings, and feels constricted on swallow- ing, and may show a little ulceration. The Eustachian tubes open freely, but inflation causes pain from the throat through the ear. The auditory canal is reddened, the membrane is perforated, the ossicles may be partially destroyed, the tympanum contains a little pus, and is hot, red and tender. Movement of the auricle causes considerable pain; the mastoid is red, hot, sensitive, and swollen; the whole side of the head aches violently, and keeps he patient restless, feverish, and, perhaps, delirious. This medicine is highly recommended by Dr. H. C. Houghton, of New York city, in acute exacerbation and sudden extension of old chronic inflammation of the tympanum to the mastoid cells. He has reported numerous cases of unmistakable mastoid inflammation, which have rapidly subsided after the administra- tion of capsicum. After the evidence presented by so close and conscientious an observer as Dr. Houghton, this medicine should be given the first place in the early stages of mastoid inflam- mation, whether it be periosteal -or intra-cellular. My experience with it is limited, and though I feel bound to try it upon suitable cases, I feel loth to permit it to take the place of such well-proved remedies as Aconite, Belladonna, Kali 268 THE HUMAN EAR AND ITS DISEASES. brom., and Hepar, because in conjunction with necessary opera- tions they have served me well. Ferrum lodidum is well adapted to cases of anaemia from de- fective digestion, malassimilation, and profound depression of the vital powers, induced partly by the profuse suppuration. When the lymphatic and tonsillar glands are in a condition of chronic engorgement and inflammation, the pus from the ear is thin and bluish, or reddish from the presence of blood ; the tympanic mu- cous membrane is ulcerated, and the temporal bone carious, this alterative nutrient will sometimes arrest the destructive process, and aid in restoring the patient to health. There is very little pain, aural hemorrhage, and hectic, as under Cinchona, but an absence of reactive symptoms, because the powers of the system are at too low an ebb. Hepar Sulph. Calc. is invaluable in some of the cases under consideration. When there is lassitude, weakness, irritability, chilliness, slight fever, various eruptions not healing readily, inflammation of the lymphatic glands of the neck, lateral or frontal headache, and sore eyes, in strumous patients, this agent is very useful. It is especially requisite, when the throat feels dry and scraped, the tonsils are hypertrophied, sharp pains extend from the throat to the ear, there is constant hawking of mucus; the external ear and meatus are itching, red, hot, and burning; a vesicular erup- tion covers the auricle, the cerumen is morbid and excessive, and the Eustachian tube opens imperfectly. There is usually a dis- charge of thin yellowish-white, cheesy, fetid pus from the ear; a pink, macerated appearance of the canal walls, and a reddened mastoid; aching in the ear and whole side of the head, worse in the cold and at night, with painful sensibility when touched. The canal is often narrowed by swelling of its walls, so that the tym- panic membrane and middle ear are invisible; the membrane is perforated, but inflation frequently fails to force air outward, and causes considerable pain. The more acute symptoms mentioned are present in the early stages of purulent inflammation of the tympanum, and in acute exacerbations during the course of the chronic disease. For such attacks, this medicine will be found more appropriate than for the slow painless subacute conditions. CHRONIC PURULENT INFLAMMATION OF TYMPANUM. 269 Kali Bichromicum is highly recommended in this disease, but my experience with it has been very unsatisfactory. It is appro- priate for cases of mild inflammation of the nose, naso-pharynx, Eustachian tube and tympanum, with a discharge more mucoid than purulent, tough, whitish-yellow and tenacious; it obstructs the Eustachian tube at times so that air cannot be forced through it, and clings to the throat and tympanum in patches and shreds, resembling a false membrane. The pain in the ear is slight and inconstant, accompanied by itching and warmth, and it shoots through the ear and about the angle of the jaw. The auditory canal is nearly of normal color, the drum-head has a small perforation, the mucous membrane of the tympanum is pink and inactive, and may show a few granu- lations and shallow, indolent ulcerations. This medicine is most appropriate for very mild inflammations of the ear, and for chronic cases that are approaching a cure, just as are Graphites, Pulsatilla, Tellurium, and others. Kali Hydriodicum is an antiplastic of decided power, and it presents iodine to the system in one of its least irritating combi- nations. It has affinities for the mucous membranes and glands, which render it curative in many morbid conditions. It is likely, in large doses, to irritate the stomach and kidneys and induce a hydraemia, which is opposed to healthy nutrition, and, therefore, must be given in small doses well diluted in water. It is frequently valuable when there are pains of the muscles, ligaments and bones, aggravated at night; hard knotty lym- phatic swellings and oedema, and pustular and furuncular erup- tions. There may be acute or chronic nasal catarrh, accompanied by dull pain ; inflammation of the pharyngeal follicles and the glands in the naso-pharynx; hypertrophied tonsils; catarrhal in- flammation of the Eustachian tube, indicated by noisy inflation or total obstruction ; swelling of the submaxillary and cervical glands; heat, redness and a scaly state of the auditory canal, sometimes, accompanied by phlegmonous swellings; periostitis and severe pain; caries and necrosis; paralysis of the facial nerve ; a small or medium perforation of the drum-head; muco-purulent discharge of small quantity and variable appearance; crusts and 270 THE HUMAN EAR AND ITS DISEASES. scales adhering to the perforation and to the smooth, red, moder- ately inflamed mucous membrane. These symptoms call for the exhibition of this medicine, espe- cially, when the patient is of a rheumatic or gouty diathesis, or has been afflicted by syphilis. Kali Phosphoricum is a new medicine for suppurative otitis, introduced to the profession by Dr. Houghton, to whom we are much indebted for careful studies in aural therapeutics. He quotes the following symptoms, arranged by Dr. Walker: " Breath offensive, fetid ; tongue coated like brownish liquid mus- tard ; diarrhoea foul, if accompanying any other disease, with putrid evacuations; dysentery, with putrid very offensive stools ; evacuations putrid, very offensive smell; intermittent fever; pro- fuse, fetid perspiration; debilitating mastitis; if the pus is brownish, dirty looking, with heavy odor; suppurations dirty, foul matter with offensive odor ; toothache with easily bleeding gums. In the muscle cells, fatty metamorphosis ; in the muscular juice, or myosin, putrid decomposition ; in the blood corpuscles, rapid decomposition; it cures septic conditions, scorbutic bleedings, mor- tification, putrid smelling diarrhoea, and a dynamic typhoid con- dition." Dr. Houghton says, " the dark color and offensive smell of the discharge are the characteristic features. I have used potash in many cases having the above indications, and am gratified at the results obtained. In otitis externa, the epidermis is moist, crusts form and scale off, leaving the canal red and shining, but a few days suffice to form similar crusts; the inner third of the canal and membrane is either filled or the walls are abundantly covered with thick, dark-colored pus, fetid and sometimes grumous or granulous; the tissues when cleaned are rough, easily bleeding or covered with small granulations. In otitis media, the membrane of the tympanic cavity takes on the same type and gives a puru- lent product free from mucus; the bloodvessels rupture easily, and slight oozing of blood will often follow the most careful cleansing with absorbent cotton, but if the ear is kept dry by daily use of the cotton, and the remedy is given two or three times daily, a change for the better is soon observed. I judge the effect of the salt to be that of removing morbid conditions of the mi- CHRONIC PURULENT INFLAMMATION OF TYMPANUM. 271 nute bloodvessels, thus preparing the way for such a remedy as Silicea or Calcarea."* It is apparent that Kali phos. is applicable to much the same kind of cases as Calc. phos. I have no experience with the for- mer, but shall be inclined to use it in non-strumous patients in- stead of the Calc. phos., which is so valuable in strumous con- stitutions. Mercurius invades all the tissues, increases the secretions, favors elimination, deteriorates the blood, causes hemorrhages, and softens, ulcerates and breaks down the solid structures of the body. It strikes at the animal system by its powerful action upon the vegetative, and gives a life-like picture of scorbutus. When it is indicated, the muscles of the neck are sore and stiff, and the bones are affected by periostitis, nodes, caries and ne- crosis. The skin is of a sallow earthy hue, and excoriates and ulcer- ates easily; the cervical lymphatics are swollen or ulcerated, and the throat is painful to pressure. The nasal fossae present the different stages of inflammation seen in chronic nasal catarrh; the discharge is thick, scabby and foul; the pharynx is rough, tumid and vascular from the constant irritation of the discharge; the Eustachian tube opens with a noisy rattle, owing to relaxation of the mucous membrane and the profuse discharge; the throat is dark red, its tissues thickened and relaxed, and it secretes much muco-purulent matter. There are dull pains about the auricle and middle ear; occa- sional shooting pains in the whole aural region; the discharge from the ear is yellowish-gray pus, mixed with blood and debris of ulcerated tissues; the auditory canal is pale and its lining puffy and moist from the constant flow of purulent matter; the membrana tympani looks like chamois skin, and shows a large perforation; the tympanum is usually full of inspissated pus, forming adhesive caseous patches; when this is cleaned out, the mucosa is seen to be pale red and flabby, and presents large, * Kali Phosphoricum in Suppurative Otitis. By Henry C. Houghton, M.D., New York City, N. Y. Transactions of the American Institute of Homoeopathy, J. C. Burgher, M.D., Secretary. Eichbaum & Co., Pittsburgh, Pa., 1881, page 618. 272 THE HUMAN EAR AND ITS DISEASES. spongy, vascular granulations, which bleed upon the slightest touch. There may be ulcerations and sinuses in the mucous lin- ing, leading inwards and outwards to carious bone, or it may be elevated by nodes beneath it, or by polypi springing from i!s surface. For recent and severe cases, I have found Mercurius corros. most efficient. In those of slower progress with plastic exuda- tion and hypertrophy, which it is desirable to remove, the Merc. iod. flav. is better. For mild cases without any tendency to hypertrophy or destructive ulceration, the Merc. sol. is efficient, and it is the most suitable for administration in powders. I gen- erally rely on these three preparations, and believe they will suf- fice for most cases in which Mercury is beneficial and curative. Mercury should be pushed for some time, when the ear disease has been caused by syphilis. Nitric Acid is characterized by prostration, exhaustion, weari- ness, trembling of the limbs, stiffness and soreness of the muscles, and pain in the joints and bones. There is great sensibility to cold, chilliness, flashes of heat, and itching eruptions of vari- ous kinds upon the skin. The tongue is coated white, the breath foul, the stomach and bowels irritated, and the flow of urine in- creased. The gums and mouth become sore, salivation is in- creased, the throat sore, the tonsils swollen, and the nasal fossae affected by chronic catarrh in all stages, from dry irritation to the foul offensive ulceration of ozaena. The naso-pharynx is granu- lar and reddened, owing to the nasal slime that flows over it, and the Eustachian tubes open with difficulty or not at all. The auditory canal is narrowed from swelling of its walls; a thin yellow or brownish pus fills the passage; the drum-head shows a large perforation ; the ossicles are carious or have been discharged; the mucous membrane of the middle ear is pale, granular and flabby, and caries of the temporal bone may exist, with shooting pains and tenderness to the touch. The caries is likely to extend along the roof of the canal and through the mastoid process, revealing its presence by an abscess or sinus behind the auricle, and a rough feeling of bare bone to the probe. This lesion is supposed to be the result of an abuse of CHRONIC PURULENT INFLAMMATION OF TYMPANUM. 273 Mercury, or of constitutional syphilis, but the connection cannot be proved. Caries of the mastoid process is in most cases the result of neglected disease of the middle ear, and may affect the most robust constitution, though scrofula predisposes greatly to it, as it does to many other bone diseases. Rhus Toxicodendron seems to fill a gap in therapeutics, that no other medicine can. I should seek far before employing it in purulent otitis, occurring in strumous constitutions; but in strong, well-developed persons of bilious temperament, suffering from the disease, it is occasionally very useful. The symptoms that call for it may be briefly stated. There is a sore bruised feeling in the muscles, with stiffness and pain about the joints. The skin of the face is dusky red, the arterial capil- laries of the cheeks and side of the nose are dilated. Erysipela- tous inflammation occurs occasionally upon the face and head, accompanied by vesicles, pustules and oedema; the auricle may be thickened and stiff and the lobe tumefied; the mastoid red and tender, and the cervical glands and parotids swollen. The throat is dry, red, thickened, and sore; swallowing is dif- ficult ; sharp pains shoot from the throat to the ear and neck; the Eustachian tube opens freely to inflation, but the operation causes considerable pain in the throat and ear. The purulent discharge is small and cakes somewhat in the tympanum; the external canal is red and scaly; the membrane shows a moderate- sized perforation, and the mucous membrane appears smooth, vascular and shining after the pus has been removed. The patients are of a rheumatic or gouty diathesis, often broken in health from intemperance and exposure, and suffer in various ways during damp or inclement weather. Silicea acts upon the skin, mucous membranes, glands and bones. Among symptoms demanding its use are, weakness, heaviness and pain in the limbs; a feeling of general weariness and debility; sensitiveness to cold; slight febrile symptoms; headache, arising in the neck and occiput and extending for- wards to the right eye, and much sweating of the head. The skin is unhealthy, prone to eruptions that suppurate ex- cessively, and show little disposition to heal. The muscles are 274 THE HUMAN BAR AND ITS DISEASES. stiff and sore, and the bones sometimes affected by periostitis, eburnation, nodes and caries. The nose and naso-pharynx are in a condition of catarrha. inflammation ; the throat and pharynx are dry and hyperaemic; crusts of altered mucus from the posterior nares, parade down the pharynx and keep it irritated; swallowing may be painful and cause shootings into the ear; the Eustachian tube opens noisily and with difficulty. The auricle and aural region may present an eczematous eruption, which has arisen de novo, or has been caused by permitting discharges from the middle ear to come in contact with the parts ; the auditory canal itches and burns; its epidermis is partially macerated and shreddy; the surface beneath is pink, and a thin or thick yellowish-white pus, containing papery pieces of epithelium, fills the passage. The drum-head is largely perforated ; the ossicles generally destroyed; the mucous membrane is pink and granular, perhaps, showing ulcers or a polypus; caries may exist in the walls of the tympa- num, the roof of the canal, and the mastoid process, and the facial nerve be paralyzed. According to the pathogenesis, Silicea finds its sphere of action in scrofulous patients, in whom purulent suppuration of the tym- panum frequently runs a very destructive course. Dr. Houghton thinks Silicea acts upon the substantia propria, or the fibrous middle layer, of the membrana tympani, and favors the healing of perforations. Sulphur has a pathogenesis which resembles that of Silicea in some respects, and it may be given as an intercurrent remedy in some cases of this disease. Terebinthina has been lauded elsewhere as a local application, and should be given internally oftener than it is. It possesses the stimulating, yet, soothing properties of a balsam, and has a strong affinity for the mucous membranes. It is of value in general debility, heaviness and stiffness of the limbs; irritation of the digestive and urinary tracts; eczematous eruptions upon the skin; slight feverish reaction, peevishness and restlessness; fulness of the head and ears; hyperaemia of the nasal mucous membrane with nose bleed; roughness and dryness of the throat; burning soreness and swelling of the gums; diffi- THE ARTIFICIAL MEMBRANA TYMPANI. 275 cult dentition of children, and a moderate flow of thin yellowish pus from the ear, which alternates sometimes with an eczematous eruption on the head. The eczema may have extended into the auditory canal, and caused ulceration of the drum-head, and purulent inflammation of the tympanum. The perforation is of moderate size ; the mu- cous membrane within red, shining and smooth, and the ossicles are frequently unaffected. Dr. Cooper, of London, England, recommends this medicine strongly for infantile cases, where denti- tion, otalgia, and purulent inflammation make the morbid picture. Quite a number of other medicines have been recommended for this disease, but the symptoms that have led to their selection have not been clearly stated, and until they are, reliance had bet- ter be placed upon those mentioned. It is necessary to resort to medicines, noticed under acute in- flammation of the tympanum, in case violent symptoms super- vene at any time from cold, obstruction, etc. When the purulent inflammation is greatly diminished, and the disease approaches a cure, higher potencies should be given, until the last trace of dis- ease that is curable has vanished. The Artificial Membrana Tympani.—An artificial mem- brana tympani, or drum-head, has been employed for a long time Fig. 76. Toynbee's Artificial Membrana Tympani. in aural practice. An American discovered that a piece of paper pushed in his diseased ears improved his hearing. Dr. Yearsley, an Englishman, took the hint from the gentleman, substituted a pellet of cotton for the paper, and introduced the method to the profession. Mr. Toynbee improved upon this idea and invented the instru- ment which bears his name. It consists of a thin, flexible rub- ber disk having a central eyelet plate of silver, in which is in- serted the end of a short slender wire. The latter is merely for the purpose of placing it in position and withdrawing it at 276 THE HUMAN EAR AND ITS DISEASES. pleasure. Various modifications of this instrument have been suggested by aural surgeons, but it remains to-day the favorite apparatus for the purpose for which it was invented. The extemporized drum-head, be it cotton or a disk of rubber, subserves two purposes: it protects the tympanum from dirt and air, and concentrates and transmits vibrations to the parts within. The mucous membrane is kept in nearly a normal condition, and the hearing power may be considerably increased. The conditions in which an artificial drum-head may be used with benefit are : 1. In cases of perforation of the membrana tympani, even, when only a mere rim remains around the periphery. 2. When the handle of the malleus or its short process, with a little triangle of the membrane is still in connection with the chain of bones. 3. When the malleus is lost, and the incus and stapes are still in proper position. 4. When the incus and, perhaps, part of the stapes have been destroyed, but the plate of the stapes is still movable in the oval foramen, and more or less of its limbs project outwards. 5. In some exceptional cases of relaxation and pouching out- wards of the drum-head. An artificial drum-head is contra-indicated : 1. When the ossicles, with the exception of the foot-plate of the stapes, are absent, and the tympanic mucous membrane is thickened and degenerated. 2. When the ossicles are immovably anchylosed. 3. When the remainder of a damaged membrana tympani is firmly adherent to the ossicles and inner wall of the tympanum. 4. When there is paralysis of the auditory nerve. 5. When the patient does not exercise great care to keep the ears clean, and the drum-head properly adjusted. 6. When it causes much irritation, and does not improve the hearing. Application of the Cotton Drum-head.—A little wad of clean absorbent cotton should be moulded into a disk of the diameter of the inner end of the auditory canal, and moistened with equal parts of glycerine and water or smeared with vaseline. THE ARTIFICIAL MEMBRANA TYMPANI. 277 The ear should then be illuminated by the head mirror, and the cotton taken by the small angular forceps and placed directly upon the parts in continuity with the stapes. It may rest upon the stapes, incus, malleus or membrana tympani, or fragments of one of them; and by repeated changes of its position and pres- sure, one must determine where it should be to improve the hear- ing the most. Sometimes it should rest lightly upon its supports ; again it should be pressed down into a firm compact layer. No description can convey an exact idea of the manipulation neces- sary, as the requirements of cases are so different. It is better to use the pledget of cotton in all cases until the parts become accustomed to the presence of a foreign body; then the rubber membrane may be applied, if deemed applicable. When the ear is running it should be syringed, have an as- tringent wash applied, and a fresh piece of cotton introduced once a day. When it is dry the cotton should be changed once a week. After toleration is established, it may be left in position longer, but the patient should report to the physician if he feels any dis- comfort in the ear, in order that proper treatment may be insti- tuted. The physician ought to apply the drum-head for a time, during which he keeps watch of the case, and if all goes well, instruct the patient how to adjust the thing himself. Application of Toynbee's Artificial Membrana Tympani.—The rubber disk is much easier placed in proper relation with the parts than the cotton pledget. It is generally too large, as fur- nished by the instrument-makers, and is to be trimmed with the scissors to fit the inner end of the canal as closely as possible. Take it by the wire stem and push it into the canal until by in- spection and resistance it is known to rest upon the damaged membrana tympani or ossicles. Then turn it around a little, press it up, down or horizontally till hearing improves. The patient ought to be instructed early how to place it in position, and should remove it every night, for a week or two, to lessen the irritation. He should keep the canal scrupulously clean, and ought to change the instrument for a new one every month, as it shrivels and hardens in dry ears if left too long. 278 THE HUMAN EAR AND ITS DISEASES. The artificial drum-head receives all the vibrations of sound which enter the auditory canal, and resting upon a part of the mem- brana tympani, one or more ossicles, or a fragment of one of them, it augments the receptive and transmitting power and the agita- tion of the contents of the labyrinth. It presses the ossicles together, when from any cause their lig- aments are relaxed and articular parts separated, and steadies and supports a membrane, thinned by atrophy and improper inflation. It protects the exposed tympanum from extraneous substances and changes of temperature, relieves painful sensibility, and is thought to favor the cure of purulent inflammation. It improves the hearing frequently by concentrating vibrations upon the oval and round windows of the labyrinth, which with- out its intervention would be scattered and lost in a measure upon the walls of an insensitive and inappreciative tympanum. It is advisable to apply an artificial drum-head tentatively to every case of deafness where it seems applicable. Indeed, in some cases of deafness, the hearing is improved by it, when the conditions would lead one to suppose it could not render any service. A careful trial can do no harm, and the afflicted pa- tients should be given all the chances. It is a mooted question, whether it is advisable to employ an artificial drum-head in chronic purulent inflammation of the tympanum, for the purpose of increasing the hearing. It causes some irritation, obstructs the outward flow of pus, interferes with the interchange of gases, and hinders aeration and oxidation. These are all effects which tend to aggravate the disease in- stead of promoting a cure, as maintained by some authors. On the contrary, the hearing is improved more or less, accord- ing to the condition of the tympanum. An intelligent patient with troublesome deafness, whose hear- ing and chances of livelihood are improved by a cotton drum- head, may use one, provided he cleanses the ear thoroughly, applies an astringent wash, and introduces a fresh piece of cotton every day. A piece of absorbent cotton, wet with equal parts of glycerine and water, or sometimes with undiluted glycerine, is generally used, and cases are on record in which it has proved very effectual in improving the hearing. THE ARTIFICIAL MEMBRANA TYMPANI. 279 The hearing is better in most purulent otorrhoeas, when the discharge is thin and copious. Let the matter become inspissated and the tympanum a 1ittle dry, and the hearing will decline. The saturating fluid used with the cotton probably causes a freer and thinner discharge by stimulating the mucous membrane, which becomes more flexible; the round and oval foramina membranes then act with greater freedom. An intelligent consideration of the principles enunciated, and a careful adherence to means and methods described, will enable one to improve the hearing by the artificial membrana tympani in a limited number of cases. 280 THE HUMAN EAR AND ITS DISEASES. CHAPTER VII. COMPLICATIONS OF CHRONIC PURULENT INFLAMMATION OF THE TYMPANUM. Polypi.—In a previous section, it has been stated, that granula- tions and polypi arise very frequently upon the tympanic mucous membrane of a suppurating ear, especially, when the ear has not been treated, and the parts have been for a long time soaking in decomposing pus and inflammatory debris. Polypi seldom arise when the parts are kept clean by frequent syringing, even, with simple water. Granulations are exceedingly common, but the larger granula- tions and distinct tumors, which have been dignified by the title of polypi on account of their fancied resemblance to animals of the sub-kingdom of ccelenterate radiates, are not common. In the seventy cases of purulent otitis, that have been under my treatment during the last three years, only six were compli- cated by polypus. Two were of the firm fibrous kind, and the other four were of the mucous variety. Polypi vary in size from that of a grain of rice to the diameter of the meatus, and may be increased in length to that of the audi- tory canal. They are most frequently seen upon the anterior half of the inner wall of the tympanum, near the opening of the Eustachian tube, and this elective preference, so favorable to a continuation of the functions of the round and oval membranes and ossicles, is due to the fact, that the muciparous glands of this region are much larger than in any other part of the mucous lining. Polypi may spring, however, from any part of the tympanum, from the walls, the tympanic mouth of the Eustachian tube, the mastoid cells, the surface of one of the ossicles, the inner surface of the membrana tympani, the edge of its perforation, and breaks in the continuity of the skin of the auditory canal. A case is re- corded, in which the movement of a polypus in the tympanum POLYPI. 281 caused lateral movements of the eyes, and it was supposed to be connected with the dura mater, probably through a fissure in the roof, or an unnatural patency of the petroso-squamosal suture. Polypi generally occur singly, but there may be quite a group of various sizes, crowding each other for space and nourishment. They take different shapes, round, club, and bottle-shaped, ac- cording to conditions around. They may lie closely in depres- sions, or project in different directions; they frequently extend outwards through a perforation in the membrane, occasionally, including one of the ossicles, fill the entire tympanum, displace the ossicles, occlude the canal and meatus, and may exercise suf- ficient pressure to enlarge the osseous or cartilaginous portion of the canal. Polypi interfere with sound vibrations, cause a stopped feel- ing, and injure the hearing. They are often accompanied by pulsating tinnitus from congestion, heavy head, vertigo, nau- sea, and pain in the head, which extends down the side of the neck and along the arm. They have produced hemiplegia, but often present few symptoms; they increase the irritation and dis- charge, prevent proper treatment of the diseased mucous mem- brane, and sometimes obstruct the outward flow of pus, which, seeking an outlet, may get into the mastoid cells, the lateral sinus or the brain case, and cause fatal disease. There are four kinds of aural polyps; two so rare as to be curiosities, and two common and well known to aural surgeons. The varieties are the Angioma, Myxoma, Fibroma, and the Mu- cous. Angiomas are soft, red, irregular-shaped growths, arising in the mucous membrane of the tympanum ; they are composed of a newly formed network, or mesh of bloodvessels, held together by considerable connective tissue; contain blood corpuscles in the spaces, and are covered by pavement epithelium. Arenous tumor, or vascular naevus, of a bluish hue and little elevated has been seen upon the inner wall of the tympanum. When these growths are punctured or torn, copious and alarming hemorrhage some- times ensues, and the physician must be prepared to combat it. This variety is fortunately very rare, only two or three cases having, as yet, been reported. 19 282 THE HUMAN EAR AND ITS DISEASES. Myxomas resemble in their coarse aspects the ordinary mu- cous polypi, and the microscope must be brought to bear upon a section before a certain diagnosis can be made. Myxomas in the tympanum consist of structureless mucin jelly, held together by an anastomosing network of spindle and irregular stellate cells, and a liberal intermixture of finer fibres; they have a few blood- vessels, contain some round, granular, nucleated cells like lymph corpuscles; are covered by pavement epithelium, and feel soft and smooth. Schwartze thinks these tumors may be developed from the mucous tissue, known to fill the tympanum at birth, under the stimulation of tympanic disease to which the infant is so subject. They are very rare and easily mistaken. Fibromas originate in the periosteum of the tympanum, and push the mucous membrane outward as they develop. They are composed of dense connective tissue fibres, with anastomosing stel- late and spindle cells; are sparingly supplied with bloodvessels, and covered by several layers of pavement epithelium, into which fibrous papillae project as in the skin. They do not show papillae upon the surface, but look bluish-gray, smooth and tough like callous skin. No glands or cysts are found within these growths, the glands of the expanded and thinned mucous membrane having been strangled by the pressure of the dense fibrous tissue. This variety of tumor is seen next in frequency to the mucous polypus, and is easily recognized after cleaning by the color, con- sistency and dry-looking surface. They resist Wilde-Blake's snare, and I have known instances where the usual silver wire was broken in attempts to cut them through a little outside of the base. They affect rheumatic and gouty patients by prefer- ence, and grow very slowly. Mucous polypi are granulations run riot, and they are more frequently seen than the three previous kinds altogether. They are purple, pale pink, bluish-red, raspberry-red or crimson in color; their surface is smooth and glistening, a little papillary or lobulated; it is covered at the base with cylindrical, sometimes, ciliated epithelium, and on other portions of the surface by that of the pavement variety. This is many layers thick, and here and there sends tubular processes of epithelial cells into the tumor, POLYPI. 283 so that a section has an appearance something like that of an epithelioma. These tubular processes are hyperplastic formations of the glands of the tympanic mucous membrane. Cysts, lined and filled by epithelium and mucous fluid, some- times exist in these polypi, owing to closure of the tubular glands, thus forming true retention cysts. • The substance of the growths consists of ordinary loose con- nective tissue, with spindle and stellate cells, containing in the interspaces many granular cells and much mucin. Bloodvessels enter the base of polypi, run through the centre, and distribute branches to all sides quite freely, so that upon removal there is frequently a copious hemorrhage. These tumors grow very fast, and spring up rapidly after removal; they often ulcerate upon the outer extremity, and are the kind generally found in dis- eased ears of scrofulous patients. The diagnosis of a polypus is generally an easy affair. The ear should be syringed and wiped clean, a speculum introduced, and the parts illuminated and examined. A fine probe or a plat- inum wire loop will inform one of the consistence, mobility, size and attachment of the growth, as it can be pushed between the tumor and the canal walls, and moved about freely in most cases. The spot from which the growth springs should be determined as nearly as possible, so that a snare for removal may be applied properly. Occasionally it is difficult to find out the exact spot of implantation. Polypi have arisen in the canal, extended into the tympanum, and perforated the windows of the labyrinth, and the mastoid antrum; but they are generally rooted in a deeper posi- tion than their projecting surface. Treatment.—Aural polypi should be removed as soon as dis- covered and as often as they recur. Unless this is done, it will be impossible to cure the diseased mucous membrane, or to insure the safety of the patient. The growths are sometimes constricted and cut off by the edge of a perforation in the membrane, and the pressure of pus behind, and there is no doubt they sometimes undergo ulceration at the base, as they do upon the outward aspect, and are thus discharged spontaneously or upon the first attempt at syringing. These results are rare, however, but when they do occur, they should 284 THE HUMAN EAR AND ITS DISEASES. not be accredited to the action of any medicine given internally, as has been done by some writers with more credulity than scien- tific knowledge. There are three methods of removing polypi from the ear, which I will designate as the desiccating, the cauterizing, and the surgical. The angiomas and myxomas are so seldom encountered, that in treatment I will consider them with the mucous growths, as soft polypi, and will call the fibromas the fibrous polypi. It is well to be prepared with haemostatics at all times, but, especially, when removing an angioma, or naevus, as copious hemorrhage may be expected, that is sometimes very obstinate. Recurrence may be predicated of the myxomas, but all polypi are likely to sprout up again after removal, so that in all cases the total destruction of the morbid growths should be insured. Soft polypi of small size may frequently be made to disappear under the continuous action of astringent solutions, instilled daily. The remedy constringes the tissue and vessels of the growth, which desiccates, shrivels and finally disappears, while at the same time the solution causes granulations to undergo the same process, and the mucous membrane to take on a healthier action. Alum, sulphate of zinc or sulphate of copper, in solutions of ten to fifteen grains to the ounce of water, may be instilled in the ear twice a day under the physician's supervision, until the object is effected, or it becomes evident that the growths cannot be re- moved in this manner. The strength of the solution must be diminished, should too much irritation ensue; the action upon a tumor may^ be increased by pricking it with a cataract needle, as suggested by Dr. Roosa, This desiccating method is very suita- ble for fractious children, and ought to be tried in suitable cases. Soft polypi of moderate size may often be destroyed rapidly by caustic applications made by the physician. The pure solu- tion of subsulphate of iron, a saturated solution of nitrate of silver, chromic or nitric acid, and burnt alum, are most appro- priate for the purpose. The last remedy ought to be blown or placed upon the tumor every day, and kept there in the intervals of application by a pledget of cotton. The other agents should be applied by a tuft of cotton upon the holder, as already de- scribed, and, after a few minutes interval, the ear should be syringed with tepid water, dried carefully with cotton, and a POLYPI. 285 pledget of cotton left in the ear to catch the drainage from the slough, which will otherwise excoriate the meatus; the warm douche should be used frequently to cleanse the parts. Fragments of a polypus may be removed by forceps, the roots of the growth cauterized till all disappear, and then the treatment adapted to the condition of the mucous membrane carried on to the end. When a polypus cannot be removed in any of these ways; when it is of goodly size and easily seized, especially, if it is of the fibrous variety, and the patient is old enough to be managed easily, it is better to resort to surgical measures. The instruments necessary are few and inexpensive. The an- gular forceps, and the Pomeroy forceps have been already figured. Fig. 77. Hinton's Polypus Forceps. Hinton's ring polypus forceps have the blades fenestrated ; they do not slip when the growth is seized, and they are bent at an angle like the others, so that the hand does not interfere with illumination. The polypus and surrounding parts should be well lighted up by the head-mirror. Small polypi may be pinched and twisted off by the toothed forceps. Larger ones, flat, round or oval, should be seized and crushed with the Pomeroy or Hinton for- ceps, and twisted around and freed from their base by the exercise of a little dexterity, without removing the surrounding tissues to an injurious extent. A little more care must be exercised in ex- tirpating the fibrous growths, as they have deep and strong attach- ments. Most fibrous polypi and soft polypi of such a shape and size, that a loop of wire can be slipped over them down to the base, ought to be cut off by the Wilde-Blake snare. 286 THE HUMAN EAR AND ITS DISEASES. This consists of a small square rod of steel, with a fixed ring upon one end for the thumb, and a socket in the other, into which fits at an obtuse angle a slender steel tube. Upon the square rod is a sliding canula, having a ring for the forefinger beneath, and a button above, to which is fastened the ends of a fine silver wire. Fig. 78. Wilde-Blake's Snare. This double wire passes through the tube and projects in a loop from the distal end. When the instrument is held properly, and the forefinger is drawn towards the palm of the hand, as in pull- ing the trigger of a pistol, the wire is drawn upon, and the loop made smaller. When the loop is around a polypus, this action will cut it off clean, and bruise the base enough to limit the hemorrhage. Fig. 79. Polypus Scissors. To remove a polypus with this admirable instrument, illumi- nate the parts by the mirror, without introducing the speculum, slip the wire loop far in over the growth, with the tube upon the side where there is most room, hold the instrument firmly, and pull the canula ring towards the hand by the forefinger. This will generally cut the polypus off at its base, and it will fall out as the instrument is withdrawn. Some fibrous polypi break the wire of the snare, and are so dense and tough, that they require removal piecemeal by forceps, OTHER TUMORS. 287 knife, and blunt pointed scissors. A special pair of scissors with blunt, curved blades will prove useful occasionally. Polypi are insensitive growths, and there will be little pain from crushing or cutting them, but the canal and tympanum are hyper- sensitive, and the manipulation for this and other reasons should be very gentle. Hemorrhage after abscission or removal by other means is gen- erally slight. I usually inject the ear with cold water, until the blood ceases to flow, then dry the ear with absorbent cotton, and touch the base of the polypus, and any large granulations that may be near, with one of the cauterants previously mentioned. The excess of this is to be washed away, the canal again dried, and a tuft of absorbent cotton pushed in as a protection from cold and drainage. The roots, or base, must be cauterized until the surface is smooth and the tendency to relapse is arrested, and it is better to use sim- ple water douches, three or four times a day, to remove slough and matter, as long as the severe measures are necessary. Later, the astringents and stimulants appropriate to the case, and the measures described under chronic purulent inflammation are to be employed. In case hemorrhage should persist after the removal of a poly- pus, plug the ear tightly with styptic cotton and apply a pressure bandage. If this should not arrest the blood, a saturated solu- tion of tannic acid, or the officinal solution of subsulphate of iron may be injected into the ear. In a severe case, occurring in a plethoric patient at my clinic at the Pittsburgh Hospital from removal of a mucous polypus, after these measures had all failed, and the patient had lost half a pint of blood, I arrested the flow by tamponing the canal with wads of moist cotton, rolled in pure tannic acid. These were removed the next day, a cauterant applied, and the woman was finally discharged cured. Other Tumors.—There are other growths occasionally seen in the tympanum and temporal bone during purulent inflammation, either as the consequence or the cause of it. Cholesteatoma may arise in the temporal bone or tympanic 288 THE HUMAN EAR AND ITS DISEASES. mucous membrane, and appear as small pearly gray tumors, which gradually increase, extend into surrounding parts and project outwards into the canal, looking not unlike a fibrous polypus. The tumor consists of a loose mass of fatty epithelium, choles- terine crystals, threads of fungus, pus cells, and inflammatory debris. This caseous matter increases rapidly; sometimes pene- trates the mastoid cells, the Fallopian canal, the labyrinth, and the internal auditory meatus, causing paralysis of individual nerves and meningitis. Epithelioma is the most common of all the malignant diseases of the tympanum, and arises from purulent disease of the mucous membrane. This is another fact that shows the necessity of local treatment in all such cases. Carcinoma and Sarcoma.—Medullary and scirrhus carcinomas, and spindle-celled and osteoid sarcomas arise within the ear, and invade and destroy the internal ear and mastoid cells; or they may originate in the parotid, in a cervical gland, or in the tissues around the auricle, and extend into the temporal bone and brain, causing destruction of the ear, and fatal cerebral disease. Treatment.—The treatment of these adventitious growths must be active and radical. Extirpate all of the morbid tumor possi- ble, cauterize the wound with one of the acids or the actual cau- tery, keep the parts wet with a solution of carbolic acid and glycerine, one part to sixty, and treat morbid constitutional symp- toms as expeditiously as possible. Arsenicum iod. and Kali hydriod. are considered the most use- ful remedies against malignant growths. Exostoses.—Exostoses occur upon the ossicles and the tympanic walls occasionally, during the course of a purulent inflammation, though their usual seat is upon the wall of the external canal. It must be remembered, that the mucous membrane of the tympanum and its periosteum are so intimately blended, as to form practically one covering for the bone, and a serious inflammation of this dual membrane includes two processes: a superficial affection with in- creased secretion, and a periostitis with a tendency to ossific deposit upon the bone. In every kind of inflammation of the middle ear, there is a EXOSTOSES. 289 liability to hyperostosis or exostosis, and it is probable some slight increase of the bone takes place in most cases, though it is often impossible to recognize it. It is only when the deposit is consid- erable in amount, or occurs in small circumscribed swellings, nod- ules or spiculae, that one can make a positive diagnosis. Even then one must study the history, and remember that they may not be new, for bony tumors of all sizes, even, filling the entire tympanum, are occasionally congenital. There is generally a heavy, stopped feeling in the ear; dimin- ished hearing, and if inflammation exists, a dull throbbing pain. The tumors are generally pinkish or yellowish-white, smooth and shining, and, if the parts are clean, they attract the attention immediately. They occur most frequently in scrofulous constitu- tions, and are often accompanied by chronic suppuration of the mucous membrane, and fistulous openings leading to carious bone. I had a boy under treatment for chronic purulent inflammation of both ears, of seven years duration, resulting from scarlatina. The drum-heads and ossicles were gone, the mucous membrane was succulent and granular, and nodular exostoses projected from the inner wall and the floor of each ear, thus diminishing the cavities considerably. The watch could not be heard on contact, but loud voice and the fork were appreciated, and inflation caused a low hiss from each ear. There was pain and tenderness, but no fistulae nor caries. Rheumatism and gout are charged with promoting the growth of these tumors, and it is very natural to conclude, that diatheses which are recognized by inflammatory tendencies of fibrous tissues, the periosteum, fasciae, ligaments, tendons, etc., should not leave the middle ear unaffected. I have already mentioned that they promote the growth of fibrous polypi in purulent otitis, and this hypertrophy of fibrous tissue outwards must be accompanied by more or less ossific deposit beneath. In the sclerosis of the tympanic mucous membrane, and the hy- pertrophy which accompanies this condition and chronic catarrh of the tympanum and tube, hyperostosis is a frequent occurrence, and often renders efforts for the restoration of hearing nugatory. Sometimes this hyperostosis entirely solidifies the mastoid cells, and consolidates the process into a condition of eburnation. The most remarkable case of intra-tympanic exostosis I have ever 290 THE HUMAN EAR AND ITS DISEASES. seen was in a woman, 30 yearsold, with a decidedly gouty diathe- sis. She was well developed, fleshy, and plethoric; of nervo- bilious temperament, florid complexion, and intelligent mien. She had been married eight years without having conceived, owing probably to conical cervix and narrow os tincae, and suf- fered frequently from• disordered digestion, and rheumatic pains in the extremities. She had had scarlatina in infancy complicated by purulent in- flammation of the middle ears, which had continued some months and then ceased spontaneously. Upon examination, I found R. E. Hw. %$; L. E. S0D. The patient heard loud voice, and the fork upon the vertex was heard clearly, and best on the left side. The right auditory canal was dry and nearly normal. The drum-head was whitish-gray, much depressed, irregularly wrin- kled, and adherent to the promontory around the foreshortened and firmly fixed malleus handle. Its periphery had a wide border of yellow fibrous thickening and degeneration, and two distinct, small round exostoses, one from above the oval window, the other from below and in front of the promontory, pushed the drum-head outward. A balloon of membrane the size of half a grain of rice, situated below and behind the promontory, was lifted by inflation, showing that the Eustachian tube was pervious and the tympanum not entirely obliterated. The condition upon the left side was even more remarkable. The canal was dry and without cerumen, but tolerably healthy; the drum-head was smooth and dirty white, except a small per- pendicular band of gray along the malleus handle and around the short process. It was firmly adherent throughout its extent to the inner tympanic wall, and strong inflation did not raise a fibre. The adhesion over the promontory embraced in a sulcus the displaced malleus. The anterior and posterior portions of the tympanum were each filled by a yellowish-white, smooth, rather flat exostosis, springing from the inner wall and extending outwards to the inner end of the auditory canal, and having the respec- tive segments of the drum-head stretched firmly over them. The outer surfaces of these growths were inclined towards each other PARALYSIS OF THE FACIAL NERVE. 291 nearly at a right angle, the central thinner portions formed the border of the vertical sulcus of gray membrana tympani before mentioned. A probe passed along the anterior and posterior walls of the auditory canal struck the tumors upon a level with the annulus; when moved to the centre of the canal, it passed deeper until arrested by the membrane and malleus in the sulcus between the tumors, and upon the inner tympanic walk Exostoses in the tympanum may attain a certain size and be- come stationary, or increase until they destroy the conducting apparatus and cause total deafness. They are dangerous when associated with purulent inflammation, as they may obstruct the outward flow of pus, and induce mastoid and cerebral disease. Treatment.—Treatment is of little avail for the removal of exostoses in the tympanum, and he would be a rash surgeon, who should attempt it by mechanical means, unless it was a question of life or death. It might become necessary to bore through or chisel away an obstruction, when a close study of the conditions, and the princi- ples of conservative surgery must guide the man upon whom the great responsibility falls. Fortunately the occasion is ex- tremely rare. Any disease of the ear should be treated according to direc- tions given elsewhere, and the diathesis of the patient should be duly considered in the selection of medicines. The reader is referred to the article upon exostoses in the ex- ternal auditory canal. Paralysis of the Facial Nerve.—This complication occurs occasionally in disease of the ear. The nerve passes through the Fallopian canal in such close proximity to the tympanum, an- trum, and mastoid cells, that inflammation in these cavities, effu- sions into the cellular spaces, and caries of the temporal bone are liable to exert pressure upon its fibres, and, even, to destroy their continuity. Periostitis and exostosis, affecting the internal auditory meatus or the Fallopian canal; the use of strong caustics in the tympa- num, when the nerve trunk is exposed by caries; traumatic in- jury of the bone; cerebral disease, and tumors have caused paral- ysis of the facial nerve.' 292 THE HUMAN EAR AND ITS DISEASES. The symptoms of paralysis are easily recognized, and varia- tions in them enable one to determine with considerable certainty the locality of the morbid process upon which the lesion depends. The general symptoms are paralysis of the side of the face; immobility of the features of the one, in strange contrast to the mobility and expression of the other side; inability to close the eyelids, the mouth drawn to the opposite side, the cheek re- laxed so that food remains between it and the teeth; occasion- ally, drooping of one-half the velum palati, pointing of the uvula to the paralyzed side, and tingling and defective general and special sensibility in the lateral portion of the tongue. To these may be added deafness, tinnitus, and a heavy feeling in one- half of the head. Intra-cranial disease affecting the facial will, also, injure the softer auditory nerve. There will then be paralysis of the sta- pedius muscle ; some deafness and, perhaps, tinnitus, from a dis- turbance of the correlated action of this and the tensor tympani muscle; relaxation of the soft palate, paralysis of the chorda tympani, with its phenomena of numbness, semi-lateral loss of taste, and increased salivary secretion ; and immobility of the auricular, facial and other muscles to which the fibres of the por- tio dura are distributed. Lesion of the auditory nerve will be apparent by partial or complete loss of hearing of the tuning-fork, vibrating upon the mastoid and vertex. To these significant symptoms will be added paralysis of other cranial nerves, or such disturbances of cerebral functions as to render the diagnosis easy. When the facial and auditory nerves furnish the characteristic symptoms of paralysis, without any signs of cerebral disorder, the lesion will probably be found in the internal auditory meatus. When the auditory nerve is little affected, as shown by the tuning-fork, and the facial with its chorda tympani is paralyzed, the lesion will be in the Fallopian canal, between the internal auditory meatus and the place where the chorda is given off. When with paralysis of the face, the chorda tympani is unaf- fected, the lesion will be found below the place where it leaves the facial. The facial is sometimes temporarily paralyzed by exposure to MASTOID DISEASE. 293 severe cold, in which peripheral fibres only are supposed to be affected, and no affection of the bone can be demonstrated. There is no doubt congestion of the perineurium or of the periosteum in the mastoid, which causes pressure upon the nerve at the stylo-mastoid foramen, or a little ways up the Fallopian canal. The prognosis de- pends much upon the cause of the paralysis, but, in general, is more favorable in recent than in chronic cases, in youth than in mature age, in the strong and healthy, than in the strumous and feeble. Paralysis from cold, acute inflammation in the tympa- num and mastoid cells, and application of strong caustics is more amenable to treatment, than that occasioned by trauma, caries, and intra-cranial disease. Treatment.—No special treatment is recommended for the nerve, but that most appropriate for the morbid condition con- nected with the paralysis offers the best prospect of a cure. Mastoid Disease.—The mastoid process in the adult consists of a shell of compact bone, inclosing a group of large communi- cating cells, which extend above, behind, below, and outside of the middle ear and the inner end of the external canal. The cells on a level with the tympanum are horizontal, and those be- low them are arranged perpendicularly. The compact tissue is covered outside by periosteum, and the cellular spaces are lined by a periosteal mucous membrane, con- tinuous with that of the tympanum through the antrum and other openings in the posterior wall. This continuity of mucous surface renders the mastoid cells liable to inflammation, when- ever the tympanum is thus affected. Probably they are inflamed to some degree in all severe cases, as mastoid disease has occurred rarely with the membrana tympani intact, but the treatment in- stituted for the middle ear disease usually relieves the mastoid complication before it has reached a stage to give characteristic symptoms, or to require particular attention. The results are not always so happy, however, and the secondary inflammation goes on until it merits a special designation, as mastoid disease. Owing to a rudimentary condition of the mastoid in children, they are subject to a less dangerous affection than grown people, which usually ends in caries above and behind the external meatus. 294 THE HUMAN EAR AND ITS DISEASES. It cannot be affirmed with certainty, that inflammation of the mastoid cells ever occurs disconnected from a morbid state of the tympanum, but this condition may vary greatly in different in- dividuals, and caries of the temporal bone exist, even, without the membrana tympani being perforated. One may enumerate as causes of mastoid disease : acute inflam- mation of the tympanum ; acute exacerbation of chronic inflam- mation ; stuffing of the cells with pus and the debris of tympanic suppuration; purulent inflammation of the middle ear, with ob- struction in the external canal to the escape of pus on account of a polypus, a sequestrum of bone, an acute swelling or exostosis; and caries of the bone, arising in broken or strumous constitutions. The symptoms of mastoid disease are sufficiently well marked to attract early attention. During the course of one of the aural diseases above mentioned, owing to exposure to cold, too strong an instillation in the ear, a blow upon the head, or some of the local conditions mentioned, increased congestion of the mucous membrane of the tympanum and mastoid cells supervenes. Any discharge that has previously existed from the auditory canal diminishes or ceases, not always, however; a heavy aching pain begins deep in the ear and mastoid, and extends to the occiput; sharp intermitting pains shoot through the side of the head; the skin over the mastoid becomes red, slightly swollen, and sensitive to the touch, and the patient feels chilly, uncomfortable and sick. The signs of acute disease may now subside, owing to sponta- neous removal of the cause, or to the general treatment adopted; the tissues behind the auricle may lose their congestion, and the milder symptoms of the primarily affected tissues become prom- inent. A free incision through the tissues over the mastoid may empty the engorged vessels, and relieve the compression of the unyielding periosteum, so that amelioration of the symptoms may ensue, and the mastoid complications gradually disappear. The symptoms may not reach a higher grade than I have mentioned. The compact surface of the mammillated process may yield to the pressure from the exudation within the cells, the painful and dangerous symptoms disappear, a small tract of bone become carious, the purulent products pass through the posterior MASTOID DISEASE. 295 wall of the auditory canal and run out of the meatus, or distend the tissues upon and below the mastoid, and form a post-auricular abscess, which may open spontaneously, or soon attract the sur- geon's knife. Unfortunately some cases do not follow any of the benign courses sketched, but proceed in a most malignant and dangerous way. The tissues behind the ear and upon the side of the neck swell more and more; the skin becomes deep red, shining and cedematous; the parts feel doughy, have a false fluctuation on deep pressure, owing to dropsy of the cellular tissue, and the auricle is pushed out from the head sometimes to a right angle. The pain becomes very severe, especially at night; sharp par- oxysmal pains shoot over the head and down the neck; the facial nerve sometimes becomes paralyzed ; the affected side of the head is hot and sensitive to the touch ; the eyes are restless and unnaturally brilliant; the patient feels chilly and feverish by turns, and is often covered by copious sweat; the pulse, respira- tion and temperature are increased; the mouth is dry and parched; there is vertigo, nausea, and sometimes vomiting; the intellect becomes clouded by day, and delirium lends its terrors to the vain attempts to sleep ; thrombosis, pyaemia, meningitis or cerebral abscess may add their characteristic symptoms to the tout ensem- ble ; the vital powers gradually sink; a torpor creeps over the senses; convulsions and coma follow, and death brings a blessed relief to the neglected sufferer. These cases of atrocious suffering are most common in adults, because in children the outer shell of the mastoid is soft and thin and gives way soon, while in mature age it is hard, thick and compact, and will not yield to pressure. The severe symptoms are caused by the ever-increasing inflam- matory exudation and suppuration within the mastoid cells seek- ing to force a free outlet through the bone. This matter consists, in the early stages of the inflammation, of gelatinous mucus and red pulpy substance, or of muco-pus; then as the cells break down, granular matter, scales and particles of bone are found mingled with it. There may be mild cases of mastoid disease without injury to the bony dissepiments of the process, but usually there ensues a 296 THE HUMAN EAR AND ITS DISEASES. necrosis, ranging in severity from the destruction of a few cells, to a crumbling down of the whole bony apophysis. The inflammatory exudation in the cellular spaces seeks and must have an outlet. It presses in every direction with ever-increasing force. This causes the frightful suffering, and constitutes the dan- ger. Failing to perforate the mastoid outwards by carious de- struction of the bone, it can pass inwards to the lateral or petrosal sinus and cause thrombosis or pyaemia, or backward and upward and produce meningitis, cerebellar or cerebral abscess. These complications are usually fatal, and their characteristic symptoms ought to be quickly recognized, in order, to make a prognosis, and to favor an unavoidable euthanasia. The proximity of the mastoid cells to the lateral sinus, and the emptying of the mastoid vein and other venous radicles into the sigmoid portion of this great blood channel, render the passage of inflammatory products into it an easy matter. A foreign body introduced into a bloodvessel induces coagulation of the blood and inflammation of the endothelium. Phlebitis and thrombosis are thus produced near the place of entrance, and emboli may be washed onwards by the vital fluid and set up decomposition and septicaemia, while infarcted capillaries will be surrounded by py- aemic abscesses in the area which they supply, in the brain, lungs, liver, spleen, joints, or elsewhere. Phlebitis and thrombosis of the lateral sinus sometimes de- velop from inflammation of the middle ear, without the mastoid cells being affected, though disease of the process is the usual cause. The characteristic symptoms are red, painful, dense infiltration, and cedematous swelling upon and behind the mastoid and down the side of the neck. There is tenderness, pain, oedema and swelling along the jugular vein; the submaxillary glands are sometimes swollen, the throat sore, and swallowing painful. Pus forms deep in the tissues, and burrows beneath the muscles and fascia of the neck, even, as low as the clavicle. The eyelids, fore- head and face of the affected side sometimes become cedematous or erysipelatous; the eyeball becomes inflamed, the pupil dilated, and the optic nerve shows choked disk. Should the neck be little affected and these eye symptoms present, it would be reason- MASTOID DISEASE. 297 able to suppose the phlebitis confined to one or both of the pe- trosal sinuses. If the lateral and petrosal sinuses are both dis- eased, the ocular signs ought to be markedly increased. The general symptoms of this complication would be intense pain in the side of the head, vertigo, delirium, nausea, vomiting, great restlessness, anxiety, and exhaustion. Pyemia complicates most cases of phlebitis very early, so that their symptoms become mixed. The decomposed matter which has excited disease in a sinus may pass on with the blood cur- rent ; other infectious particles may enter other vessels through the many channels of communication between them and the dis- eased centre; emboli may be broken from a thrombus and washed onwards, and the lymphatics of the ear and neck may suck up the morbid juices, and carry them down to mingle with the pur- ple current of the vena cava. Then shivers creep over the body; there are flashes of heat, with bright-red cheeks and hot head, followed by cold drenching sweats; there is loss of appetite, great thirst, dry tongue and mouth, an earthy jaundiced skin, and the stupor of typhoid fever. Sudden dyspnoea indicates the lodgement of an embolus in the lungs; sharp pains in the brain, liver, spleen and muscles, and the appearance of purpuric spots upon the face, neck and trunk are signs of obstructed capillaries by the emboli. The strength rapidly declines; a busy mild delirium supervenes ; the pulse becomes thready; the stupor merges into coma, and death claims the sufferer. Meningitis is a more frequent attendant of ear disease than phlebitis or pyaemia, and very often accompanies these complica- tions. Simple meningitis from ear disease, unattended by phlebitis, thrombosis and pyaemia, is much more frequent in children than in adults; probably on account of the tender sensibility of a child's nervous system, and the slight barriers between his tym- panum and the dura mater covering the temporal bone. It is often a sequela of caries, and this is most common in children, who furnish the greatest percentage of scrofulous and enfeebled constitutions. Before adult life is reached, disease has decimated 20 298 THE HUMAN EAR AND ITS DISEASES. their ranks, and consigned a large proportion to sleep beneath the daisies. In nervous, bilious, and robust individuals, inflammatory pro- ducts consolidate readily by the fibrin they contain, and thus tis- sues are covered, and channels of transmission to other parts are closed, so that disease is confined to a limited area. This is proved by the many cases of purulent middle ear disease'in such constitutions, which exist for years without doing much damage to neighboring tissues. In enfeebled and strumous persons, the blood is deficient in fibrin, or the fibrin has lost its plasticity and power of fibrillation ; effusions and inflammatory exudations re- main liquid and gelatinous ; they readily decompose, and, not only, do not close tissues and vessels against absorption, but de- generate and augment the purulent products, and increase the means and the danger of infection. Meningitis is ushered in by rigors or convulsions; there is ver- tigo, irritability, restlessness, intense throbbing headache, and violent delirium; the face is alternately red and pale; there is painful sensibility to light and sound; the teeth are ground to- gether; the eyes are red, brilliant, staring, and sometimes crossed ; the pupils are contracted, and the ophthalmoscope shows choked disk or neuro-retinitis. There is full hard pulse, retracted abdo- men with constipation, muscular twitchings and stiffness of the neck and limbs, considerable fever, and the cri encephalique. The cerebral symptoms increase in violence, exhaustion rapidly ensues, a stupor creeps over the senses, collapse and coma super- vene, and a convulsion generally marks the close of life. Cerebral Abscess arises from purulent inflammation of the ear oftener than from any other cause. About one-third of the cases have this origin, and caries of the temporal bone frequently accompanies. Cases may occur with ear disease, but independ- ently of it, as from a blow or injury of the skull. The abscess may be in the pons, peduncle, cerebellum or cere- brum. A careful comparison of the physiology of the nervous system, with the neural symptoms present, may sometimes guide one to the seat of the lesion. In many cases, the seat of an ab- scess can only be surmised, even, when the symptoms are conclu- sive of the presence of one in the brain case. An abscess of large MASTOID DISEASE. 299 size may exist in the brain and give few signs of its presence. A whole hemisphere has been occupied by one, yet, the victim has been able to go about his business as usual, until the sudden taking off. The symptoms of the disease may develop slowly or suddenly. I will mention the most important. These are rigors, malaise, emaciation, nausea, vomiting, attacks of syncope; slow full pulse, intermitting or persistent; deep pain in the head, impaired intellec- tuation, dilated or immovable pupils, impaired hearing and sight, oppression, stupor, delirium, weakness of limbs; increase of earthy and alkaline phosphates, and diminution of the chlorides in the urine; paralysis of one or more cerebral nerves; hemiplegia or paraplegia; and convulsions, coma, collapse and death. Diagnosis of mastoid disease cannot be difficult to one who has followed my description. The pain is deep, severe, and radiat- ing ; the tissues over the mastoid may be not much affected, but generally are boggy and sensitive; the discharge from a suppu- rating tympanum frequently ceases almost entirely with the onset of the acute complication; the constitutional disturbance is marked; the subjective symptoms are often more severe than the objective would seem to warrant. When relief from severe pain does not follow from a warm douche and a proper paracentesis of the drum-head, during an acute inflammation of the tympanum, and there is no painful inflammation of the auditory canal, one is justified in a diagnosis of mastoid disease. Treatment.—The auditory canal should be examined and any obstruction to the outward flow of pus from the tympanum re- moved in all cases. A hot aural douche with the fountain syringe should be given, and Aconite tincture administered internally, a drop every hour, till relief comes, or its pathogenetic symptoms are produced. The patient should be kept warm and quiet in bed. Capsicum has been highly extolled for early stages of mastoid disease, but I think it should only take the place of Aconite in the milder cases. Belladonna will be found frequently indicated. If the swelling is slight, wrap the side of the head with sheet cotton; if it is considerable, apply a warm flaxseed-meal poul- tice, and wait, especially, if the patient be young and strumous. 300 THE HUMAN EAR AND ITS DISEASES. Some of these cases undergo resolution rapidly. It requires sound judgment to determine how long to defer surgical relief, and when it is imperatively necessary. During the period of delay, the medicines, the symptomatology of which has been already outlined, should be compared, and the newest symptoms of disease combated by them. If the symptoms increase in violence, the redness and swelling over the mastoid augment, and the suffering becomes unbearable, do not mask it by the dangerous narcotism of Morphia or Chloral, but anaesthetize the patient, and make an incision down to the bone. This should be from half an inch to an inch and a half long, according to the thickness of the tissues, parallel to the at- tachment of the auricle, and over the rounded projection of the mastoid and the summit of the swelling. It should begin on a level with the upper attachment of the auricle, and extend down- wards in the direction of the sterno-cleido-mastoid muscle. The tissues are generally quite thick, and a small bistoury is almost buried before the bone is reached. Cut deep, but not below the mastoid except for an abscess. Then encourage free bleeding; compress or practice tension on the posterior auricular artery, if it happens to be cut and bleeds too freely; wash the parts clean, examine the bone, put a tent of twisted lint dipped in carbolized oil (Acid. Carbol. gr. v., Ol. Olivce 5j) in the wound, if thought necessary, and cover by a flaxseed poultice. I do not like leeches; I think they do harm by their wounds of the skin, and the local irritation thus produced. Their action is not profound enough to influence the true seat of the disease. The incision reveals the condition of the bone, relieves tension, and diminishes the congestion without and within the process. In case there is only a periostitis of the outer surface of the mastoid, readily recognized by the red or bluish congestion of the periosteum, and its loose attachment to the bone, or this state is united to inflammation within the cells, the diminished conges- tion from the bleeding, and the relief of tension from cutting through the periosteum, assisted by poulticing and the appro- priate medicine may cause the disease to subside. Again, there may be a post-auricular abscess and necrosis of the outer surface of the apophysis, and a discharge of pus and pieces of bone from MASTOID DISEASE. 301 the incision, and proper medication may induce cessation of the severe symptoms and recovery. Sometimes after the abscess has been evacuated, a probe will demonstrate a carious tract, leading from the surface into the inner end of the auditory canal or the tympanum. Then the dangerous symptoms will disappear, and one should drill and scrape out the dead bone, make a free communication with the canal or ear, use antiseptic injections, and go on with the local and constitutional treatment. The clinical reports appended to this article will throw further light upon the various, phases of mastoid disease. I come now to consider those cases, where neither the incision nor any treatment sketched above will relieve the severe symptoms, which evidently depend upon inflammation within the mastoid cells. The pent-up fluid within the bone must have an artificial out- let or it will make one, probably, inwards as already described. Nature has shown us by carious openings out through the mas- toid the proper thing to do—to perforate the compact surface by knife, drill or trephine, and thus reach and liberate the impris- oned exudation. The operation is an established one, and its beneficial results beyond question, yet, as Burnett so eloquently says, " Men have been allowed to die with no better effort for their rescue, than a poultice bound over the bony cavities in which lay the cause of their dissolution." The mastoid should be trephined in all cases in which its outer surface is intact, and the severe symptoms continue after a free incision has been made. The patient must be profoundly anaes- thetized. The incision having previously been made, it must be enlarged if thought necessary, and the periosteum dissected up from the bone at and around the place selected for perforating it. The exact spot for the point of the instrument should be on a level with the upper wall of the external auditory meatus, one- quarter of an inch behind the attachment of the auricle. If the patient is young, or the mastoid is softened by disease, a firm- bladed mastoid knife may be sufficient to pierce the bone, and a probe will break a passage inwards to the antrum. In other cases Buck's trephine and drills will be found necessary. The sides of the wound should be held apart by retractors. 302 THE HUMAN EAR AND ITS DISEASES. The trephine should be directed inward, forward and upward against the bone, and be worked firmly and gently until a yield- ing is felt to the boring. Then substitute one of the drills for the trephine and proceed cautiously. In a turn or two, the cells Fig. 80. - * ^1 Mastoid Knife. will be opened, and a red pulpy substance or pus escape, or, per- haps, nothing at all. Two accidents are to be apprehended : opening the lateral sinus, if the instrument goes too low and deep, or there is a malposition Fig. 81. Buck's Trephine and Drills. of the blood channel; opening the middle cerebral fossa and in- juring the membranes of the brain, if the instrument goes too high or deep. The directions for using the instrument must be fol- lowed closely, then one will have only a malformation to fear. The lateral sinus is higher than the normal position in only two MASTOID DISEASE. 303 or three per cent, of skulls, so the chances of perforating it by an operation such as described is rare. The thickness of the compact substance of the mastoid at the point of operation averages in adult life one-fifth of an inch, but it may be much thicker, especially, if there is hyperostosis or sclerosis. In children the shell is thin, the cells small, and the process undeveloped, so that the operation is very rarely required. After the opening has been made into the cells, whether or not there is any discharge, inject them gently with a little warm water medicated by a few drops of carbolic acid, in order to wash out inflammatory products, and to clear a free passage from the mas- toid opening through the cells and middle ear to the auditory canal. Injections should be made twice a day, if there is con- siderable discharge from the parts. The first injection may not pass through to the ear, but the second or third probably will, and the fluid occasionally may flow through the Eustachian tube to the throat. The pressure of the water often* causes pain and vertigo of transient duration ; these'symptoms should caution the operator to be more gentle. If inspissated pus, granular matter or particles of bone block the passage, remove them by a probe and curette, and scrape out and remove any dead bone or cell walls that obstruct the discharge. A curette that I designed and had made to order by Geo. Tiemann & Co., New York city, has proved very serviceable. Fig. 82. Mastoid Curette (half size). Keep a tent of lint wet with carbolized oil in the wound, cover the mastoid region by a warm flaxseed poultice, stop the anaesthetic, and by keeping the room dark and silent, encourage that blessed sleep which frequently follows anaesthesia. The patient ought to lie with the head turned toward the dis- eased mastoid to favor discharge; he should be protected from all physical and mental excitement, and, if cerebral symptoms do not forbid, have a comfortable dose of milk punch. I take it for granted, that relief from the severe and dangerous 304 THE HUMAN EAR AND ITS DISEASES. symptoms follow the operation. During the less active treatment, Cinchona, Calcarea phos., Hepar, Kali hydriod., Mercurius, and Silicea should be compared, and the most appropriate medicine for the case administered. When there are no longer any signs of osseous disease, the swelling has all subsided, the injection returns clean from the mastoid, and the middle ear disease is doing well, the opening in the bone and soft tissues should be encouraged to heal by leaving off the poultices, and applying astringent and stimulating washes. If the operation does not bring relief from the terrible suffer- ing, it is just to conclude, that one or more of the complications already described exists. A careful consideration of the morbid symptoms presented will probably lead to a correct diagnosis of phlebitis, pyaemia, cerebral abscess or meningitis, and a very grave prognosis. Here, the better educated the physician, the deeper does the iron enter his soul, because of the powerlessness of medical science and art in the presence of death. He can hope against hope, and do something for his patient, even, if it be but to smooth the path- way heavenward. Phlebitis and thrombosis modify the aural symptoms so as to require special consideration. In the early stages, Belladonna will suit the totality of symptoms admirably, and should be given in full doses of the tincture. Hepar is useful when the cerebral symptoms are mild, the tissues of the neck are boggy, and tend- ing to suppurate; pus should be liberated by incision as soon as detected. If there is evidence of much obstruction, as shown by oedema about the face and side of the neck, Mercurius should be administered freely, on account of the plastic deposit and the ac- companying neuro-retinitis. When erysipelas occurs, or typhoid symptoms become prominent, Rhus tox. tincture, a drop every hour or two, and liberal doses of milk punch may help the pa- tient in his terrible extremity. When pyaemia adds its symptoms to those of phlebitis, a sup- porting treatment by concentrated beef tea and milk punch be- comes still more necessary. For internal medicines, I would rely upon Arsenicum, Arnica, Cinchona, Crotalus, Lachesis and Rhus, with an intercurrent medicine now and then for special symptoms. CARIES OF THE TEMPORAL BONE. 305 The disease is blood poisoning by septic elements from the aural region. The pyaemic fermentation is analogous to those processes produced in the blood by the introduction of snake poisons, and, as it is unlikely that two fermentative processes can exist at the same time, as the vinous and acetous, for instance; it is probable that in an animal virus will be found the antidote to pyaemia. Since attempts to arrest pyaemia by other medicines generally fail, it would be proper to experiment in this direction. Meningitis should be treated with ice-caps, and the patient kept in a quiet, dimly lighted room. Belladonna is the most useful medicine in the early stages. Bryonia is required when stupor and other signs of cerebral effusion appear, and Apis is, also, recommended. Mercurius should be given, when the severe symp- toms are mitigated, as it has the reputation of being the only medicine that has cured genuine meningitis. Prof. Alfred StillS, of the University of Pennsylvania, teaches that cases of menin- gitis all die; if a case recovers, he believes the diagnosis has been incorrect. This is an extreme view, because post-mortems, after death from other diseases, frequently show traces of old menin- gitis. Cerebellar and cerebral abscesses are very difficult of diagnosis; when their presence is recognized, one can only follow an expectant course, as far as they are concerned, and prescribe the medicine and adopt the local treatment indicated by the totality of symp- toms. Hepar, Mercurius, Phosphorus, and Silicea would seem most applicable. In the terrible sufferings of mastoid disease and its complica- tions, if it is found necessary to use an anodyne, I would prefer Hydrate of chloral (Chloral hydrate), in repeated doses of 10 grs., dissolved in Syrup of lemons (Syrupus Limonis), to Opium or any of its preparations. Chloral causes anaemia of the brain, and may thus lessen inflammation, while Opium produces hyperaemia and venous stagnation, which wrould aggravate the disease. Caries of the Temporal Bone.—Caries is sometimes a cause, sometimes a consequence of mastoid disease, and is naturally associated with it; but because it occurs in all parts of the tem- poral bone, I have given it a separate article. The disease differs 306 THE HUMAN EAR AND ITS DISEASES. at different ages, on account of variations in the development and density of the bone, and is common in childhood, rare in adult life. In a private and hospital ear practice of ten years, I have seen only about half a dozen cases in adults. Scrofula is generally the predisposing cause, and suppuration in the tympanum the exciting one. Decomposing pus, remaining in contact with the mucous membrane of the tympanum, may cause ulceration and caries of the ossicles and of any part of the tympanic walls. Matter gains access to the mastoid cells from the middle ear, especially, in children, and remains there until the bone becomes diseased, when it escapes. Especially is this the case, when inspissated pus, a nearly intact or adherent drum- head, a polypus, an exostosis or acute swelling in the auditory canal prevent the free escape of tympanic products. In other cases, the temporal bone fails in its nutrition, the cells break down and cause purulent inflammation beneath and in the covering mucous membrane and periosteum. In rare instances, caries may exist in the walls of the tym- panum, with the drum-head imperforate and healthy. The disease sometimes goes on in the bone, producing hyper- trophy and thickening of the overlying membranes, and sclerosis of neighboring parts. Eventually an opening occurs somewhere, and the ulceration products, consisting of pus, shreds of tissue and particles of bone, are discharged outward through the tym- panum and auditory canal, through the surface of the temporal bone, or inwards to the sinuses and brain. A rich development of granulation tissue sometimes with polypi accompanies caries, often filling the cavities with red masses bathed in pus. Caries occurs in the walls, the roof and floor of the tympanum. In the inner wall, it sometimes sets the stapes free, converts the foramen ovale and rotundum into one large ragged hole, breaks down the loose cellular tissue around the denser bony labyrinth and forms it into one or more sequestra, and promotes their discharge outwards. The cochlea, the whole internal ear, and, indeed, the major part of the temporal bone have been re- moved by the ulcerative process in the osseous and soft tissues. Of course, phlebitis, thrombosis, pyaemia, meningitis, and cere- CARIES OF THE TEMPORAL BONE. 307 bellar and cerebral abscess are frequent complications of such destructive ravages. Deafness is marked in cases where the cochlea has alone been exfoliated, and is total, when the labyrinth has become a seques- trum or has been extruded. Caries of the posterior portion of the tympanum frequently causes paralysis of the facial nerve by pressure and neuritis; yet extensive ulceration of the bone about the nerve may exist, and the Fallopian canal lose much of its isolating walls without affecting the structure or function of the nerve. The floor of the tympanum is rarely attacked by caries, but cases are upon record, which have resulted in ulceration into the carotid canal, and the jugular fossa, and have caused death by hemorrhage. Fig. 83. Oariks of the Temporal Bone (Toynbee). A favorite place for caries is in the lamella of bone above the tympanic membrane, between the head of the malleus and the external canal. I lately had a case of this kind in a youth of seventeen years. When he inflated the ear, a drop of muco-pus bubbled over the upper edge of the membrane, behind the short process of the malleus. A bent probe showed a very small cari- ous cavity just above, and involving the annulus tympanicus. The Fallopian tube and the internal auditory meatus are occa- sionally the seats of caries. The horizontal cells of the undeveloped mastoid process of 308 THE HUMAN EAR AND ITS DISEASES. infants are frequently affected by caries, and an opening takes place usually in the squamous portion of the bone, above and behind the meatus. The upper boundary of these cells, continuous with the roof of the middle ear, is quite thin and prone to ulceration, which frequently causes meningitis and cerebral abscess. Another favorite carious outlet is forward through the inner portion of the posterior wall of the auditory canal. The bony wall of the canal yields, pus bursts the dermic covering and runs out of the external meatus, leading one to believe it comes from ordinary suppuration of the tympanum. The mastoid process of adults, consisting of rows of horizontal cells above and vertical cells below, becomes carious from acute inflammation within the cells, from the slow imperfect subacute inflammation of scrofula or tuberculosis, and from periostitis of the outer surface. Portions of the bone are surrounded or cut off from nutrition by the ulcerative process; they become ne- crosed and form sequestra, which undergo slow absorption, or are discharged through sinuses or abscesses. The size and shape of sequestra will sometimes indicate their origin. When the outer compact tissue will not yield, the cari- ous process with its pus and debris may work in other directions, and produce one or more of the terrible complications mentioned under mastoid disease. The bone sometimes undergoes caseous degeneration, and though presenting the outward form, is easily cut; the caries may con- tinue for a long time, and the bone gradually shrink from molecular disintegration; or a sequestrum may be isolated and discharged, and recovery follow rapidly. Repair begins by granulations filling up the cavities; these de- velop into cicatricial connective tissue, which gradually changes into dense eburnated osseous structure by deposition of lime-salts, and a depression remains in the bone, if the opening has been outward. Sometimes the channels and cavities formed by the disease persist, and become lined by a smooth non-secreting mem- brane, resembling an ingrowth of skin such as is seen in the tym- panum of some cured cases of purulent inflammation. The symptoms of caries of the temporal bone vary with the part attacked, and some of them have been enumerated in the foregoing paragraphs. In most cases, purulent inflammation of CARIES OF THE TEMPORAL BONE. 309 the tympanum is present and masks the mild caries within the tympanum or external canal. Caries of the inner tympanic wall has been recognized through a healthy and imperforate mem- brana tympani. If the seat of the disease can be seen, one will notice an ulcera- tion, bordered by raised edges and large granulations. A probe passed over the base of the ulcer, or pushed into a fistula that may open into it, will transmit the rough, grating feeling of dis- eased bone. When the locality of the lesion is suspected, but cannot be seen, a probe bent at different angles may be gently applied to various parts in exploration. Probing in the tym- panum is delicate business, and should only be attempted under good illumination by one who knows the dangers. The discharge from carious bone is brown and offensive, and it contains little dark osseous particles, which may be recognized by the microscope. In coarse caries, ulceration, fistula, and abscess, the easily felt crepitation of the probe upon the bone, and, perhaps, the pres- ence of a movable sequestrum are pathognomonic symptoms. There is some fever and evidence of constitutional irritation in most cases of caries. The cheeks show red in surrounding pale- ness ; the side of the head is hot; chilliness, flushes of heat, and copious sweats alternate; the mind is peevish, and sleep uneasy. A slight pain or deep heavy aching is felt in the aural region; deafness in some degree exists; tinnitus, throbbing, and vertigo may occur; the mastoid process and auditory canal becomes red, tender and cedematous; and to these may be added any of the grave symptoms mentioned under mastoid disease and its compli- cations. The prognosis will depend upon the age of the patient, and the situation and extent of the caries. Children often throw off large pieces of necrosed bone, and have the disease for a long time, yet, finally recover. Adults die from less. They are more liable to complications. The deeper the caries extends into the bone, the greater the danger to audition and life. The outlook is always unpromising, and a guarded opinion should be given. Treatment.—In all cases of this disease, early and constant treatment is imperatively demanded. Though caries sometimes 310 THE HUMAN EAR AND ITS DISEASES. occurs in the temporal bone primarily without any disease of the ear, and, again, during the proper treatment of an aural affection, as already mentioned; a large majority of the cases arise from chronic purulent inflammation of the tympanum, which has not been treated at all, or in such a slipshod manner as to have had little effect in checking the disease. The auditory canal should be cleared of all obstructions; sinuses enlarged, if necessary, and emptied of inspissated pus and debris of osseous tissue; the membrana tympani incised freely, if it is retaining inflammatory products in the tympanum or mastoid cells; large granulations and polypi twisted off or evulsed; ab- scesses lanced and evacuated, and movable sequestra gently re- moved. A douche of warm carbolized water should be directed into the auditory canal, sinuses, and carious cavities of the bone, until every particle of matter, blood or loose osseous tissue is washed away. , When the seat of caries can be reached, and the anatomical relations do not forbid, the dead bone should be scraped away by the mastoid curette, until the healthy bone is reached. Small spots of caries upon the wall of the tympanum and in the canal, treated in this manner, and then touched with a little pure carbolic acid, granulate and close readily. When there is caries of the surface of the mastoid, with a sinus inward or forward, a free opening should be maintained through the soft tissues, the dead bone scraped out as much as is considered safe, and a probe passed cautiously in different directions towards the tympanum, and the bony portion of the external canal. In most cases, the sinus will be found to communicate with one or the other of these, generally, the latter, and movement of the probe will enlarge it somewhat, so that the inflammatory waste may be washed both ways, and the parts thoroughly cleaned. If the posterior wall of the osseous portion of the canal is red and tender, and a probe introduced into a carious mastoid leads nearly to this surface, I think it would be advisable to break down the thin barrier, in order to facilitate thorough cleansing, promote easy elimination of morbid products, and diminish the danger of extension of the caries inward and upward. A flaxseed poultice ought to be kept upon the mastoid, and a piece of absorbent cotton in the auditory meatus, but syringing CARIES OF THE TEMPORAL BONE. 311 and wiping with wisps of cotton must be done often enough to pre- vent any considerable accumulation of pus. As improvement of the local condition ensues, I substitute for the carbolized water, a mixture of one teaspoonful of Tar tincture to half a cupful of water, and inject this freely into the diseased places. This is antiseptic and stimulating. With the dead bone scraped away; sequestra removed by gentle traction, and an incision made, if necessary; the parts cleansed and disinfected daily; appropriate medicines prescribed ; and the general health improved, the patient is tolerably safe, and recovery may be expected sooner or later. Of course, disease of the mid- dle ear if present is to be treated according to directions already given, and the special measures made necessary by disease of the osseous surroundings are to be supplementary. What has been presented under complications of mastoid disease applies with equal force to caries, because the former is both cause and conse- quence of the latter. Meningitis and pyaemia are more frequently seen as a result of caries, than the other affections mentioned. The principles of treatment have been already formulated. Patients suffering from caries should be well clothed, fed, arid housed, just what many poor children cannot get. Frequent salt baths, woollen underclothes, and a dry residence; a strong diet of oatmeal, corn and wheat bread, milk, eggs, and meat, with two or three doses of cod-liver oil (Oleum Morrhuoz) a day ; persistent and conscientious local treatment, and the administra- tion of indicated remedies, will in most cases bring about a cure. Arsenicum, Belladonna, Cinchona, Calcarea phos., Ferrum iod., Hepar, Mercurius, Nitric acid, Rhus tox., and Silicea are are the most appropriate medicines for the conditions one is called upon to treat, but unusual phases of the disease may demand others. The reader is referred to the medicines mentioned under chronic purulent inflammation of the tympanum for their leading characteristics. I present a few typical cases from my practice, illustrative of caries and mastoid disease. Case I.—A girl thirteen years of age, blonde, thin, pale, and anaemic, was brought to my Eye and Ear Clinic at the Children's 312 THE HUMAN EAR AND ITS DISEASES. Hospital, Philadelphia, though she was hardly fit to be out of bed. She had suffered from severe scarlatina a year before, dur- ing the course of which an acute inflammation of the middle ear had developed, causing rupture of the tympanic membrane and a flow of pus, which had continued until three days before. She had then taken cold, and had pain in the right ear, with lateral headache and fever. The next day she was better, but a swelling was noticed behind the auricle. The mother stated that, the night before I saw her, the patient complained much of pain about the ear and side of the head ; was very sensitive to noise and light, feverish, restless, and slightly delirious. She had staggered when she got up in the morning, and had later vomited some of her breakfast. I found the patient's pulse, respiration and temperature in- creased ; she shrank from bright light, said noises hurt her head, staggered a little in walking, and complained that the whole side of her head hurt her dreadfully. The external auditory meatus was filled with decomposing pus and large granulations, and the auricle stood off from the side of the head, owing to a fluctuating swelling the size of a pullet's egg over the mastoid. The whole aural region was exquisitely sensi- tive, and when I injected warm water gently into the ear, she almost fell off the chair. Here was a condition of cerebral hy- peraemia bordering upon meningitis, dependent upon confined pus and mastoid disease. I etherized the patient, extracted a bunch of polypi from the tympanum, then made a long incision over the mastoid, and lib- erated over half an ounce of pus. This was my first case of mastoid disease and I was somewhat anxious about it. The tis- sues around the abscess were thick and boggy, and after I had evacuated the pus, the thin incised portion sank in to such a de- gree, that I feared the whole mastoid was gone, and I had opened into the brain case. Cautious exploration with the forefinger soon revealed the state of the case, and restored my equanimity. There was a perforation in the surface of the mastoid, its cells wrere carious and broken, and I passed a probe inward and for- ward until it entered the inner portion of the auditory canal, and clicked against another introduced through the meatus. Warm CARIES OF THE TEMPORAL BONE. 313 carbolized water was injected into the mastoid opening and out of the meatus, a tent of twisted lint was pushed into the incision, a flaxseed poultice ordered applied, and Kali brom. gr. v, dis- solved in water, given every three hours. The next day I visited the patient at her home, and found her relieved from her sufferings and dangerous symptoms. The local treatment was continued, and cod-liver oil ordered. She came to the clinic after a few days, and through systematic local and con- stitutional treatment the discharge declined and finally ceased, the sinuses healed, the middle ear disease yielded, and her health became fully restored. Case II.—A girl, eight years old, had chronic purulent in- flammation of the tympanum, a sequela of scarlatina, for eight months. One day the discharge from the meatus ceased, severe pain in and about the ear ensued, and she was brought to the hospital for treatment. 1 extracted a fragment of bone from the external canal the size of a small bean, evidently a piece of the cellular mastoid, found the posterior canal wall carious, scraped out a few scales of bone, and injected warm carbolized water. After several weeks treatment of the caries and the coexisting purulent otitis, and improvement of the general health, the patient entirely recovered. Case III.—Another girl, aged nine years, thin, anaemic and scrofulous, had scarlatina and chronic purulent otitis. The un- healthy pus literally streamed from her ear. I never saw so copious a discharge from the meatus. The family doctor had told the mother the patient would out- grow the disease, and it would be dangerous to interfere. A painful swelling had appeared over the mastoid process, which led to her consulting me. I found a post-auricular abscess, cut down, evacuated the pus, and removed the whole outer shell of the mastoid process, which was loose and necrosed. The patient was much improved by the treatment adopted, but ceased her visits after four months. Case IV.—A boy, nine years old, of lymphatic temperament had a light attack of measles and a concurrent otitis media, which resulted in perforation of the tympanic membrane and a purulent discharge. The patient was scrofulous, the ear affection fell into 21 314 THE HUMAN EAR AND ITS DISEASES. the chronic stage, and fetid pus flowed from the meatus in mod- erate quantity continually. He had several acute exacerbations, during one of which the mastoid tissues became swollen, formed an abscess, and opened spontaneously behind the auricle. The opening had persisted, and from it came a moderate discharge. In several subsequent acute exacerbations, he had suffered severely from lateral headache and cerebral excitement, and upon one oc- casion he became delirious, and so ill that his life was despaired of, and his physician, who had been treating him a year with noth- ing but powders internally, remained in almost constant attendance for three days. It was during another severe attack that I was called to his aid. I found the boy in high fever, with severe lateral and frontal headache, and some delirium. There was very little discharge from the mastoid sinus or the meatus; the mastoid was swollen and tender, and a huge mucous polypus almost entirely occluded the auditory meatus. I removed the polypus, touched its base with Nitric acid, enlarged the opening behind the ear, extracted several pieces of dead bone, injected a warm antiseptic solution through the mastoid and out of the meatus, and gave Belladonna tincture in water. The relief was almost magical, and, the next day, I found my patient playing around the room entirely free from pain. I cleaned the ear and mastoid daily, ordered injections of a solution of Sulpho carbolate of zinc (Zinci sulpho-carbolas gr. x, Aqua f§j), three times a day. In four days, the mastoid sinus had healed, and only a slight show of pus flowed from the meatus. The local treatment of the middle ear was continued, varying the astringent injection somewhat, Calcarea carb. was given in- ternally, and, in six weeks, the patient was discharged cured, and able to hear the watch two inches. Case V.—A boy, thirteen years of age, of nervo-fibrous tem- perament, had suffered four years from chronic purulent inflam- mation of the tympanum, a sequela of diphtheritic pharyngitis. His health was good and the discharge from the ear slight. He had been under homoeopathic treatment in the early period, and latterly under none. He had taken cold, and had severe tonsil- litis and great pain in the ear and mastoid. I found a little CARIES OF THE TEMPORAL BONE. 315 discharge from the ear, and a polypus in the tympanum, extend- ing into the canal. I twisted this off with forceps, ordered hot- water injections, and gave Aconite tincture in water. The next day the pain about the mastoid was severe, there was less dis- charge from the ear, and considerable fever. The medicine was continued, and a poultice applied to the post-auricular region. The next morning the patient was doing well, but towards even- ing he became much worse. The discharge had not increased; the mastoid region was swollen, hard and sensitive; there was severe lateral headache, vertigo, and hyperaesthesia to sound and light. I considered action imperative, anaesthetized -the patient, cut down upon the mastoid, and, using a small trephine soon made a hole into its cells, and liberated about half a teaspoonful of pus. A clear channel was made by a probe through broken- down bone cells into the tympanum, and the usual treatment instituted. The pain and threatening symptoms disappeared under Kali bromidum; Cod-liver oil, Cinchona and Ferrum iod. were given internally later; the mastoid wound healed rapidly, and the discharge was arrested by nitrate of silver, and alum in- jections, in about two months, when he wTas dismissed cured. During two years that I watched this case, the ear gave no fur- ther trouble. 316 THE HUMAN EAR AND ITS DISEASES. CHAPTER VIII. CHRONIC INFLAMMATION OF THE EUSTACHIAN TUBE AND TYMPANUM. I have, in another chapter, united acute catarrhal and acute purulent inflammation of the tympanum, considering it inadvis- able for practical purposes, to separate two phases of an inflam- mation, that differ so little in symptoms, course, and treatment. I shall consider chronic catarrhal inflammation of the Eustach- ian tube, and of the tympanum, and the so-called proliferous in- flammation, under the above caption, believing of the first two, that each is both cause and consequence of the other, and that the last is a late pathological change depending upon them. Catarrhal Inflammation of the Tube and Tympanum.— This common disease is characterized by considerable sero-mucus discharge from the mucous membrane of the Eustachian tube and middle ear, with more or less disease in the naso-pharyngeal space and throat. At least one-half the diseases of the ear that apply for treatment are of this kind, and unfortunately most of the patients do not realize their condition, nor seek medical aid, until the pathological process is far advanced, and the delicate auditory apparatus is seriously injured. The disease has become chronic, fixed, and progressive, perhaps, without ever having been acute; either having had no treatment, or the coddling, inefficient, un- scientific measures recommended by gossiping neighbors and care- less physicians. Persons with normal ears can hear a common watch five or six feet. They can hear ordinary conversation, when the auditory power has diminished so that they can only hear the same watch four to six inches. As most of the sounds essential for one to hear are as loud as medium voice, and concentrated attention will improve audition in some degree, patients, who have lost the power of hearing the watch at various distances between four inches and six feet, will not generally be conscious of their defects CATARRHAL INFLAMMATION OF TUBE AND TYMPANUM. 317 until accident or a comparative test reveals them. Dr. Roosa has very happily called this " superfluous hearing," and says, " people who spend many hours of the day in noisy places .... may lose very much of their hearing power before they are aware of it." Every aurist knows, that many persons, who do not consider themselves deaf at all, cannot hear a watch at a foot distance. A gentleman brought his wife to me for treatment of a purulent otitis, and said his own hearing was excellent. I tested his ears and found R. E. Hw.^, L. E. Hw.^-g; thus showing a decline in audition due to the disease about which I am writing. This is only one of many such incidents, that have occurred in my personal experience. Among the predisposing causes of this disease, the most promi- nent is a catarrhal diathesis. This I have found more common in strumous persons, with light hair, blue eyes, thin skin, and delicate mucous membranes; but the dark types of scrofula fur- nish many cases, and rheumatic and gouty persons have a por- tion. The inveterate and disappointing cases, those in which treatment long continued and scientifically applied has very little effect in arresting the profuse discharge, though the hearing may be improved a little, are in lymphatic and scrofulous constitu- tions. Rheumatic and gouty persons are not so liable to excessive discharges, but it is a question whether this is not counterbalanced by their tendencies to hypertrophy, hyperplasia, and calcification. These constitutional diatheses are transmitted from generation to generation, and thus heredity must be mentioned as a predisposing cause. I have had histories of deafness in three generations of a family and treated members of the last two. The diathesis was arthritic and the temperament bilious. Youths and middle-aged persons are more often afflicted by ca- tarrh than the aged, who present the greater number of prolifer- ative cases. In my experience, the female sex has furnished more cases of both varieties of the disease than the male, but this may be because females seek the doctor for every ailment quicker and oftener than males do. An enfeebled state of the body from the presence of disease, for instance, chlorosis, leucocythaemia, asthma, tuberculosis and 318 THE HUMAN EAR AND ITS DISEASES. syphilis, or following any severe affection, such as diphtheria, the exanthemata, and continuous and malarial fevers, predisposes to chronic throat and ear diseases. Defective personal hygiene; neglect of baths; insufficient clothing; badly ventilated, cold, damp homes; exposure in oc- cupation to drafts, strong winds, and wettings; irregular hours and dissipation; contracted nasal fossae, necessitating breathing with the mouth open, may all be mentioned as predisposing causes. The exciting causes are multiple; they include many of those which produce acute inflammation in the region, and others slower but not less certain in their action. Some of these affect the ear apparently through the external auditory canal and membrana tympani, and extend secondarily to the Eustachian tube; others act upon the nose, pharynx and throat, and produce inflammation of the Eustachian tube, which shuts off the air from the tympanum, and thus inaugurates a morbid process therein, or which creeps along the mucous mem- brane till it reaches and involves the lining of the middle ear and mastoid cells. I will first enumerate those causes, which have appeared to me to affect the ear primarily through the membrane. Getting water in the canal from careless washing; dipping the head under water, particularly after being heated ; wetting the hair frequently to make it lay well after combing; cutting the hair close in cold weather; covering the ears with the hair at one time, and leaving' them exposed at another; stuffing the auditory canal habitually with cotton; an accumulation of cerumen and dirt from an excess of hairs in the meatus; scratching, scraping and digging in the ears to relieve itching and to remove cerumen; spending many hours daily in noisy workshops and mills; an attack of mumps; eczema of the canal and membrane; furuncles and abscesses in the canal; foreign bodies in the canal; mechanical injury of the drum-head, and medicinal solutions dropped in the ear for ear- ache from neuralgia of the trifacial nerve. Other causes, connected with morbid states of the nose, pha- rynx, and throat, excite inflammation in the Eustachian tube, which extends quickly into the tympanum, as in coryza, hay fever, etc., or creeps slowly along the mucous membrane into the ACUTE PHARYNGITIS. 319 cavity. It shuts off the air from the tympanum frequently, and thus inaugurates a subacute inflammation in its mucous mem- brane. Coryza, influenza, and hay fever begin by acute inflammation of the nasal mucous membrane, which generally extends into the pharynx, and frequently involves the lining of the Eustachian tube and tympanum. The Schneiderian membrane tingles as if bathed in weak am- monia; sneezing is frequent; there is a dry stuffed feeling in the nose and frontal sinuses from congestion; clear serum soon be- gins to flow from the nose, and handkerchiefs are saturated rap- idly; there is diminution of smell and taste; a nasal tone to the voice, and some febrile reaction. When the trouble, reaches further, the throat is a little sore, there is frequent swallowing to remove discomfort and a feeling of tension at the mouths of the Eustachian tubes. The inflammation may affect the tubes, fill their lumen and the tympanum with mucus, cause dulness of hearing and rales on inflation, and, perhaps, some pain through the aural region. This condition may develop acute inflammation of the tym- panum, as before mentioned, but is more likely to subside, leav- ing traces of the storm along the mucous tract. Other attacks come to augment the mischief, and chronic disease becomes firmly seated in the tissues of the tube and tympanum, as well as in the nose and pharynx. The mucous membrane of the nose during the acute stage is moist, red, velvety, and tumefied. Glistening serum and small patches of adhesive mucus cover the surfaces, and the swelling often prevents nasal respiration, and hides the depressions and scrolls of the turbinated bones. Acute Pharyngitis arises often from the same causes as coryza, and frequently complicates it. It is an inflammation of the mucous membrane of the buccal pharynx, generally involving the naso-pharynx, the soft palate, and the pillars of the fauces, and frequently extends to the larynx. It is usually a common sore throat from taking cold, but may be a local manifestation of erysipelas, diphtheria, measles, scarlatina, small-pox or syphilis. 320 THE HUMAN EAR AND ITS DISEASES. It is preceded by malaise and depression of spirits, and is ushered in by a chill; fever follows, and the throat symptoms soon become decided. The throat itches, and feels dry, rough, swollen, and painful; swallowing causes more or less sore and sharp darting pain in the throat, often extending to the ear and down the side of the neck; the throat outside is sensitive, some- times swollen, and some of the submaxillary glands are engorged and tender. Inspection of the throat reveals deep redness, congestion and swelling of the mucous membrane; the uvula is often cedema- tous and elongated; the tonsils more or less swollen, and the epiglottis thickened and rigid. If the laryngeal mirror be used, the naso-pharynx, posterior nares and larynx will be found frequently to participate in the mucous inflammation. If the nose is affected, nasal respiration will be interfered wTith, the sense of smell and taste blunted, the voice altered, and some other symptoms of coryza present. The Eustachian tube and middle ear are frequently affected by the disease; then there is fulness, tinnitus, deafness, mucous ra4es, and pain shooting along the tube to the ear. In simple cases, the hyperaemia and swelling of the region soon cause increased secretion; there is a copious discharge of serum from the dilated vessels, and of mucus from the irritated follicles; the swelling gradually melts away, and the throat returns to a normal condition, or, here and there, traces of the attack may remain in patches of thickened or atrophied mucous membrane, enlarged follicles, hypertrophied tonsils, and subacute catarrh of the Eustachian tube and tympanum. Whenever pharyngitis has a specific cause, such as diphtheria, syphilis or an exanthematous disease, the symptoms are severe, prolonged, and modified by the particular affection coexisting. Then great injury to structure and functions ensues, and the au- ditory apparatus frequently suffers severely. Ulceration, abscess, sloughing, and gangrene in the naso- pharynx and throat destroy and distort the tissues, and are fol- lowed by cicatricial adhesions and contractions, which interfere with or prevent the normal action of the muscles of the pharynx and palate. CHRONIC NASAL CATARRH. 321 I have had two patients with a permanent round perforation, the diameter of a lead-pencil, through the velum between the uvula and tonsil, resulting from scarlatina. Several others have had mutilated soft palates, with portions firmly attached to the posterior and lateral walls of the pharynx. Some were caused by scarlatina, others by diphtheria. Syphilis causes frightful ravages in the soft and hard palate, pharynx and larynx. The worst case I have ever seen came to the Pittsburgh Hospital for treatment. The palatine process of the superior maxillary, the palate bones and vomer, with their soft tissues, were completely destroyed by syphilis, leaving a yawning cavern behind the alveolar arch and nasal cartilages up to the base of the skull, in which one could have buried a fist. The mouths of the Eustachian tubes could be plainly seen; the pharyngeal mucous membrane was thickened and granular, and the tubes and tympana were in an advanced stage of chronic catarrhal inflammation. Besides the acute and chronic inflammations excited in the Eustachian tube by the pathological conditions mentioned above, cicatricial closure of the Eustachian tube occurs occasionally from ulceration of the pharyngeal opening or of the pharynx imme- diately surrounding it. It is seen, also, within the tube, and is said by Schwartze to be frequent at the tympanic end, owing to caries of the temporal bone. Chronic Nasal Catarrh is usually accompanied by chronic inflammation of the naso-pharynx and pharyngeal tonsil. It re- sults from repeated attacks of coryza, or cold in the head, and becomes a serious disease, when the subject is strumous or syph- ilitic. The nose and pharynx feel alternately dry and moist; dry when indoors and in a warm atmosphere, moist and discharging sero-mucus when in the cold. The nose becomes stopped in some patients during the night, or is occluded all the time by swell- ings, scabs and crusts; respiration takes places through the mouth, and the throat becomes dry and rough. In the morning, there is usually a clearing spell; blowing anterior, taking strong inspirations, and hawking out muco-pus 322 THE HUMAN EAR AND ITS DISEASES. from the naso-pharynx. The frontal sinuses feel full, the fore- head and eyes strained and uncomfortable; the lachrymal canals are sometimes obstructed, and the eyes ■water; the eyelids often twitch, taste and smell are blunted, the respired air has a dis- agreeable odor, the voice has a nasal sound, and attempts to speak long or to sing, are sometimes interrupted by fetid mucus drop- ping from the posterior nares into the throat. There is generally a slow procession of stringy mucus down the posterior pharyngeal wall; and in severe cases, called ozaena, blood and foul masses of inspissated muco-pus and crusts, shaped into casts of the cavity, where they have been retained and have degenerated, appear in the throat and are removed by the finger or pass down into the stomach. The nasal and pharyngeal mucous membrane, in mild cases of chronic catarrh, is deep red; the epithelium is succulent and granular; the submucous tissue infiltrated, hypertrophied, and cedematous. In other cases, this hypertrophy is accompanied by atrophy ; the epithelium has disappeared in places; the mem- brane is pinkish, thin and closely adherent to the cartilage and bones ; finally, the nasal passages become enlarged from atrophy of the mucous membrane and spongy bones. Ulcers are seen here and there; mucus, pus, and disgusting brownish-green crusts cling to the depressions; the expired air is sickening in odor, and in some cases the disease is contagious. Patients should be cau- tioned not to let other persons use their toilet articles. When there is a vitiated constitution, the ulceration may go deeper, the bones become carious, and frightful ravages occur in the palate, nose and face. The naso-pharyngeal mucous mem- brane is in sympathy with the morbid states of the nasal fossae; it presents the same hypertrophy, atrophy and ulceration as are seen in the nose, and its disease is aggravated by the foul dis- charge that is almost constantly in contact with it, being greatly augmented by hypersecretion of the pharyngeal tonsil. This sheet of spongy glandular tissue is in some of these cases swollen to an inch in thickness, and, not only, furnishes considerable secretion, but, also, obstructs in a measure the posterior nares, and, even, the mouths of the Eustachian tubes. These latter are POLYPUS. 323 certain to become affected by the pharyngeal complication, if not by obstruction, and thus tubal and tympanic disorders originate. Polypus of the nose and naso-pharynx occasionally arises de novo, or as an accompaniment of catarrhal inflammation. In nasal catarrh, the covering of the turbinated bones sometimes becomes so dropsical, as to project and much resemble a mucous polypus. Mucous cysts filled with fluid or glandular secretion are seen occasionally in the nose. Mucous and fibroid polypi spring from the mucous membrane, and are more frequently located in the posterior portion of the nasal fossae than elsewhere. True polypi arise rarely from the wall of the pharynx. The first symptom to attract attention is frequent snuffing to free the inferior meatuses from a stuffed feeling; later, greater obstruction is felt on damp days, owing to greater swelling, and finally to total occlusion from increased growth. There is a mucous discharge sometimes mixed with blood from the anterior and posterior nares; the respiration is partially by the mouth, which dries the pharynx and induces disorder; asthmatic symp- toms are not infrequent; the voice has a nasal tone, and some deafness is noticeable. The mucous tumors are bright red, smooth, soft, elastic and succulent. They vary from the size of a grain of rice to that of the fist, generally occur in groups, are usually knob-like or pe- dunculated in shape, readily insinuate themselves into depres- sions and cavities, and sometimes prove dangerous to life. The fibrous polypi are pinkish, smooth or tuberculated, of 'firm consistency and moderate size. They do not swell in damp weather, but grow slowly, and are generally solitary. They spring from the submucous tissue, are very firmly attached to the cartilage or bone, difficult to remove entirely, and, therefore, prone to relapse. Polypi may be diagnosed by dilating the anterior nares with Frankel's speculum, by the laryngeal mirror behind the palate, and by palpation with probe and index finger. Fortunately other tumors are rare in this region, but enchondromas, sarcomas, and carcinomas have been encountered. Polypi may be the cause or consequence of chronic catarrh of the 324 THE HUMAN EAR AND ITS DISEASES. nose and pharynx, and this is prone to affect the integrity of the Eustachian tube, if the mechanical irritation from the presence of a polypus near or against the opening of the tube does not. In total obstruction of the nose, the air does not find ready access to the tympanum, rarefaction of the air therein occurs, and ear disease is excited. Adenoid Tumors are benign growths, which arise in the upper pharynx of persons of a lymphatic temperament, owing to hyper- trophy of the pharyngeal tonsil. This organ consists of a sheet of glandular tissue, which extends from one Eustachian tube to the other, over the sides, back and vault of the pharynx, and these tumors spring from its stroma. They vary in size from mere granulations, to thickenings and growths that fill the vault and totally obstruct the posterior nares. When located upon the lateral walls, they are disk-like and sessile, but in the roof are conical, leaf-like, flask shaped, and pedunculated. They consist of a net of fibrous tissue filled with lymph cells and many vessels; are covered with cylindrical epithelium, mostly ciliated, and bleed easily when touched by the finger or an instru- ment. The presence of these tumors causes mechanical irritation, con- gestion and catarrh of the nose, pharynx, and Eustachian tube; there is a copious secretion of greenish-yellow mucus; diminished smell and taste; a smothered tone of voice; a stopped feeling in the ears with deafness; obstruction of the nose, with breathing through the mouth; snoring at night; dryness and discomfort of the throat; sometimes enlarged tonsils, and a pinched, stupid ex- pression of countenance, owing to falling inwards of the nose, and the almost constantly open mouth. These tumors are not so common in this country as in Europe. They are seen in childhood and youth more frequently than in adults, and are thought to disappear spontaneously very often, as age advances. The disorders which they excite in neighboring parts render it necessary to treat them early and actively. Dr. Loewenberg, in his monograph, Les Tumeurs Adino'ides du Pharynx Nasal, says : " Nous croyons de notre devoir ftappeler Vattention generate sur cette maladie, d'autant plus qu'elle se rencontre ADENOID TUMORS. 325 tresfrequemment et que, malgre Vensemble tres-frappant des symp- tdmes causes par la presence des tumeurs adendides pharyngiennes, les veritables causes du mal sont gentralement cherchees ailleurs, au grand detriment du malade, ainsi que nous I'avons constate maintes et maintes fois." The diagnosis may be tolerably certain from the symptoms enumerated, but should always be confirmed by ocular inspection with the laryngeal mirror, and by palpation with the probe, catheter and fingers. Besides the danger to hearing from extension of the inflamma- tion of the mucous membrane of the pharynx to that of the Eus- tachian tube, and from occasional obstruction of the tube by proximity of a tumor, occlusion of the nose prevents proper aeration of the tympanum, and thus causes what may be called a disease in vacuo. This has no necessary connection with the cause of obstruction, which may be from chronic catarrhal in- flammation, polypus or adenoma indifferently. The subject is so important, that I give an outline of its mechanism and genesis. In the act of swallowing, the palato-pharyngeal folds and the soft palate are drawn backward and upward against the posterior wall of the pharynx, and shut off the naso-pharynx from the throat. In a normal state of the parts, the air above the palate is somewhat compressed, and rushes into the Eustachian tubes which are opened by deglutition, and into the nasal fossae, while some of the air below goes into the stomach. As the veil of the palate falls down to its usual pendulous position, though this action is somewhat limited by spastic contraction in old cases, a slight rarefaction of the air is produced above it, and air passes in through the nose and sometimes through the mouth to restore the equilibrium. The action of the palate and posterior pillars of the fauces can be readily seen during gagging. Now when the nose is stopped and the air supply is cut off anterior, the backward and upward movement of the posterior pillars and soft palate compresses the air in the naso-pharynx, generally diminished in size from disease, and, as the palate falls, a greater rarefaction occurs than in the normal state, because no air can come through the nose, and this is increased greatly by the attenuation of the air in the throat produced by swallowing. 326 THE HUMAN EAR AND ITS DISEASES. As all gases follow the law of diffusion, the denser air is sucked instantaneously out of the tympanum to restore equilibrium, and the Eustachian tube closes. The rarefaction in the throat is only momentary, because air rushes up from the lungs and in at the mouth, which is generally opened immediately after swallowing to relieve the sense of suffocation, caused by suspension of respi- ration, even, the few seconds required for swallowing—but the Eustachian tube remains closed and the tympanic air rarefied. Every one is familiar with the fact, that air of moderate density opens the Eustachian tubes and escapes easily, but rarefied air cannot, while it requires considerable condensation to open the tubes and inflate the ear by the Valsalvian method. The air in the tympanum therefore remains rarefied, unless the ear is inflated artificially, because the pressure of ordinary air cannot open the Eustachian tube, and every act of swallowing renews the rarefac- tion, if it does not increase it. As a result of this, the tympanic membrane is pushed inward by the greater pressure of air upon its external surface, and the tympanum is prepared for a morbid process. Thus an occluded nose may alone excite various dis- eases of the middle ear. Enlarged Tonsils.—Acute inflammation of the tonsils de- mands no other consideration from me, than that given under acute pharyngitis. Chronic inflammation, or hypertrophy, of the tonsils, was thought formerly to be a direct cause of deafness, by inducing mechanical pressure upon the Eustachian tubes. More exact clinical observation has demonstrated this to be an error, and has proved ear diseases in connection with tonsillar hypertrophy to depend generally upon morbid states of the pharynx. Loewen- berg believes that many cases of deafness, reported as caused by enlarged tonsils, were in reality due to adenoid tumors in the naso-pharynx. Enlarged tonsils rarely exist without some disease of the pharynx, which may be secondary on account of the irritation caused by the glandular hyperplasia pushing the posterior pillars of the fauces backward and upward, and, also, by its curving around the velum into the naso-pharynx, as I have seen in some instances. In most cases, the picture presented clinically is one of CHRONIC PHARYNGITIS. 327 chronic pharyngitis and enlarged tonsils, and it is unimportant and often impossible to say which has been the primary affection. Enlarged tonsils cause difficulty of swallowing, thick imper- fect articulation, inability to utter high tones, occasional hoarse- ness, noisy respiration especially at night, sometimes a tickling cough, and frequent hawking and clearing the throat of thick mucus. The tonsil is rough, uneven, tuberculated and pale or red; it has light streaks of cicatricial and hypertrophied connec- tive tissue; the follicles are deep and dark between the protuber- ances, or show as white spots of caseous secretion and sometimes ulceration. This condition of the gland renders it liable to acute exacerbations of inflammation upon slight exposure which still further increase the organ. Children are more subject to this disease than adults, and in rare cases, enlarged tonsils shrink with the establishment of puberty. When a tonsil has reached a size which makes it interfere with the physiological action of the palate, throat and larynx, it should be reduced by medicines or by a surgical operation. Chronic Pharyngitis.—Immediately following the redness, congestion and swelling of the pharyngeal mucous membrane from acute disease, or developing slowly as the result of irrita- tion, exposure, and bad treatment, the pharynx presents several varieties of chronic inflammation, which must be differentiated in order to treat them rationally. They are distinguished from each other by their objective, rather than their subjective symp- toms, and though the varieties run into each other, the appear- ances are sufficiently distinct to warrant separate consideration. Besides the causes of chronic pharyngitis found in diseases of the nasal fossae, naso-pharynx and throat, from general or specific influences, there are some others worth mentioning. The pharynx is admirably situated to catch the particles of dust and dirt that pass through the nares, as well, as those that enter the throat during temporary or permanent respiration through the mouth. In atmospheres loaded with inorganic and organic matter, the mucous membrane of its posterior wall is kept in a state of con- stant irritation. 328 THE HUMAN EAR AND ITS DISEASES. Millions of microbia, monads, bacteria, rhizopods, spores of fungi, grains of pollen, whole algae, organic debris, and mineral particles are seen in the air we breathe; is it any wonder that the pharynx should become diseased, when currents of air loaded with this matter enter by the mouth, and make such deposits upon the tender epithelium? Buccal respiration has a very deleterious influence upon the pharynx. When air enters the lungs by way of the mouth, it cools the mucous membrane of the throat, except in exceptionally high external temperatures, and abstracts moisture from it, so that dryness and roughness are felt in swallowing, and inflamma- tion soon ensues. Taking iced drinks and ices in excess, and often in alternation with hot beverages and food; for instance, ice water or iced tea at dinner, ice cream followed by hot coffee, etc., as seen fre- quently among intelligent people, and even in physicians' families, excites chronic disease of the throat. In my opinion it is what goes down the throat, and not gas, regurgitated food, and sympathy, that produces the so-called gas- tric pharyngitis. Drinking spirituous liquors undiluted; swal- lowing accidentally hot or corrosive liquids; using spices in ex- cess ; smoking and chewing tobacco; breathing dry stove, furnace, and foul air; exerting the voice greatly in singing and public speaking; all these, cause irritation of the pharynx, and various degrees of inflammation. Pharyngitis presents three well-marked phases, which I shall designate as the hypertrophic, atrophic, and granular. Hypertrophic Pharyngitis has fulness and roughness of the throat, a sensation that excites to frequent hawking or swallowing to ease the parts; coughing, gagging and expectoration of con- siderable whitish-yellow mucus; occasional soreness after expo- sure and during cold stormy weather; slight hoarseness and ina- bility to use the voice long without coughing and clearing out the mucus ; more or less catarrh of the nose ; some degree of deaf- ness, and, perhaps, tinnitus. The mucous membrane of the throat and pharynx is of a crim- son color, rough, swollen and succulent; but the vessels are not to be seen in the general congestion. The follicular glands par- CHRONIC PHARYNGITIS. 329 ticipate in the general inflammation and hyperplasia of the mu- cous membrane and submucous connective tissue, but are little distinguished in the general tumefaction. The soft palate is hy- peraemic and thickened; the uvula is cedematous, and either elongated or thick and knobby; the pillars of the fauces stand out in great massive rolls during gagging, and the whole buccal pharynx fills the space between with a membrane, ridged and rough with enlarged papillae and acinous glands, frequently having clots of jelly-like mucus clinging to the surface, and, per- haps, extending up behind the veil of the palate. The space between the palate and the posterior pharyngeal wrall is so much diminished by the swelling, and the throat is so sensitive to the touch of instruments, that it is very difficult to see the con- dition of the mouths of the Eustachian tubes, and the naso-pharynx, but this may be surmised from the state of the parts below, and made certain by using the catheter, Zaufal's speculum, and the finger. This particular form of pharyngitis occurs in children and adults otherwise healthy, and is common in persons who use to- bacco and distilled liquors freely. It is generally accompanied by considerable catarrhal inflammation of the Eustachian tube and tympanum, and requires a well-regulated hygiene and per- sistent treatment for its cure. Atrophic Pharyngitis is the opposite of the hypertrophic. The mucous membrane of the whole pharynx and generally of the posterior portion of the nasal fossae is involved in the morbid process, but the soft palate and tonsils are only slightly affected. There is dryness, roughness, itching and burning of the throat; occasional attacks of huskiness of voice, when speaking or sing- ing, followed by swallowing or hawking out mucus; dropping of mucus into the throat from the naso-pharynx, when the head is inclined backward; slight soreness in the throat during damp or cold weather; titillations in the throat causing dry shallow cough ; rattling in the ears when blowing the nose; fine ringing tinnitus, and some degree of deafness. The mucous membrane of the throat shows patches of pale pink, yellowish-gray, and deep red. It appears thin, translucent, and shining; clings closely to the flaccid and slender muscles be- neath and upon the walls of the pharynx; is sprinkled with 22 330 THE HUMAN EAR AND ITS DISEASES. a few rounded elevations, caused by enlarged mucous glands and papillae, among which dilated and tortuous venous radicles and arterial twigs may be seen meandering. Here and there, groups of larger glands and papillae, and areas of local hyperaemia form a redder, thicker portion, which is in the condition of chronic inflammation, which precedes the atrophic state shown by the surrounding paler membrane. Some of the follicular and racemose glands have disappeared and left little spots of ulceration or small, smooth, cicatricial de- pressions; others are enlarged the size of bird-shot, and form pale, gray, rounded prominences; again, a few may show open mouths, stuffed with retained grayish fatty secretion. The vault of the pharynx is moister than the parts below, owing to the hypersecretion of the adenoid tissue, which shows its ridges pink and juicy. The groups of large glands about the mouths of the Eustachian tubes and the chain that reaches between them are generally quite prominent and pregnant with glandular secretion. Shreds and strings of tenacious mucus are seen adhering to the walls of the pharynx and working slowly down its posterior surface, while jelly-like clots lie in the depressions about the tubes and in the fossae of Rosenmiiller. The uvula is often elongated and slender, and rests upon the base of the tongue or adheres to the right or left arch of the velum, as if devoid of muscular power—a thing the sport of cir- cumstances. The veil of the palate is sometimes very deep from relaxation or paresis, and occasionally one side hangs lower than the other from the latter cause, as emphasized by Dr. Woakes. During a recent visit (1881) to London, I had the pleasure of examining with Dr. Woakes, at the London Throat Hospital, some of the typical cases of paresis of the palate described by him. The soft palates drooped excessively ; some of them hung at least two inches below the palate bones, but they seemed to perform their functions well. All of the patients had impaired hearing, but they presented, also, conditions of pharyngitis and chronic inflammation of the middle ear. I was not convinced that the paresis caused the deafness. I CHRONIC PHARYNGITIS. 331 regarded it as a concomitant rather than a cause of the aural con- dition. I must say that a clear paretic condition of the palate, such as described and theorized about so exquisitely by our Trans- atlantic cousin, is exceedingly rare in the United States. The muscles of the throat and pharynx, though evidently par- tially atrophied and, therefore, weak, act with great promptness and efficiency in many cases. During examination, the upward movement of the velum is often so great, as to clearly show the position of the posterior border of the palate bones. The palato-glossus and palato-pharyngeus stand out like thin ribbons during gagging, and the weakness of the latter and the palate muscles is made apparent by attempts to inflate the ears with the air-bag during the act of swallowing. A moderate puff will burst open the partition between the naso-pharynx and throat, the cheeks will bulge outward, and the air escape by the mouth. This weakness is again proved in some cases by the passage of food, during an otherwise normal deglutition, from the throat up into the vault of the pharynx, and into the nasal fossae. I have noticed this in several patients. A lady ate pudding, and some unchewed raisins, a little while afterwards, were blown out of the nose. Another ate some grapes, and, some hours later, one was removed from the anterior nares. Others have complained to me of bread and apples passing in this malapropos way. In every case, the patient was unconscious of the reversion of nutri- ment until it appeared in the handkerchief. I think the debility of the muscles will account for most of these phenomena. The velum is sometimes paralyzed after diphtheria; swallowing is clumsily performed ; the local sensibility is impaired ; the voice is imperfect and has a nasal tone, and the consonants h, d and g are pronounced m, n and ng. The tensor and levator palati and the pharyngeal constrictor muscles are paretic, and symptoms of ear disorder appear, if the lesion lasts very long. Atrophic pharyngitis demands earnest attention, because it in- terferes with the physiological action of the Eustachian tube, and thus menaces the integrity of the middle ear. This kind of phar- yngitis is rare in children, advances slowly and insidiously in 332 THE HUMAN EAR AND ITS DISEASES. strumous and tuberculous youths and adults, and is frequently seen in old people. Granular Pharyngitis is intermediate in symptoms and pa- thology with the hypertrophic and atrophic varieties, and is very common and very obstinate to treat. There is no atrophy, and very little hypertrophy. The symptoms are not very marked, and include many of those enumerated already. There is dry- ness and a sense of discomfort in the throat, and tough pieces of mucus are hawked out frequently. The patient is likely to have a stopped nose during sleep, and to breathe through the mouth, so that the throat becomes parched and awakens him. Acute exacerbations of inflammation, sometimes accompanied by tonsil- litis and laryngitis, are rather frequent, and each attack aggra- vates the existing congestion, and leaves it worse than before. The throat, pharynx, and posterior nares are of a uniform deep pink or florid hue; there is an active hyperaemia of the mucous membrane; its epithelium is thick and velvety; the mucous glands and papillae of the sides and back of the pharynx are dis- tinct, and greatly enlarged; sessile and pedunculated tumors, formed by hypertrophied glands and fungoid granulations, are seen here and there, causing irritation and increased secretion of slimy mucus; the glands of the anterior surface of the velum show as small points, and sometimes injected arterial twigs are seen extending even to the roof of the mouth. The tonsils are of natural size or enlarged; the velum and pillars of the fauces are of normal thickness; there is no apparent thickening of the muscles and submucous connective tissue, and the parts act well during respiration and deglutition. The mucous membrane is principally affected, and its granular surface and hypersecretion constitute the salient symptoms. The disease may pass into the hypertrophic or the atrophic variety, but usually it remains with little change for a long time, the common property of the inhabitants of cold and inhospitable climates. This condition of the throat is seen in a large proportion of the cases of chronic inflammation of the Eustachian tube and tympanum, and the patients are mostly adults. Post-pharyngeal Abscess.—This consists of a collection of pus beneath the mucous membrane at the back of the pharynx, CHRONIC INFLAMMATION OF THE EUSTACHIAN TUBE. 333 in the middle or upon one side. The most frequent cause of this accumulation is inflammation of the submucous connective tissue, arising idiopathically in strumous or debilitated constitu- tions, or originating in disease of the throat. A small percentage of cases are sequelae of burrowing cervical abscesses, and disease of the cervical vertebrae. A small, round or oval tumor develops in the pharynx, accom- panied by symptoms of the morbid condition upon which it de- pends. It is oftener seen upon the side just behind the tonsil, than in the middle of the pharynx. It projects forward, inter- feres with respiration and deglutition, occasionally causes suf- focative symptoms, can be seen and felt in the pharynx, and sometimes detected by palpation at the angle of the jaw. The prognosis is good, when the affection does not arise from disease of the vertebrae, but the pus must be evacuated early, as it may burrow down the neck or burst unexpectedly into the trachea. Of 144 cases from various causes in children, treated by Dr. Bokai, of Pesth, Austria, the mortality was eleven.* The medical treatment of this affection must be determined by the morbid conditions that attend it. The abscess must be evacu- ated by the aspirator or a long bistoury, as soon as fluctuation is detected. Chronic Inflammation of* the Eustachian Tube, of moderate degree, often exists in patients with very little implication of the tympanum. After it has continued a while untreated, or has passed a certain stage, the middle ear becomes involved in the morbid process, and the aural symptoms increase in prominence. The mucous membrane of the mouth of the tube becomes con- gested and swollen, in sympathy or connection with some of the diseases in associate parts. The inflammation extends along the mucous lining towards the tympanum, but is limited for some time to the cartilaginous portion of the tube, as the symptoms abundantly testify. These symptoms remain after acute ones have disappeared, or come on so insidiously as .to attract little attention. There is usually a slight sympathetic uneasiness in the external auditory canal. The membrane is of normal color or a little * Archives of Otology; New York City, N. Y.; 1881. 334 THE HUMAN EAR AND ITS DISEASES. redder than usual along the malleus handle. The patient finds it necessary to clear mucus from his throat often, and has some of the symptoms given under nasal and pharyngeal diseases. He hears a soft click and mucous rattling, with a rush of air into the middle ear, when he blows his nose. The click is caused by separation of the adhering mucous surfaces, as the air forces them apart, and the rattling by the sero-mucus in the tube. There has been a little ringing in the ear which has now ceased; the ears feel full a little while, because the walls of the tube being swollen and stuck together by mucus, the excess of intra- tympanic air cannot immediately escape and restore equilibrium. The hearing is dulled at first from this over-distension of the tympanum, but improves, as the excess of air is absorbed, or as it escapes by pressing the tube open, when assisted by swallowing, by ajar of the body, or by movements of the lower jaw. Val- salvian inflation produces similar symptoms, but sometimes where there is much swelling or mucus, this does not succeed, and it is hard to inflate, even, with the air-bag and catheter. The mouth of the tube is obstructed and inflation difficult, also, when there is relaxation or paresis of the palato-tubal muscles. If the patient swallows during the act of inflation, it will aid consider- ably in opening 'the tube. Introduction of the catheter will sometimes cause much pain and some hemorrhage from the mu- cous membrane. This comes from spasm of the muscles, causing the palate to contract upon the end of the catheter, and may be prevented by having the patient breathe all the time through the nose. The auscultation tube in position, when inflation succeeds, will bring to the examiner's ear the sound of distant rales. These may be sounds of simple moist bubbling or loud, coarse rattling, owing to the tube being quite full of secretion. This latter con- dition is common in children with enlarged tonsils and granular pharyngitis. The hearing should be tested by the watch both before and after inflation, in order to determine its effect. The watch and fork are heard in mild cases almost as well as in the normal state. Five or six. inflations should be made the first visit, to expel CHRONIC INFLAMMATION OF THE EUSTACHIAN TUBE. 335 mucus from the tube, before the therapeutic value of the action can be known. There is no danger of forcing mucus into the tympanum, as it clings to the walls of the tube, and permits the air to pass by or through it. Too frequent inflation is injurious, but it should be done as often as needed, else mischief will ensue. If inflation succeeds and the hearing does not improve, one can be certain of disease in other parts of the auditory apparatus. There is no pain in simple tubal catarrh but in acute exacer- bations or ulcerated conditions, it may be of moderate degree. Damp and cold weather increases the symptoms, and dry warm weather ameliorates them. Anything that irritates the throat, as spices, spirituous liquors and tobacco, aggravates the disease. The patient is hardly conscious of any change in his hearing from these, unless the morbid state is severe. The laryngeal mirror will reveal the condition of the naso- pharynx and mouths of the tubes. In some patients, the short dis- tance between the palate and posterior pharyngeal wall or the great sensibility of the throat will prevent an examination with the mirror. The index finger may be passed up behind the palate and give a good idea of the conditions. A glimpse may be sometimes gained through the nasal fossa by a Zaufal's speculum, but this is necessarily imperfect knowledge of doubtful value. A tolerably accurate conception of the disease can be had from the totality of symptoms attainable. Post-mortem examinations at different stages of tubal disease have cleared up the pathology of the region. The mucous membrane of the tube may be pink, relaxed, and covered with a moist slime, in mild cases; in others, it is in a condition of cellular infiltration and congestion. This is of dif- ferent degrees, from a delicate capillary injection, to an enlarged network of arteries and veins, which extend out of the tube and upon the pharyngeal wall. In the meshes, there may be minute hemorrhages, or large extravasations from ruptured vessels, and, if these are old, they will appear as gray and grayish-black pig- ment spots. The lumen of the tube occasionally contains blood clots. Hyperaemia, originating in the pharynx and mouth of the tube, diminishes as it approaches the tympanum. When the hyperae- 336 THE HUMAN EAR AND ITS DISEASES. mia originates in the tympanum, it may diminish in the tube towards the pharynx. The tube contains more or less mucus mixed with free ciliated epithelial cells. This may be quite fluid, owing to a large pro- portion of serum present, or like jelly from diminution of it. In the latter form, it consolidates into pellets and strings, occludes the canal, and plugs the pharyngeal opening. In the graver varieties of Eustachian inflammation, there is hyperplasia of the submucous connective tissue; the muciparous glands become hypertrophied, and the surface of the mucosa, rough, granular, and elevated into longitudinal wrinkles. Swell- ing is rare in the osseous portion of the tube, increases towards the pharynx, often closes the tube at the isthmus, and converts the opening to a mere slit. Of course, the difficulty of inflation and other treatment increases with the disease. Ulceration takes place in all parts of the tube, affecting by preference the pharyngeal extremity, and the cicatrices that result frequently constrict and even shut up the canal. Fibrous adhesions and bands have been found in the tube, as a result of chronic inflammation ; especially, at the tympanic end, when disease of the-tympanum or temporal bone has coexisted. Polypus and other tumors very seldom appear, and foreign bodies are rarely found in the tube. Such cases are curiosities of aural literature. There are other sources of constriction or stenosis of the tube. Schwartze mentions oedema of the mouth of the tube during con- gestion of the superior vena cava; insufficiency of the palato- tubal muscles in fissure of the palate; and hyperostosis near the tympanic orifice. He says: " Stenosis in the middle portion of the canal appears to be extremely rare. It is in practice, from inexact observation, thought to be much more common than it is in reality. Not infrequently an angular bend in the course of the tube, or a projection of the carotid canal into the osseous tube is mistaken for stenosis on attempting to pass a bougie. Real stric- tures in the sense in which urethral strictures are formed, by thickening and atrophic shortening of the tissues, appears not to occur in the Eustachian tube."* * The Pathological Anatomy of the Ear, Schwartze, p. 138. CHRONIC INFLAMMATION OF THE EUSTACHIAN TUBE. 337 The atrophic, sclerotic, proliferative inflammation of the Eusta- chian tube differs widely from the catarrhal. It is a sequela of the latter in some cases; in others, it seems to result from a slow subacute inflammation, or from the atrophic changes of senility. There is atrophy of muscles, glands, and epithelium, and diminu- tion of secretion; hardness and dryness of cellular elements, with hyperplasia of the submucous connective tissue. The mucous membrane sometimes loses its folds, or rugae, and epithelium, and presents a smooth, inactive surface. The pharynx may be comparatively healthy, especially in old people, but in most cases either the granular or atrophic pharyn- gitis will be present. The tube can generally be easily inflated by any of the methods described, and the patient will deftly ex- hibit his skill in the Valsalvian method, and declare that his ears ought to be all right, since he can blow them out so easily. The hearing for the watch is diminished, owing to the existence of the same proliferative disease in the tympanum, and the fork upon the vertex is not heard quite as well as in normal ears. When the tympanum is inflated through the catheter, one hears through the auscultation tube a rushing sound of air passing through the tube, ending in a high toned thud or rattle, as the membrana tympani flaps outward. The patient hears the rushing and blow upon the tympanic walls, and is conscious of pressure in the ear, but this is only momentary, because the excess of air escapes as it came, through the patent or easily dilated tube. In some cases that have been preceded by severe catarrh, and in others where there is a gouty diathesis, the tube is sometimes narrowed and even closed by fibrous membrane, and thus inflation is hindered or entirely prevented. The tube is generally enlarged to three or four times its normal size, on account of atrophy of its soft tissues and osseous walls; the, pharyngeal opening is gaping and deep, and its cartilaginous ring shows very plainly, and projects considerably above the sur- face of the pharynx, so that a decided ridge is felt in manipulating with the catheter. Very little treatment is required for this condition of the tube different from that adopted for the tympanum, unless obstruction 338 THE HUMAN EAR AND ITS DISEASES. takes place from local intratubular hyperplasia, which will de- mand the use of bougies. Another condition of the Eustachian tubes must be considered, where relaxation or paresis of the soft palate and palato-tubal muscles occurs from exhaustion of the vital powers, mental or physical strain, and general constitutional disease. Disease of the associate parts is not essential to this condition, but there is usually a pale, flabby state of the mucous membrane and muscles, such as described under atrophic pharyngitis, but catarrh is not a prominent symptom. There are few signs of ear trouble. There is absence of tinnitus and vertigo, but a slight deafness is generally present, which may have come on suddenly. This varies considerably, being increased when the patient is fatigued, and diminished when rested, and after a night's sleep. The deafness is not progressive, and the membrana tympani is little affected. The velum droops low upon one or both sides; the ear can seldom be inflated by the Valsalvian method, or by the air-bag, except through the catheter, and then the sounds heard with the auscultation tube are a soft click as the tube opens, accompanied by more or less weak rales, and a crackling as the membrane moves outward. The necessity of the catheter for inflation is considered by Dr. Woakes, as diagnostic of paretic obstruction, but this must be qualified, as several other conditions of the tube require the use of the instrument before air can be forced into the ear. The uvula is short and points or is adherent to the better side, the one not paretic or the least affected, which is generally the right; but it may be cedematous, hang straight down, and rest upon the base of the tongue. The pillars of the fauces are flattened and relaxed, and the parts are partially or entirely insensible to touch. Dr. Woakes believes, in these cases, the salpingo-pharyngeus and internal pterygoid muscles, supplied respectively by the glosso- pharyngeal and the third division of the fifth nerves, open the Eustachian tube and keep the tympanum aerated. He thinks, that the tensor palati and tensor tympani muscles, receiving ner- vous influence from a common source, the otic ganglion, are un- able to perform their physiological functions, by which there is relaxation of the muscles around the mouth of the Eustachian CHRONIC INFLAMMATION OF THE TYMPANUM. 339 tube, and the drum-head is not held in that delicate state of ten- sion and accommodation seen in the normal state. Weber-Liel asserts that the paralysis of the palate muscles is accompanied by an antagonistic spasm of the tensor tympani, and this causes depression of the membrana tympani and deaf- ness. This is not reasonable, and I think cannot be demon- strated. The lack of muscular tonus causes the symptoms given above, and, if the lesion persists long untreated, organic disease of the mucous membrane of the tube and middle ear may supervene. The snares of a drum are drawn according to the pitch desired by the player. The drum-head of the ear is adjusted to sound by the tensor tympani muscle, and its paresis causes considerable deaf- ness. The Eustachian tube must be kept open and the tympanum full of air, until medical and other means shall restore the nerves to their normal activity. Chronic Inflammation of the Tympanum.—Chronic inflam- mation of the tube and tympanum arises simultaneously from a common cause, and continues as an entity, the morbid condition of each part reacting upon the other. Chronic inflammation of the Eustachian tube of long duration or considerable severity finally involves the tympanum. Chronic inflammation of the tym- panum originates in some affection of the external canal and drum-head, or from a general cause operating through these, as the rheumatic or gouty diathesis or the degenerations of senility. It may continue limited to the middle ear, as found in a few cases of proliferation and sclerosis, but the affection gen- erally extends along the Eustachian tube to its pharyngeal ex- tremity. Chronic inflammation of the tympanum of the catarrhal vari- ety is invariably connected with the same disease in the tube. There is subacute inflammation of the mucous membrane, with increased secretion of sero-mucus, and considerable impairment of hearing. The patient has become suddenly conscious of his infirmity in one or both ears, on account of an increase of symptoms or having his attention called to the ears in some way, or he has known that his throat and ears have been in an uncomfortable condition 340 THE HUMAN EAR AND ITS DISEASES. for some time. He may trace the affection to some special cold he has taken or to repeated colds at intervals, but frequently the disease has advanced so stealthily, especially, when the pharynx is in a morbid state, that the beginning cannot be approximately stated. The patient is conscious he has ears, owing to a sense of fulness or a stopped feeling in them. He can locate this deep within. It is not a sensation of external canal obstruction, but of pressure somewhere between the canal and throat. The sensa- tion varies from a slightly thick feeling to one of considerable ten- sion. Cold air, damp weather, a glass of beer or wine, smoking a cigar, and the horizontal position will increase the fulness and attract attention. At the same time, a tinnitus which is present in most cases increases. It is frequently a fine ringing, and this has a rhythm of increase and decrease synchronous with the car- otid pulsation. Occasionally the voice resounds in the ear in a distressing manner every time the patient speaks. The tinnitus may be hissing, whiffing, rushing, roaring, rumbling, etc., accord- ing to the grade of the disease. It is raised a note or two some- times, when the lower jaw is moved in chewing. It may cease entirely at times, and then come on suddenly and decidedly. It may be so feeble in tone, that silence is necessary for the patient to tell whether or not it is present, or it may be so loud the patient cannot sleep or perform mental labor well. When it increases with fatigue, and the fork indicates diminished cranial perception, the labyrinth is generally diseased. Perforation of the membrana tympani may cause it to cease for a time or increase its volume. If the tympanum becomes filled with mu- cus, it often ceases altogether or become coarse and rhythmic. It increases with the disease, and often ceases in late stages. Infla- tion of the tube and ear with the air-bag often causes it to disap- pear for hours or days. Inflation is the most essential measure for its permanent removal. There is occasionally a soft clicking heard, such as one can make with the tongue against the roof of the mouth, occasioned by the opening of the Eustachian tube, owing to spasmodic action of the palato-tubal muscles. Cracking is heard in spasmodic contractions of the tensor tympani, acting upon the membrane. In drier cases, crackling is produced by movements of the same, i CHRONIC INFLAMMATION OF THE TYMPANUM. 341 when the air goes in, and again when it escapes. There are mu- cous rales in the tube and drum during swallowing, but the air does not make a distinct crackling in the ear, as when the parts are healthy. The patient is morbidly sensitive about his deaf- ness, and will frequently deny it stoutly; he thinks persons around him speak very low. The hearing is considerably diminished, the watch can be heard only a few inches, the fork vibrating upon the vertex is not heard well, voices sound muffled, there is inability to catch certain letters and syllables, and the patient is obliged to ask for the repetition of words and sentences. The vowel sounds are as often mistaken as the consonants. In a case with Hw. 640, it was difficult to distinguish between a and Jc, e and d, g and t, g and z, i and r, j and Ic, m and n, p and t, t and 2, and q and u. Audition varies with the phases of the disease, the permeabil- ity of the Eustachian tube, and the degree of aeration of the middle ear. Generally the watch can be heard a few inches; in some cases, not on contact. Inflation often lengthens the hearing dis- tance ; but it may shorten it exceptionally by forcing mucus from the tube into the ear, by distending the membrane too much, and by moving thicker mucus into improper relations with the chain of ossicles and the inner membrane. Inflation may not change it at all, because a swollen tube may prevent the entrance of air into the ear, or the tube and tympanum stuffed with mucus cannot receive enough air to act upon the parts. In drier cases of chronic inflammation, hearing is often better in a noise. The stiffened articulations of the ossicles, and the thickened membrane of the round and oval windows are sup- posed to be limbered up and loosened by the strong vibrations of loud sounds, so that feebler ones acting harmoniously with them are perceived by the auditory filaments. The latter effects may be compared to the air of a melody, tinkling in dulcet tones through and above the louder and more powerful tones of varia- tions. Notwithstanding the diminution of auditory power, the patient much of the time has a sensation as if his hearing were exceed- ingly acute. There is a hyperaesthesia of the auditory nerve, a 342 THE HUMAN EAR AND ITS DISEASES. morbid sensibility to all sounds; the ears are on the qui vive for any and every sound around, and those unexpected or louder than usual, cause discomfort in the ear closely allied to pain. Indeed, pain is occasionally caused in this disease by loud sounds. The external ear is hypersensitive to touch and drafts of air. The patient manifests much timidity during examination, and shrinks at the touch of fingers and speculum. There is discom- fort in the external ear from exposure to dampness, cold air or wind. This increases to a slight aching in the ear, with occa- sional darts of pain along the Eustachian tube to the throat, which is often a little sore upon one or both sides. This soreness is common in the morning after exposure to night-air, but disap- pears soon after breakfast. Patients say they cannot sit out of doors after dark in summer or take a ride in the wind without the ears aching, unless they wrap up the head or stop the ears with cotton or wool. Vertigo is another symptom in this disease, though it is some- times absent. It is generally mild and inconstant, but may be severe enough to make the patient stagger, and grasp hold of something to prevent falling. Severe attacks of vertigo are occasionally caused by disorder of the stomach, and are accompanied by flatulence, nausea, increased tinnitus, and deafness. Peripheral irritation of the pneumogastric nerve in the stomach passes by a branch from the trunk to the inferior cervical sympa- thetic ganglion; this gives vaso-motor nerves to the cerebral arteries, which anastomose with the vessels of the labyrinth, and these with those of the tympanum. The ganglion, also, gives off the inferior cardiac branches. Through this ganglion the circulation of blood in the ear, already disturbed by the aural disease, is further disordered ; the labyrinthine pressure is altered, and vertigo results. Giddiness comes on frequently from variations in the intra- tympanic pressure. When the Eustachian tube is obstructed, and the air of the tympanum is rarefied, the external air presses the membrana tympani inward, and the ossicles transmit this pres- sure to the membrane of the foramen ovale and the labyrinthine CHRONIC INFLAMMATION OF THE TYMPANUM. 343 fluid. This condition predisposes to tinnitus upon slight plus or minus variations of pressure, occasioned by temporary anaemia or hyperaemia, and by aerial and mechanical changes in the tym- panum. The simple pressure comes on so gradually, that the auditory filaments become accustomed to it, and require a pertur- bation of some sort to excite the vertigo. The cochlear nerves respond to the fluid agitation by tinnitus, and the vestibular by rotating affections of the body's equilibrium. Sudden movements of mucus in the tympanum, brought about by action of the membrana tympani, the tensor tympani muscle, or the Eustachian tube, often furnish an exciting cause of vertigo. Moderate inflations do not usually cause vertigo, because the air goes into the tympanum, strikes and pushes the drum-head out and the foramen rotundum in, and thus in a measure, forces the stapes outwards, and counteracts the direct pressure of the air upon the foot-plate and its consequent action upon the vestibular cur- rents. When the drum-head is thick and rigid and the ossicles an- chylosed, inflation will often cause distressing vertigo. Powerful inflations of air, by over-distending the tympanum, tearing adhe- sions, and pressing violently upon the stapes and round window, may cause vertigo, syncope, and unconsciousness. A lady patient had depressed and adherent drum-head, stiffening of the articulations of the ossicles, and considerable tympanic mucous secretion. I inflated very strongly through a catheter, she turned pale, fainted, and I caught her as she fell off the chair, and placed her upon a lounge. The pulse was very feeble and face ghastly. I put Spirits of Ammonia to her nostrils, and bathed the face in Spirits of Camphor until she became conscious; then, as the de- pression continued, I gave her a few drops of Compound Spirits of Ether. It was half an hour before she was able to go home, and several hours before she felt all right again. She said, that when I compressed the air-bag, she felt a sudden loud report in the affected ear, and then darkness and silence reigned. When I examined the membrane, I thought it moved outward rather more than before, under the influence of Seigle's speculum, and concluded an adhesive band or an anchylosis had given way from the violent inflation. I do not inflate very strongly now, 344 THE HUMAN EAR AND ITS DISEASES. unless with the design of freeing the membrane or making the chain of bones more supple. Drs. Roosa and Ely have reported a very alarming case of syn- cope from syringing and cleaning the ear, in the case of a gentle- man with purulent disease of the tympanum. I shall treat of the vertigo of Meniere's disease elsewhere. The symptoms of disease in the Eustachian tube, pharynx, and associate parts have been already presented in previous pages, and should be referred to by the reader. The voice is frequently affected in chronic inflammation of the tympanum and tube. It loses its clearness and volume, and cannot express the higher notes of the musical scale with- out great effort, and then only for a short time. The voice cracks, breaks, and becomes hoarse or squeaking, when an attempt is made to sing high notes, or when the effort is prolonged. A slight exacerbation of moderate and unsuspected tubal and tym- panic inflammation with little throat affection in a singer, broke his voice so that he could not sing within several notes of his accus- tomed place. Trying in my presence, he sang up the scale as usual, but could not maintain nor give volume to the upper notes, and soon began to cough. He said the effort made his larynx ache, and the anterior muscles of the neck very tired. The laryngeal mucous membrane was a little hyperaemic, and the posterior pharynx roughened. A few weeks treatment of the throat and ears restored his voice to its former range. Another patient, with chronic aural disease of some severity and long continuance, was distressed because he could no longer speak or sing at prayer-meeting. He had Hw.gsT, a dry condition of the tubes and tympana, and a slightly granular pharynx. When he talked or sang a few moments, his voice would become harsh, his throat itch, and a dry, hacking cough would force him to cease. The mucous membrane of the larynx was normal, and the muscles acted harmoniously. Treatment for a year improved the hearing a little, smoothed the pharynx, and perfectly restored the vocal powers. As deafness increases, the patient loses that nice distinction of tones by which he regulates the smoothness and volume of vocali- zation ; the voice gradually becomes unrhythmical and unmusical. CHRONIC INFLAMMATION OF THE TYMPANUM. 345 and takes a sharpened or querulous tone, anything but pleasant for the listeners. It has been my fortune never to have had but one patient, who was totally deaf and not dumb. He was a powerful and hearty blacksmith, 56 years old; he could not dis- tinguish shouted words, and carried a slate and pencil. The membrana? tympanorum were entirely adherent to the inner walls of the ears; inflation produced no effect, and the tuning-fork on the vertex and mastoid was heard only faintly. The disease had existed for fifteen years, and was caused by dipping the head, in water when sweating. The trumpet, and concert dentaphone were, of course, useless, and writing and signs were my only means of communication with him, but he could speak readily enough. His articulation was loud, harsh, of variable volume, and&in irregular jerky tones. Affections of the voice in chronic inflammation of the tym- panum depend, in a large majority of cases upon congestion or inflammation of the mucous membrane of the larynx, orig- inating independently, or caused by the pharyngeal and throat diseases so commonly present. Weber-Liel and Woakes believe that the laryngeal trouble may arise through reflex action from the ear. The auricular branch of the pneumogastric nerve trans- mits an impression from the external auditory canal to the trunk of the vagus, and its superior laryngeal branch excites the respi- ratory centre in the medulla oblongata, and causes contraction of the crico-thyroid muscle. The auricular irritation passes, also, through the inferior gan- glion of the vagus and a communicating nerve filament to the superior cervical sympathetic ganglion, which supplies vaso-motor nerves to the carotid branches that nourish the tissues of the larynx. The tympanic branch of the glosso-pharyngeal and its main trunk anastomose with the vagus and its auricular branch, and with the superior cervical sympathetic ganglion, and bring the tympanum into nervous communication with the muscles and mucous membrane of the pharynx and larynx. The ear is thus brought into intimate relationship with the organ of voice. Disorders of function and nutrition in one part may bring on sympathetic affection in the other. The larynx may become 23 346 THE HUMAN EAR AND ITS DISEASES. affected by ear disease, and the ear may become affected from laryngeal disease. A foreign body in the ear may cause coughing and sneezing; blowing in the meatus induce nausea and vomit- ing ; a cold blast in the ear excite catarrh and croup; a bougie pushed into the isthmus of the Eustachian tube produce laryn- geal pain; and disease of the middle ear develop laryngeal con- gestion and inflammation. Acute inflammation of the larynx causes otalgia and acute in- flammation of the tympanum; perichondritis of the crico-aryte- noid cartilages is accompanied by otalgia ; asthma is followed by deafness; tuberculous disease of the larynx is complicated by purulent inflammation of the middle ear; and a bruised larynx produces deafness and sometimes unconsciousness. Burnett quotes a case from the records of the Academy of Sciences, of Paris, 1705. i( A young man, twenty years old, lost both hearing and speech, after his larynx had been squeezed by a strong man in a fight. All means tried for the restoration of hearing failed in this case." I saw a similar case in 1879, through the kindness of Dr. J. H. McClelland. A middle-aged laborer in a rolling-mill had been grasped fiercely by the throat and thrust to one side by a fellow-workman. The patient was recumbent, pale and feeble; his pupils were dilated, and his hearing deficient. He could not speak, nor swallow, except a few drops of water at a time, and each attempt brought on distressing choking, owing to paresis of some of the throat muscles and spasm of others. The diagnosis was shock and bruising of the cervical sympathetic ganglia. Ignatia was given, and the man recovered perfectly in two or three days. Sneezing is a very common symptom in catarrhal otitis, and depends, as much upon increased sensibility to cold, as upon local irritation. It may occur in single explosions, but is oftener in paroxysms during the night or early part of the day. The most trifling exposure or irritation will often cause from one to a dozen sneezes, sometimes violent enough to shake the windows. The outburst is followed by a flow of serum from the nose, and sen- sations of stuffing and rattling in the ears. Every one has heard the joke about a person taking cold from a draft through a key- CHRONIC INFLAMMATION OF THE TYMPANUM. 347 hole, and from leaving the pew door open in church. I am al- most ready to believe, that hyperaesthetic victims of catarrhal otitis have furnished evidence upon which such stories are predi- cated. I have known patients so sensitive they would sneeze repeatedly from exposure to a breath of cold air upon the head, touching a cold object, leaving off a cuff or collar, changing to lighter shoes or a dressing gown though remaining in a warm room, and from taking cold water or ice cream. The respiratory centre in the medulla oblongata receives exci- tations from the nerves of general sensibility upon the surface of the body, especially the trifacial, from the pneumogastric nerve, and the sympathetic system. Aural conditions influence the medulla through the auricular branch of the pneumogastric, the auriculo-temporal branch of the trifacial, and the tympanic branch of the glosso-pharyngeal nerves. The respiratory centre sends a motor impulse along the respiratory motor nerves, the facial, pneumogastric, spinal accessory, intercostals, etc.; a deep inspira- tion is followed by drawing together of the pillars of the fauces over the base of the tongue, and a violent expulsion of air through the nose. The shock often forces the velum upward, and makes the mucous membrane feel rough and uncomfortable, even, as far forward as the middle of the roof of the mouth. Sneezing wrarns the patient of danger to the ears by increase of the catarrhal process, and indicates a debilitated state of the health. Other results of reflex action in aural disease, especially, in the chronic kind I am discussing, are seen in increased vascularity, altered sensibility, and muscular spasm of the parts. The auricle, side of the head, one cheek, the neck, and, even, the chest and back may become of a carmine hue; the capillaries are distended with blood, and the temperature is raised, as in blushing or the early stage of erythema. The color of the auricle in some places deepens to crimson and, even, purple without running, into inflammation, and tinnitus supervenes, or if this has existed previously, it is considerably increased. The attacks are usually sudden and transitory; all the morbid symptoms depart as quickly as they have appeared; only to return again, when local irritation or any emotional excitement furnishes the impetus. 348 THE HUMAN EAR AND ITS DISEASES. Experimental and pathological lesions of the cervical sympa- thetic ganglia produce corresponding symptoms to the above, and render it certain, that they are produced through and by the vaso-motor nerves of the sympathetic system. The auricular branch of the pneumogastric and the trifacial, and the tympanic branch of the glosso-pharyngeal join the superior cervical sym- pathetic ganglion, and bring the external auditory canal and middle ear into direct connection with one of the chain of regu- lators of the vascular supply of the head and neck, and suffi- ciently explain the above phenomena. Sore spots are felt upon the head, neck, shoulder, and chest, here and there, and neuralgic shocks and pains shoot along the course of nerves upon the same side as the diseased ear. It is not uncommon to find soreness in the region of the inferior semicir- cular ridge of the occipital bone, over the parietal protuberance, in the temple, and along the side of the neck in front and behind the sterno-cleido-mastoid muscle. Neuralgia is suffered most fre- quently in acute disease of the ear, but may be present in the chronic stage. Pain darts from the ear to the throat, to the occi- put, to the vertex, into one eye, into the teeth, and down the neck. It sometimes take a reverse course. One of my patients had a severe pain in the teeth of the right lower jaw, in the ear, side of the neck, and middle of the clavi- cle. The pain over the clavicle was as severe as in the ear or teeth, and I traced out the connection from a newly filled ulcerat- ing tooth, along the inferior dental to the auriculo-temporal branch of the trifacial; by anastomosis of this, to the facial, and along the latter to the auricular branch of the auricularis magnus of the third cervical, which transmitted the irritation by commis- sure to the fourth cervical nerve, giving off the supra-clavicular to supply the clavicular region where the pain ended. The reader may trace the course of reflex action in any case of neuralgia with interesting and satisfying certainty, if he feels so inclined. Muscular spasm is another symptom of not infrequent occur- rence, when the ear is in a morbid state. The contraction is limited to a few fibres, or involves the whole bundle forming the CHRONIC IMFLAMMATION OF THE TYMPANUM. 349 muscle. It occurs in the muscles of the face, neck, and throat, and is occasionally accompanied by objective snapping noises. I have had one case somewhat similar to Leudet's, reported by Burnett. The patient was a strumous youth, 13 years old, of fair development and growth, but easily exhausted, subject to sudden gastric disturbances and severe headaches, and having suspicious stumpy incisor teeth. He was a little deaf, and had a moderate naso-pharyngeal catarrh, which I did not consider at first, as he was brought to me for eye treatment. I found both the corneae gray with interstitial keratitis, and vision reduced to counting fingers at one foot. The parents were robust, healthy people with no specific history or symptoms. I was rather sus- picious of the father's veracity, because he displayed so much anxiety in regard to the boy's condition, and asked so many ques- tions about the disease, its probable cause and progress. The eye affection yielded rapidly to treatment, and some six weeks after the first visit, I examined the ears, removed masses of altered cerumen and epidermic shreds, and diagnosed chronic, rather dry, catarrhal inflammation of the tympana. I applied glycerine and water to the external canals, inflated the ears with the air-bag, and ordered a salt-water gargle, continuing the eye treatment of mercury as before. After twelve days treatment, he returned unexpectedly, and his father said he was afraid something serious was the matter with the boy, as he had jerking under the jaw of the right side. There were clonic muscular spasms, at the rate of five or six a minute, below the right jaw, and in front of the sterno-cleido-mastoid muscle, in the superior cervical triangle. They had appeared two days before, and had been continuous during waking hours. There was no pain connected with them, no abnormal sensations in the right ear, nor any cerebral symp- toms whatever. There had been headache, vertigo, and nausea one afternoon, due to a fresh pork dinner and violent exercise immediately after in playing base-ball; but I thought this could not be causative of the phenomenon. The membrana tympani presented the dull gray, opaque color of chronic inflammation of the tympanum noticed at the first examination, but there was added to the pre- 350 THE HUMAN EAR AND ITS DISEASES. vious condition a marked injection of bloodvessels along the handle of the malleus. During the spasm, the depression between the larynx and angle of the jaw was elevated, pushed outward laterally, about one-fourth of an inch ; the inferior maxilla was at the same time drawn downward about the same distance, and I could feel the tone of firm contraction under my fingers, pressed upon the in- ferior maxillary region. The movement was immediately fol- lowed by relaxation, the jaw returned to its proper position against the upper one, and the time occupied from beginning to end was not over two seconds, while the interval between the spasms averaged five seconds. Closing the jaw firmly, depressing it to its full extent, moving it to one side and the other, and pressing firmly upon the mus- cles had no effect in diminishing the frequency or force of the spasm. Inflation was easily accomplished, and lessened the num- ber of the contractions immediately. A careful study of the symptoms of this interesting case ren- dered it certain, that the spasms were confined to the digastric and stylo-hyoid muscles of the right side, and I was gratified to find an anatomical reason for this in the distribution of nerves. These muscles are under the influence of a filament given off by the facial nerve after its emergence from the stylo-mastoid- foramen, and, in my opinion, this nerve was irritated by the mild exacerbation of inflammation in the tympanum. This would seem reasonable, because a general treatment of the aural catarrh cured the spasm. Let us see how this might occur. There are several anasto- moses between the nerves of the tympanum and the facial, but I shall allude only to those that seem to have transmitted the mor- bid impulse in this case. The tympanic nerve, a branch of the glosso-pharyngeal, is the great sensitive nerve of the middle ear. It gives off from its plexus in the tympanum a filament, that unites with one from the facial nerve to make the small super- ficial petrosal, which goes to the otic ganglion. The glosso- pharyngeal filament transmits irritation from the diseased tympa- num to the ganglion. This reflects the waves of irritation back along the facial filaments of the small petrosal to the trunk of CHRONIC INFLAMMATION OF THE TYMPANUM. 351 the facial, just where its intumescentia ganglion reinforces its power and aids in controlling its functions, and from here the impulse passes down the nerve to the filament that supplies motor impulse to the stylo-hyoid and digastric muscles. It is probable that other muscles supplied by the facial were influenced in a less degree, and I did not notice their action, because I was not fully posted upon the neurological relations of the phenomenon. Spasms of the tensor tympani and palato-tubal muscles are quite frequently mentioned in otological writings. It is certain that spasm of the tensor tympani occurs per se, and may be in- voluntary or, rarely, produced at will. It is seldom attended by vertigo. This muscle has a tonus which keeps the membrana tympani at a certain tension for the reception of sound vibrations, but the degree is altered voluntarily, when the mind is concen- trated upon auditory sensations in expectant attention. An irritation in the external meatus or canal, in the tympanum,. the Eustachian tube, pharynx or larynx can reach the otic gan- glion of the same side through some of the nervous chains already traced, and this may cause spasm of the tensor tympani alone or accompanied by contraction of the tensor palati and other muscles. The drum-head in these cases moves in and out with the abnormal contraction and relaxation of the tensor tympani, as can be seen under illumination, and demonstrated byPolitzer's manometer. The velum moves backward and upward, then returns to its proper pendant position, as the tensor palati and other palate muscles contract and relax. These muscular actions are occasionally accompanied by an objective clicking sound, which may be heard near the patient, but sometimes, even, at a distance of several feet. It varies in character, and resembles the rattle of parchment, the cracking of the finger-nails, a low clucking like that produced by drawing the tongue away from the roof of the mouth, or the thud produced by snapping the thumb and second finger. The sound is not constant in rhythm ; it may be synchronous with the pulse, rapid and intermittent, or increased to as many as 140 clicks a minute. In a case recorded by Burnett, swallowing, breathing, and speaking arrested the noise; rapid respiration increased it from 352 THE HUMAN EAR AND ITS DISEASES. twenty to thirty snappings a minute. The tuning-fork rose in pitch with every spasm. The voluntary production of the sound has generally been in ears that were in a normal state, but the involuntary in those that were affected by various degrees of subacute inflammation. Burnett mentions instances of bilateral and of unilateral contrac- tion of the ^ensor tympani in normal ears, which were under voluntary control. The involuntary cases of the phenomenon are upon one or both sides, according as one or both ears are dis- eased ; but it is not impossible that the power of the will should be exercised upon the tensor tympani and palato-tubal muscles to produce the sound, even, when disease is present in the tube and ear. The sound originates from muscular contraction, but is not in the muscle itself, but in the parts moved by the muscle. When the tensor tympani contracts spasmodically, there is a rapid movement of the drum-head inward and outward, and this pro- duces a crackle or rattle like that which terminates the sound of inflation in old people, with large, dry Eustachian tubes and tympana. When the palato-tubal muscles are the seat of spas- modic action, the walls of the Eustachian tube are more or less separated by each muscular spasm, and the well-known snap- ping or clucking sound is heard, followed by a thud and crack- ing, if air passes into the tympanum. I have had only one case bearing upon this subject. A gen- tleman, sixty years of age, had proliferative inflammation of the tympanum, and a loud snapping during swallowing, perceptible a foot away from him. The noise could be heard through the mouth and ear, and coincident with it, the handle of the malleus and the membrane moved inward. I considered this due to spasm of the tensor tympani and exaggerated action of the palato-tubal muscles, induced by the act of swallowing. The sound ceased after a few weeks treatment of the chronic inflammation in the ear. Burnett was able to stop the sounds in one of his patients by pressing upon the velum, and through this upon the Eustachian tube, though he felt the muscular spasms go on regularly beneath his finger. After spontaneous perforation of the membrana tympani in this case, the noises and the spasms ceased entirely. CHRONIC INFLAMMATION OF THE TYMPANUM. 353 On account of this the author recommends "artificial perforation of the drum-head in any similar case, if relief from the symptoms should be urgently required." The induced current, applied to the velum and Eustachian tube, has cured some cases, and may be tried in connection with the treatment for any disease that may exist in the region. Mental disease is not infrequent in chronic inflammation of the tympanum. It is reasonable that the brain should suffer from reflex action, as do other parts about the ear, since it consists of nervous matter—great ganglia—conscious of all bodily conditions and omnipotent over all. Patients complain of a drawing, strained feeling in the head, as if the scalp were tired and the surface of the brain compressed. The wits are wool-gathering, and thought wanders purposeless from subject to subject without continuity or masterly grasp. The memory is defective, concen- tration of the mind upon a subject is exceedingly difficult, mental labor must be forced, and causes general fatigue. When tinnitus is present, nervousness is marked; the patient starts at every unusual or loud noise; is timid in darkness; afraid in crowds and crowded thoroughfares, and apathetic and seemingly stunned in places that require self-possession and quick action. Vertigo comes now and then to disturb the equilibrium and destroy courage, and, if gastric disorder exists, and adds its car- diac and cerebral disturbances to the picture, the patient may have severe occipital pains and numbness of limbs, and may whirl around and fall down, conscious, but utterly demoralized. Of course, the above are strongly drawn symptoms of extreme cases. A patient may have one or more of them, mild and en- durable, in connection with the aural disease, while another may have most or all of them, and be thoroughly miserable. When it is remembered that persons have become insane from the presence of impacted cerumen in the external canal, and others have blown their brains out under the torture of a con- stant tinnitus, the above description will not seem exaggerated. The objective symptoms and pathology of the catarrhal variety of chronic aural inflammation are so different from those of the 354 THE HUMAN EAR AND ITS DISEASES. proliferative, that they must be separated in order to avoid con- fusion. A state of excessive congestion and secretion is characteristic of some catarrhal cases, and the symptoms connected with this differ much from those given in textbooks upon ear diseases. It is an early stage of chronic aural inflammation, which is not often brought to the aurist's attention. It is, also, a chronic condition in some patients, which seems to have escaped the attention of such celebrated writers as Toynbee, Roosa and Burnett. The external auditory canal in the early stage is congested and itchy, and contains an excess of cerumen, mixed with dirty white shreds of exfoliated epithelium, loose hairs and dirt. This collec- tion may be sufficient in amount to close the canal, or only enough to fill its depressions and obstruct the speculum", as it is pushed into position for ocular examination. The membrana tympani is in such cases rosy or dull red; its vessels may not be visible, or some will be seen passing from the canal upon the membrane towards its centre, and others running from above down along the poste- rior border of the malleus handleto the umbo. There may be cicatrices of healed perforations visible. The light triangle is dimmed in lustre, diminished in size, elongated, bisected, or en- tirely absent. In rare cases, the membrane will permit one to see the level of a secretion or of blood in the tympanum, and these coexist with syphilis, heart disease, lung affections, and Bright's disease; but, generally, there is so much opacity that nothing can be seen within. The manubrium of the malleus is obscured or shows a yellow knob on the lower end, and the general thickening and sogginess of the drum-head interfere with its elasticity and mo- bility, so that it moves outward and the malleus handle moves forward very slowly, when Seigle's speculum is operated or infla- tion is performed. There is little depression in this disease. Greater pressure is required to push a thicker membrane inwards. There is so much sero-mucus in the tympanum that it acts by counter pressure, and air goes through the mucus in the tube to the tympanum to some extent to augment this, and prevent that marked depression seen in later and drier stages. CHRONIC INFLAMMATION OF THE TYMPANUM. 355 The tympanum, mastoid cells, and Eustachian tube are par- tially or entirely filled with clear or yellowish sero-mucus, some- times reddened by exuded blood; thicker mucus clings to the angles and depressions; the ossicles and tensor tympani are clogged by it; the foot-plate of the stapes and its oval mem- brane, and the membrane of the round window are pushed in- wards, and augment the pressure of the labyrinthine fluid. Con- stant pressure of mucus against the membrana tympani is likely to cause thinning, and this predisposes to easy rupture. Inflation is often not felt in the ears, and the auscultation tube will leave one in doubt whether he has heard rales, though a few bubbling ones can generally be distinguished. Swallowing during the act of inflation will aid in opening the tube. The middle ear is stuffed with secretion, and while the fork on the vertex is heard rather exaggerated, the watch may not furnish any sound to the expectant ear. The mucous membrane of the tympanum, mastoid cells and Eustachian tube is deep red or purplish, succulent and velvety. The epithelium is spongy, and here and there presents granular patches and villous processes; there is passive congestion ; the blood moves slowly; the veins are distended and show elongation and varicose swellings; ecchymoses are not uncommon; the submu- cous connective tissue is hypertrophied, and its meshes filled with leucocytes; the tubular and racemose glands are hypertrophied and dilated; and the mucosa generally thickened. This is limited to certain parts, to the drum-head, the articulations of the ossicles, and the round window, or is more general over the whole surface of the limiting bone. It diminishes the size of the tym- panum, and may be so considerable as to obliterate the entire cavity. If the disease continues any length of time, bands and new membranes are produced, and contractions and adhesions supervene. This wet form of chronic inflammation of the middle ear re- mains wet for a long time, is obnoxious to treatment, and very discouraging to both patient and physician ; but it so surely tends to sclerotic and proliferative processes, and destruction of the hearing power, that continuous and energetic treatment is imper- 356 THE HUMAN EAR AND ITS DISEASES. ative. The mild cases and, even, some of the worst ones some- times get well, and all can be greatly improved. Schwartze says: " The very highest degrees of catarrhal swell- ing of the tympanic mucous membrane are capable of complete retrogression, the membrane resuming its cobweb-like delicacy, and moulding itself accurately to the osseous walls and contents of the tympanic cavity. The cellular infiltration of the subepithe- lial connective tissue disappears by fatty degeneration and decay, and possibly, in part, by being absorbed into the lymph vessels. For this purpose weeks are necessary. In many cases, however, retrogression is incomplete, and there remain projections and duplicatures of the mucous membrane in the form of pseudo- membranes or synechiae, by which different parts of the ear are abnormally adherent, or the tympanic cavity is permanently affected in its size and form."* Moderate secretion in the tympanum and tube and an absence of congestion characterize the second stage of some acute inflam- mations of the middle ear without perforation of the drum-head, as well, as subacute inflammations primarily accompanied by ex- cessive secretion, some primary subacute inflammations of the tympanum, and various morbid processes arising therein from tubal disease. The symptoms of this state are very different from those just given. It is the morbid condition fully described in most textbooks upon aural disease, as chronic catarrhal inflam- mation of the middle ear. It is the one most frequently seen in practice, because persons attacked with aural catarrh do not gener- ally apply for treatment until degenerations have occurred, and deafness and tinnitus have awakened anxiety. It properly in- cludes both mild catarrhal and proliferative cases. The external auditory canal, in the less humid inflammation, is yellowish-white mixed with gray. It is dry, scaly, itchy ; con- tains little or no cerumen ; is sensitive to cold, and in sympathy with the morbid changes within. The membrana tympani is thickened, and has lost its clean, healthy, bluish-gray lustre. It varies in color from opaque * The Pathological Anatomy of the Ear, Schwartze, p. 95. CHRONIC INFLAMMATION OF THE TYMPANUM. 357 creamy yellow to dull gray, and its periphery often shows a yel- lowish-white ring of thickening. The light triangle when present is dimmed, so that it is diffi- cult to determine where the canal ends and the membrane begins ; the color is like asbestos, blue granite, or ground glass. Its area is diminished and shape altered. It may be elongated into a slender line; bisected horizontally, so that it shows a crescent at the base and a point of light near the umbo; broadened and shortened to a blunt cone; scattered in three or four light points ; or entirely blotted out. One or more dirty white spots of calca- reous degeneration may be seen in the membrane, for the most part, in the middle portion, though, rarely, they extend in cres- centic form along the periphery. Old cicatrices when present and small show as gray or yellowish-white marks, a little depressed below the surface, and may project outward like little blisters, when inflation is performed. When they are large, they are darker than the rest of the drum-head. The manubrium of the malleus has a yellowish-gray color, its edges seem to have additions of cartilage, and there is a sort of disk of the same color around the lower end which gives it a knob-likte ap- pearance. A few vessels may course along its posterior border and above the short process. The short process projects above the surface, as a yellowish-white button that catches the eye quickly, and from this the anterior and posterior folds of mucous mem- brane upon the inner surface of the drum-head can be seen, pass- ing to the periphery in sharply drawn lines. The greater the retraction of the malleus handle, and depression of the membrana tympani, the more noticeable these folds and the short process become. The tympanic changes and the obstructions of the Eustachian tube rarefy the air in the ear, and the air pressing upon the outer surface of the drum-head forces it inward. The handle of the malleus is drawn inward by the tensor tympani muscle, and pushed in by atmospheric depression of the drum-head, in various degrees. It may hang nearly in proper position, or be drawn or pressed inward and backward, until, in the foreshortened view, its length seems diminished more than one-half. 358 THE HUMAN EAR AND ITS DISEASES. It is not certain that the tensor tympani is in a state of tension, in every case of depression of the drum-head. I have seen cases of air-depressed membrane, where the plane of the outer surface of the manubrium remained nearly in the same plane with the membrane, and it was evident from this, and the restoration of both to the normal position by inflation and other treatment, that the tensor tympani was not affected. In other cases of de- pression, the anterior edge of the manubrium was turned sharply inward, and the posterior border made a sharp line over which the drum-head seemed drawn tightly, making a tolerably plane surface of membrane behind, and a deep dark pocket in front. These could not be restored by inflation and treatment, probably because the tensor tympani was in a state of spastic contraction or rigidity. Weber-Leil thinks the tensor tympani is continuous with the palato-tubal muscles, and, when the latter become diseased and relaxed, the former becomes contracted antagonistically. This is mere theory, and there are a great many facts to render it un- tenable. The cause of retraction of the manubrium is of value in prog- nosis, and has a bearing upon the operation of tenotomy of the tensor tympani. When the drum-head is depressed or retracted, it be- comes more concave and of very irregular surface. If it is thin and partially transparent, the long process of the incus, the pink- ish-white promontory, clots of mucus and blood, and air-bubbles may occasionally be seen through it. Adhesions of the membrane to the inner wall of the tympanum are bluish or yellowish-white, and do not move during inflation, by which they can be distinguished from cicatrices. Inflation moves the drum-head considerably outwards when not adherent, and causes increased redness around the upper part of the malleus handle. These changes are to be observed when the patient practices the Valsalvian method of inflation, and the aurist illumi- nates and watches the membrane. If the ossicles are fixed and the malleus handle and portions of the membrane adherent direct or through the intervention of bands, portions of the membrane will move out in bulbous or CHRONIC INFLAMMATION OF THE TYMPANUM. 359 balloon-like processes, while the other parts will darken and re- main immovable. With Siegle's speculum one can draw these loose places out and show their character and extent per- fectly. It would be a tedious and useless labor to describe the various pictures of distorted membranes met with in this disease. They are as numerous and curious as the figures in a kaleidoscope, and should I write down all the varieties I have seen, I would have to add to them day by day as patients presented. Authors state that, in rare cases, the tympanic membrane loses its normal color and transparency, without there being any dis- ease in the middle ear. Of course, this might happen from the domestic treatment of earache, or from disease confined to the membrane. No one would make a diagnosis of chronic inflammation of the tympanum from these drum-head symptoms alone. In other patients with the tympanic disease under considera- tion, the membrane may be normal in appearance, because other portions of the mucous membrane are affected, and that cover- ing the inner surface of the drum-head has escaped. The mem- brane may present any of the above conditions in the dry pro- liferative stage, and the sclerotic and atrophic changes of senility. Then it may be thinned by atrophy, and flap in and out like the mainsail of a schooner lying head to the wind. In the stage of tympanic inflammation under consideration, the sounds heard through the auscultation tube during inflation Vary with the condition of the Eustachian tube. Valsalva's method gives the purest sound, and should be preferred in test- ing. Sometimes the tube is obstructed by plugs of mucus, swell- ings, fibrous membranes or bands, and exostoses; then nothing is perceived during inflation but the sound of the velum's move- ment. In such an event, introduce a catheter and try again. If not successful, rotate the catheter a little, as it may have got into a follicle or against a fold of the mucous membrane from which a little manipulation may free it. The sound through a small catheter is higher than through a large one, and should be recog- nized apart from the tubal and tympanic noises. The catheter 360 THE HUMAN EAR AND ITS DISEASES. whistle should be learned by forcing air through it with the air- bag before using it in the ear. If obstruction persists, pass a bougie smeared with cold cream through the catheter down to it, and push gently onwards, turn- ing it now and then till a sudden freedom is felt as it enters the tympanum. To guard against error and injury, it is well to measure the length of the catheter upon the bougie, add to this the estimated length of the Eustachian tube and mark both places upon the bougie, then push it through the catheter into the tube until the outer mark is reached, and the obstruction is passed. Only a very moderate degree of force is permissible; inflation may be performed the next day after the tube is made pervious, but not the same day, on account of the danger of producing emphysema. There is a good deal of bugbear about this danger, because a travelling quack once produced it by applying an air (force) pump to the tube. Ordinary inflation will never produce emphysema, unless instruments have torn the mucous membrane of the Eus- tachian tube beforehand. When inflation succeeds, rather loud rales are heard, mingled with cracking and snapping, and the usual thud. A moment or two after inflation, the patient sometimes hears a cracking as some air escapes into the throat; the sensation of fulness goes away from the ear, and the membrana tympani falls inwards to a state of equilibrium. When the tympanum and tube are dry, and the latter is en. larged, as in many cases of proliferative inflammation and senile atrophy, the air by Valsalva's or Politzer's method goes into the ear with a loud rush and cracking sound. The membrane, if free and thin, flaps outward and makes a noise that can occasion- ally be heard by an observer at several feet distance. Inflation may sometimes cause tinnitus to cease, but it gener- ally only elevates its tone, and reddens the drum-head along the handle of the malleus, showing an induced hyperaemia. The mucous membrane of the middle ear passes gradually from the state of congestion and swelling to that of hypertrophy of the connective tissue, and development of fibres, bands, and false membranes. The glands are destroyed by increase and con- traction of the connective tissue in which they lie; the vessels CHRONIC INFLAMMATION OF THE TYMPANUM. 361 are diminished in size and number, and absorption is stopped; the secretion is first morbid, then diminished, and finally arrested ; masses of inspissated mucus mingled with shreds of fibrin cling to the tympanic walls and the ossicles; the cavity becomes un- naturally dry, and the movable parts rigid. This pathological change is not uniform, different parts of the mucosa show different stages of the process, just as the Schnei- derian membrane does in chronic nasal catarrh. The membrane upon the inner surface of the drum-head or over the promontory may be non-secretory, dry and stiff; while in the antrum, and around the entrance of the Eustachian tube, it may show some congestion and secretion. The pieces of dried mucus plug the mastoid cells, fill depres- sions, cling to the fenestrae, surround and clog the ossicles, and sometimes remain free in the cavity, to travel about when the patient makes unusual movements. Two patients suffering with chronic inflammation of the drum reported that they felt something fall in the ear, and had great tinnitus, when they inclined the body forwards. Another had increase of tinnitus and a stopped feeling in the ear after a sud- den jar, as in making a misstep, which symptoms were relieved by bending the body forward as in a Turkish salaam. Some patients have heard better when lying down; others in the erect position, probably from displacement of mucus. These mucous masses must necessarily interfere considerably with the proper action of the auditory apparatus, and the hearing will be made variable or very defective, according to their quantity and loca- tion. In rare cases, blood is extravasated into the tympanum spon- taneously in diphtheria and Bright's disease, and, as a result of strangulation, vomiting, and violent coughing. It appears through the drum-head bluish-red or black, and may change its level, as the head is bent forwards or backwards. If it does not cause purulent inflammation and rupture of the membrana tym- pani, it may be reabsorbed, or form a dry clot of obstruction, and produce the same trouble as a mass of mucus. Adhesions occur between the membrana tympani and the long process of the incus, the stapes, and the inner wall of the tympa- 24 362 THE HUMAN EAR AND ITS DISEASES. num ; the anterior half of the tympanic cavity may be separated from the posterior, the upper from the lower, forming cystic spaces. Narrow tympana are especially subject to such adhesions. Firm grayish-white threads and bands of connective tissue are developed between mucous surfaces, and extend from the drum- head to the walls and the ossicles. They result from inflammation of the mucous membrane, the organization of blood clots, and the retrogression of mucous tissue, which normal in foetal life, some- times remains unabsorbed after birth. The handle of the mal- leus is often bound to the promontory; the long process of the incus to the posterior wall; an arm of the stapes to the border of the oval window, and the tendon of the tensor tympani to the roof. A thick fibrous membrane may cover the walls, obliterate the foramen rotundum, close the Eustachian tube and antrum, and, even, fill the whole middle ear with dense fibrous tissue. Toynbee found these adventitious bands in twenty per cent, of cases examined. The position of these growths determines the impairment of hearing; upon the stapes and vibrating mem- branes, they are much more injurious than upon other parts. Atrophy may be produced by inflation, and by senile changes, bands may become threads, a thread may pull away from the drum-head and leave a perforation. Progressive hypertrophy may go on, favored by the exuberant life of youth and middle age, and by exacerbations of tympanic inflammation. Like all such pathological new formations, these are subject to fatty degeneration, sclerosis, contraction, calcifica- tion, and ossification. The tensor tympani muscle is often shortened, its muscular fibres become fatty, fibrous or absorbed, and its tendon surrounded by a thickened sheath, generally bound to the walls or ossicles by bands or fibres, thus preventing action. Deposition of lime salts in the membrana tympani frequently coexists with hyperostosis of the external auditory canal, the ossicles, walls of the Eustachian tube and tympanum, and cells of the mastoid process. The ossicles become displaced by the adhesions and contractions of the membrana tympani, the mucous membrane, and the fibrous CHRONIC INFLAMMATION OF THE TYMPANUM. 363 bands. The malleus and incus are sometimes united to the roof of the ear by ossification. The capsule of the incudo-stapedial articulation relaxes occa- sionally, the incus is pushed aside, and the articular surface of the stapes is seen with the drum-head drawn tightly over it. Its foot-plate may be at the same time fixed immovably in the oval window by osseous deposits, especially, in old age; and hyperos- tosis of the base cause a projection into the vestibule. After synostosis has existed a long time, the crura atrophy and become very fragile. The malleo-incudal and incudo-stapedial articulations become rigid, owing to thickening and calcification of the capsules and surrounding tissue, and the consolidated chain represents the col- umella, a single bone that performs the functions of a chain, be- tween the membrana tympani and the vestibule in the ears of Saurians. Hyperostosis due to periostitis occurs frequently upon the ossi- cles and walls of the tympanum, and osseous bridges extend from part to part, and greatly hinder the transmission of vibrations. The pyramidal eminence may be connected with the foramen ovale; the crura of the stapes with the edges of the vestibular foramina, and the foot-plate with the promontory. The foramen rotundum is sometimes closed to a mere slit by hyperostosis of the tympanic wall, and the mastoid cells are encroached upon and often filled by a new growth of bone, which is sometimes so dense, that it is designated eburnation, or ivory exostosis. In calcification, the lime salts are deposited in granular masses in the meshes of the true and false connective tissue; in ossifica- tion, lamellae and spiculae of bone are found in the same tissues, rather nearer the bone; while in hyperostosis and exostosis the development is beneath the connective tissue and upon the sur- face of the bone. Diagnosis and prognosis are not difficult in this disease. The instruments and methods of examination of the ear, throat, phar- ynx, and nose have been already described. Careful considera- tion of the pathological changes apparent to the eye, of the results of inflation and catheterization, and of the subjective symptoms elicited from the patient, will enable the student of aural disease 364 THE HUMAN EAR AND ITS DISEASES. to form a tolerably correct opinion of the macroscopic appearance in the tympanum and tube, and to make a true diagnosis. Steam- ing the ear through the catheter a few times, and using the air- "bag awhile will bring early improvement, if the membranes of the fenestras of the labyrinth are not affected. If no improve- ment follows, they are thickened or covered over, and ameliora- tion of the hearing will be doubtful. When the naso-pharynx can be brought to a tolerably healthy state, and its excessive secretion reduced nearly to the normal amount; if relaxed and paretic muscles can be restored to a fair degree of activity, and no organic obstructions exist; inflamma- tion of the Eustachian tube may be lessened or cured, and dis- ease in the tympanum greatly diminished, and, in many cases, permanently arrested. The prognosis is, however, much influenced by the age of the patient and stage of the disease. In childhood and youth, the prospects are much more favorable than in the middle and de- clining periods of life. The trouble is, that patients delay apply- ing for treatment for years, and then such alterations in tissue and function have occurred, that no power short of miraculous can restore them to useful hearing. Prolonged treatment in cases where the membrane is not much distorted, and the Eustachian tube is pervious, frequently accomplishes wonders; and this should encourage both patient and physician to a faithful trial of all the means, which the careful study of aural disease has in- dorsed of late years as scientific and rational. General Treatment of Chronic Inflammation of the Tube and Tympanum.—It is best, by questioning the patient categorically, to get as complete a history as possible of hereditary tendencies, the previous and present condition of health, and the existence of any diathesis or dyscrasia. Record a succinct account of the onset and progress of the affection in the ear and associate parts, and try to determine the cause or causes of it. Get all the subjective symptoms in proper order, proceeding from the external ear, through the tympanum and tube, to the pharynx, throat, and nose. Then make a care- ful examination of the functions and pathological conditions, which will indicate the course of treatment to be pursued. INFLAMMATION OF THE TUBE AND TYMPANUM. 365 The best endeavors have often failed to improve the hearing in aural disease, because the diagnosis has lacked precision, and catarrhal and proliferative cases have been treated just alike. The general health of the patient should be made as nearly perfect as possible by careful regulation of the bodily functions and the personal and domestic hygiene, and by avoidance of those things, acts, and exposures, which are known to aggravate the aural disorder. The patient must have wholesome food at proper intervals, frequent baths, comfortable clothing, daily exercise out of doors, sufficient regular sleep in a well-ventilated room, and a compara- tively healthy occupation. The hair should rarely be wet, and never in cold weather; water and soapsuds must be kept from entering the external canal during washing; a wet towel over the finger will clean the meatus sufficiently ; no cotton, wool or other substance should be kept persistently in the ear to protect from cold ; ear-laps, mufflers, etc., may be worn if necessary; oil, glycerine, laudanum, ear-drops and other domestic remedies for itching and aching ought to be tabooed ; the clothing should be loose about the neck, and a bald head kept covered from the cold. Respiration through the mouth; the use of tobacco, strong liquors and condiments; exposure to continuous loud noises and explosions, to drafts, cold winds, sudden changes of temperature, and impure air should be avoided. Intense mental application congests the head and aggravates aural disease, and long-continued exercise of the auditory power brings exhaustion to the tympanic muscles and the auditory nerve, and both should be prevented. The causes of the morbid condition should be removed when possible; the external may not be discoverable or operative ; the internal may be simply local, in the nose, pharynx and throat; or constitutional, consisting of diathetic conditions, embraced in struma, rheumatism, gout, malarial poisoning, and syphilis. As external causes should be removed when discoverable, so these dyscrasiae, upon which many cases of chronic inflammation of the tympanum depend, ought to be taken into consideration when one prescribes for the aural disease. Very frequently the symptoms of the ear and throat are so 366 THE HUMAN EAR AND ITS DISEASES. few and unimportant, that the physician would be at a loss what medicine to give, did he not consider disturbances and indications in the general system. Again the aural symptoms may be the only ones that can be perceived upon the most searching examination, but our knowl- edge of therapeutics as applied to the ear is now considerable, and is being increased continually by contributions from thor- oughly educated specialists, so that only the ignorant and lazy grope in darkness. Special treatment will be found upon page 419 et seq. Treatment of Coryza, and influenza, or epidemic catarrh, must now be considered. When the patient is seen early, order a hot foot-bath and frequent libations of hot lemonade, containing or not a teaspoonful or two of whiskey, and confine him to a warm room if possible. The diet should be mild and nourishing, such as oatmeal porridge, boiled rice, milk toast and jelly, milk, beef- tea, eggs, and oysters. Camphor may be given very early in the affection, but gener- ally the disease is fully under way before the patient applies for treatment. Aconite is the remedy par excellence, and should be given in water every half hour or every hour, until amelioration occurs, or the dry irritable condition of the mucous membrane, the sneezing and oppression of the head, the chilliness and flushes of heat or continuous fever pass away, as copious secretion is estab- lished. The patient should snuff up or douche the nose frequently with water heated to 100° F., and containing a tablespoonful of glycerine and an even teaspoonful of salt to the pint. Ten drops of Camphor tincture (Tr. Camphorce) to an ounce of water is, also, an excellent stimulant for this condition. If the pharynx is, also, affected, gargle the throat with the salt solution, holding the head back horizontally so that the fluid will reach up behind the palate. Some persons can gargle so well, that they can eject the fluid from the nose. When the Eustachian tube gives symptoms of obstruction or involvement, inflate gently with the air-bag once or twice daily. After the sero-mucus diminishes somewhat, I stop the salt solu- tion and spray the nose and pharynx with a teaspoonful of Tar TREATMENT OF CORYZA. 367 tincture (TV. Picis liquidoe) in one or two ounces of warm water. This stimulates the relaxed vessels, and favors their return to a normal calibre. In my experience, solutions of Quinine (Quinia Sulphas), and Carbolic acid (Acid. Carbolicum) have had little beneficial influ- ence upon the catarrhal process in coryza or hay fever. Children are often rebellious to treatment with douche or spray, but may be coaxed to breathe steam from one of the above solutions, heated and exposed in a partially covered bowl. Smokers derive comfort from using cubeb cigarettes, but tobacco is too irritating and debilitating, and should be forbidden. Belladonna may be required early in some few cases, and in a transient phase of coryza or influenza; especially, if the pharynx and bronchial tubes are involved in the disease. Congestion to the head and face, hot moist skin, sore, raw feeling in the nose and throat, and oppression of the chest, call for its administra- tion. Arsenicum is a remedy that comes next to Aconite in efficiency. The symptoms lack the fever of Aconite. There is frontal head- ache and fulness of the frontal sinuses ; a copious, watery, exco- riating secretion from the nose and eyes; hoarseness, debility, rapid pulse, restlessness, night exacerbations, and relief from warmth. Natrum arsenicosum covers very much the same group of symptoms, and has a perfectly reliable pathogenesis made by provers in Allegheny County, Pa., who to this day suffer from their heroic self-sacrificing efforts to give a true picture of drug- action to the profession. Allium cepa is a favorite remedy for acute catarrh. The dis- tinctive symptoms demanding it are: headache and pain about the temples; profuse lachrymation of a non-irritating character; a little smarting of the eyelids; an acrid discharge from the nose, with violent sneezing; pain in the larynx; hoarse, rough cough ; aggravation in a warm room, and amelioration in the open air. Euphrasia is suitable, when there is photophobia, pressure and burning in the eyes, red, swollen eyelids, scalding lachrymation, a copious flow of bland serum from the nose, frequent sneezing 368 THE HUMAN EAR AND ITS DISEASES. and coughing, hoarseness and profuse expectoration, aggravation at night, and in a recumbent position. Eupatorium is an old reliable domestic remedy, much used in decoction of the herb for catarrhs, aching over the whole body, and the general symptoms of a cold. In tincture, it acts finely in mild cases, and should not be neglected. The characteristic symptoms are: soreness of the eyeballs, headache, weight in the occiput, coryza and sneezing, hoarseness, cough, chilliness, and fever. Rumex is highly recommended in headache, dull aching of the eyeballs, fluent coryza, sneezing, raw feeling in the nose and throat, dryness of the naso-pharynx, mucous expectoration, hoarse- ness, rawness and pain in the larynx, tickling fatiguing cough, sensitiveness in the open air, aggravation at night, on lying down, and in raw cold weather. Kali hydriod. should be tried, when there is headache, fulness at the root of the nose, conjunctivitis, a steady flow of acrid secre- tion from the nose, frequent and violent sneezing, general chilli- ness, soreness of the nose, a frequent stopped feeling of the nose, roughness of the throat and larynx with dry cough, rattling in the Eustachian'tubes, fugitive pains in the joints, and a strumous, rheumatic or gouty tendency. I have found Kali bichromicum more suitable for the advanced stage of this disease. Mercurius is one of the most useful medicines for the later stages of the affection. It should be selected for frontal head- ache, soreness of the nasal bones, conjunctivitis with excoriating lachrymation and photophobia; a moderate corrosive sero-mucous discharge from the nose, much sneezing, epistaxis at night, relaxa- tion and sponginess of the Schneiderian mucous membrane; dry sore throat with sticking pains, tinnitus, rales in the Eustachian tubes, and deafness; a slimy tongue and mouth, general weakness, and profuse sour sweat at night. In both strumous and syphilitic cases, it sometimes improves the condition of the patient in a short time. Hepar, Mezereum, Nitric acid, Sanguinaria, and a few other remedies are occasionally useful in the disease under considera- tion. Epidemic influenza requires no different treatment in the early TREATMENT OF ACUTE PHARYNGITIS. 369 stages. Its principal symptoms correspond with those of coryza. The patient should have rest from all business care, a mild easily digested diet, and the medicine indicated by the important symp- toms. The medicines that have had a salutary effect upon the morbid process are, Aconite, Arsenicum album, Bryonia, Natrum arsen- icosum, Kali hydriod., Magnesia sulphate, Nux vomica, Phos- phorus, Rhus, and Veratrum.' Some medicines that are beneficial one season are of no use the next. Treatment of Acute Pharyngitis, or common sore throat, varies with the parts affected. In the beginning, a hot foot-bath, lem- Fig. 84. Perfume Atomizer. onade, etc., should be ordered ; the neck surrounded with flannel; the throat gargled or sprayed every hour or two with a warm aqueous solution of Kali mur. (Potassii chloras grs. xvi, Aqua f§j), and Aconite or Belladonna administered internally. Fig. 85. Knight's Atomizer. Of all topical remedies, a warm solution of chlorate of potassium is the best. It diminishes the congestion and heat, moistens the parts, dissolves thickened mucus, and acts as an antiseptic. It will greatly diminish the danger in diphtheria, and if used early enough will generally abort the disease. The solution can be applied to the parts very effectually by an atomizer. 370 THE HUMAN EAR AND ITS DISEASES. The Perfume Atomizer is a cheap instrument with metal tubes suitable to put in the hands of the patient or nurse. Knight's Atomizer is a very useful office instrument, having metal tubes for spraying the buccal pharynx and nose. Newman's Atomizer Fig. 86. Fig. 87. is a very good one. The Reversible Atomizer is firmly connected in all its parts, which are made of metal, and currents can be sent upward, downward, and laterally, without removing the tube from the throat. Richardson's reversible jet apparatus, with Fig. 88. Fig f. r Newman's Atomizer. hard rubber tubes, has reversible currents, and is not injured by * medicated solutions. It is the most generally useful of any fig- ured and is not very expensive. TREATMENT OF ACUTE PHARYNGITIS. 371 The hand atomizers have one or two rubber bulbs, connected by rubber tubing with the base of a tube which helps form the ato- mizing apparatus. When either rubber bulb is compressed, air is forced along the tube across the capillary point of another tube, pro- ducing a partial vacuum therein. The fluid having been intro- duced into the bottle, rushes up and along this second tube, es- capes at the point, is broken into a fine spray, and driven onward by the current of air. When the bulb near the bottle is com- pressed, an interrupted, when the farther one, a continuous spray is produced. Fig. 89. Cleborne's Tongue Spatula and Spray Apparatus. This combined tongue depressor and atomizer, lately invented by a distinguished naval surgeon, is admirably adapted to keep the mouth open, the tongue down, and the spray in the proper direction. The reversible atomizer can be fixed in the bottle, and then the spray can be used more effectually. The steam atomizer has glass atomizing tubes, and the steam from its boiler takes the place of the air current. It is better to use this in the 372 THE HUMAN EAR AND ITS DISEASES. earlier stages of acute disease, and when false membranes are to be detached. Medicines in solution are introduced into the bottle of the hand atomizer, and into a cup upon the side of the steam appa- ratus. Those containing gums and resins soon clog the fine tubes. Fig. 90. Steam Atomizer. The fluid should be above the lower end of the tube within the bottle or cup. The capillary points should be directed towards the surface to be medicated, and the preferred bulb compressed firmly. The application must be interrupted frequently, in spraying the nose and throat, in order to give the patient a chance to breathe. Pass the atomizer tube first into one nostril, and then the other, and spray the naso-pharynx; then have the mouth well opened, hold the tongue down with a tongue depressor, and spray the buccal pharynx and throat above and below. Quite young chil- dren, handled gently, will endure this method, when they are incapable of gargling, and will not submit to the steam atomizer. The steam atomizer may sometimes be employed, but its usual tube must be changed for larger ones, in order to spray the naso- pharynx. In mild cases, a solution of Borax (Sodii biboras gr. v, Aqua fSj) is a soothing and efficient spray or gargle. Powders of the first decimal trituration of Kali murias are a good local remedy, and may be given with directions to let each powder dissolve upon the tongue, and then swallow slowly. TREATMENT OF ACUTE PHARYNGITIS. 373 Chlorate of potash lozenges may be used in the same way, and an infant will take a quarter or half of one, now and then, with much benefit to the throat. Potash salts are antiplastic; when absorbed into the blood, they diminish fibrinogenouselements, favor free exudation in mucous membranes, and diminish the tendency to plastic deposits. Tannic acid is frequently used in spray, and as a gargle. A drachm of the powder, dissolved in an ounce of glycerine and three ounces of water, makes a topical application of value in relaxed mucous membranes and oedema of the uvula, after the acute inflammation has somewhat subsided. Lactic acid in solu- tion (Acid. Lacticum gr. xx, Aqua f §j) is an excellent local applica- tion in diphtheria, and diluted Chlorine water (Aqua Chlorini f5j, Aqua f Sj) has been much lauded in the same disease. Vapor of lime-water, inhaled from a vessel as lime is slacking, often proves effectual in expelling false membrane. Water containing Alcohol, Capsicum, Carbolic acid, Alum, Sulphate of zinc, Sulphate of copper, etc., are recommended by authors, but are less efficacious than those remedies mentioned above, and some of them are decidedly objectionable on account of their effects upon the teeth and the general system. I use the sprays quite warm, and order the gargles to be taken in the same way, when possible. Cold solutions, however, do very well, and are often preferred by patients. It will frequently be necessary to combine the local treatment for coryza, with that of acute pharyngitis, especially, the use of a warm medicated solution by snuffing, or by the nasal douche. A slight fulness in the ears, an unusual resonance of sound when speaking, and rattling of mucus in the Eustachian tubes when blowing the nose, indicate the necessity of gentle inflation. This should be done as often as the symptoms recur, but probably once or twice a day will prove sufficient. Aconite is useful at the onset of the disease to reduce the gen- eral fever, and diminish the congestion of the throat. Chilliness, followed by decided fever, restlessness and anxiety; painful de- glutition ; burning, stinging pain in the throat, neck and ear; crimson color of the fauces and pharynx; swollen tonsils, and full feeling in the throat, call for its use. 374 THE HUMAN EAR AND ITS DISEASES. Apis is given for dryness, burning and stinging in the throat, sense of constriction, difficult swallowing, swollen or ulcerated tonsils, cedematous swelling of the throat and neck, and engorge- ment of the submaxillary glands. Acid. Nitricum is a most excellent remedy in diphtheria of the throat, with rawness of the nose, livid swelling of the throat, great tumefaction of the tonsils and submaxillary glands, large for- mation of false membrane, and a fetid, gray, slimy discharge from the throat and nose. Pulsatilla suits mild cases of sore throat, with implication of the Eustachian tubes and ears, in children and persons of strumous and lymphatic constitutions. The inflammation of the mucous membrane in such patients, results in an early and copious flow of sero-mucus, and resolution follows soon, or a chronic disorder of a mild character remains. Belladonna is a specific for many cases of sore throat, and most benefit is derived from its use in the early stages of the disease. After forty-eight hours, another remedy will generally be found to suit the case better. It relieves the pain and swelling of pharyngitis and tonsillitis sometimes in a surprising manner. A lady had quinsy, the throat was nearly closed, both tonsils im- mensely swollen, only a few drops of water could be swallowed at a time, constitutional disturbance was great, and the patient much alarmed. Belladonna internally for twenty-four hours had not relieved. I continued the medicine, but supplemented it by a two-inch wide Belladonna plaster, extending over the tonsils from ear to ear. Relief without suppuration came in twelve hours and restoration to health soon followed without any other medicine. The symptoms demanding this medicine are : active conges- tion of the head ; hot, moist skin ; soreness, fulness and constric- tion in the throat; painful swallowing with frequent inclination ; throat dry, rough, burning, bright fed, swollen and painful; tonsils and submaxillary glands often swollen; sharp pains through the throat and Eustachian tube, especially when swallow- ing ; the neck sensitive to touch, and the ears frequently affected by fulness, tinnitus, deafness and pain. Mercurius stands next in efficiency, if it does not alphabetically, particularly, if the patient has syphilis. It is indicated when there TREATMENT OF ACUTE PHARYNGITIS. 375 is malaise, indigestion, disturbance of nutrition, and weakness; the breath is fetid and offensive; the tongue is pallid and swollen; there is a slimy secretion in the mouth and fauces; the mucous membrane of the fauces and pharynx is deep red, sore, swollen and ulcerated ; false membranes sometimes appear; the uvula is elongated and cedematous; the tonsils are bluish or dark red, tumefied, ulcerated, and the seat of throbbing, stinging pains; the submaxillary glands are engorged; the Eustachian tubes are obstructed ; pains shoot through the throat and neck; the larynx is inflamed causing hoarseness, and the neck is painfully sensitive to touch and motion. These symptoms threaten suppuration of the tonsils or sub- maxillary glands, and this may be often arrested by steady admin- istration of the medicine for some days. The time for the ad- ministration of Mercurius is later than that for Belladonna, pos- sibly after this has failed; and the pain is not so severe as when Belladonna is suitable. The sthenic stage of Belladonna has passed, and asthenia begins to appear in the marked alteration of the secretions and the failure of strength, so commonly seen in provings of Mercury. Mercurius corros. and Mercurius solubilis are good preparations to use, but many practitioners prefer Merc. iod. rub., Merc. oxid. rub., and Merc, cyanid. for throat affec- tions. Lycopodium is useful only in a limited number of cases. It is given very often, however, for sore throat upon the right side, when the totality of symptoms, and, even, the local ones posi- tively contraindicate it. Among reliable indications for its ad- ministration are: confusion of mind, melancholia, vertigo, head- ache, palpitation of the heart, attacks of dyspnoea, excessive flatu- lence, irritation of the mucous membranes everywhere, coryza with acrid discharge, hyperaesthesia and noises in the ear; super- ficial inflammation of the pharynx and fauces, indicated by burn- ing, rawness, pain on swallowing, and tawny redness; moderate swelling of the tonsils, and some soreness to the touch below the angle of the jaw. Lachesis has a precious list of symptoms, and is thought to have an affinity for the left side of the body, and thus is a sort of antithesis of Lycopodium. 376 THE HUMAN EAR AND ITS DISEASES. I was treating, in 1878, a severe case of diphtheria, with Nitric acid. The nose had improved much, the throat, though better than at first, had been at a standstill for several days. Strength was failing fast. I compared symptoms again, and settled upon the acid, which was continued. The next day the membrane upon the left side had diminished, and a patch had appeared upon the hitherto clean right side. I said to myself, " that's a Lachesis symptom." I concluded to wait another day as the boy seemed a little better, and the other symptoms were not very characteristic between the two medicines. The next day the membrane was gone from the right side, the boy was better, the Nitric acid was continued, and in a short time my patient was well. If I had changed to Lachesis at the time I saw its peculiar symptom, the boy might have died, or the snake virus have re- ceived undeserved credit. Symptoms which should call attention to Lachesis are: great depression of vital power, gray sickly pallor of the face, mental exhaustion, praecordial distress, palpitation of the heart, oppres- sion of the chest, swelling of the submaxillary glands, neck and throat. The tonsils are livid red, threatening gangrene; some- times ulceration is already present; there are choking sensations; shooting pains in the throat, extending along the Eustachian tube ; tinnitus and pain in the ear; roughness and soreness of the larynx ; hoarseness, spasms of the glottis, hacking cough, and great sen- sitiveness in the neck and larynx to outside pressure. The pic- ture is one of adynamia, and is seen in exanthematous fevers most frequently. Phytolacca has proved of considerable value in acute pharyn- gitis, especially, in the early stages, and where the attack is in a rheumatic or syphilitic subject. The symptoms that call for its administration are: general debility, nausea, and severe head- ache ; stiffness and soreness of the muscles ; rheumatic and neu- ralgic pains in various parts of the body; swelling of the' lym- phatic and other glands, and irritation of the eyes and nose. The tongue is rough and sore on the edges, very red at the tip, with severe pain at the root; the throat feels full, dry, rough and smarting; the soft palate and tonsils are swollen; the mucous TREATMENT OF ACUTE PHARYNGITIS. 377 membrane of the throat is dark red, sometimes ulcerated, or there is a dark pseudo-membrane upon it; a thick tenacious saliva fills the fauces, causing hawking and cough ; swallowing brings a feeling of a lump in the throat, and severe pain that shoots along the Eustachian tubes through the ears. Poke-root tea has a good reputation, where the plant is indige- nous, for the cure of rheumatism, and the refined medicine pre- pared for use has a sort of specific influence upon very painful attacks, which are sometimes called rheumatic, sometimes erysipel- atous sore throat. Rhus toxicodendron corresponds with Phytolacca in many of its symptoms, and is a precious medicine, rescued from the obscu- rity into which it had been cast by materia medica authors. One should resort to it, when there is great prostration, chilliness and fever; great restlessness and uneasiness; anxiety, vertigo, and mental disturbance; palpitation of the heart, oppression and sore- ness of the chest, soreness of the larynx, with hoarseness and cough; paralytic weakness and aching of the limbs; numbness, pricking and trembling sensations; stitching pains and cramps in different parts of the body ; stiffness, soreness, and tension of muscles and joints; eczematous and erysipelatous eruptions, es- pecially, upon the face; swelling and suppuration of glands. The eyes and nose are variously affected ; the tongue is sore, red, and sometimes cracked; there is thirst, bad taste, and foul breath ; the mouth and throat are dry; the mucous membrane is dark red or bluish purple, turgid with venous blood, and may show ulceration or false membrane; there is swelling of the throat, tonsils, submaxillary glands, and cellular tissue of the neck; the parts are sore and stiff; sharp pains dart through the throat and neck, and swallowing is difficult and very painful. The medicine seems more suitable for diffused sore throat than tonsillitis, and for that particular kind, that occurs in plethoric persons of intemperate habits, with a rheumatic, gouty or syphi- litic diathesis. Kali bichromicum acts powerfully upon the mucous membranes, and is adapted to both acute and chronic pharyngitis. It is indi- cated by prostration; aching in the bones; fugitive pains; pale face; disorder of the stomach and intestines; oppression of the L5 378 THE HUMAN EAR AND ITS DISEASES. chest; hoarseness and cough ; conjunctival inflammation ; coryza or chronic nasal catarrh; red tongue, coated whitish-yellow at the base; dryness of the mouth; thick, tough, viscid, stringy mucus in the nose, throat, and larynx; fulness, burning and raw- ness of the throat, extending down the oesophagus; soreness and shooting pains through the tonsils, throat and ear; the mucous membrane is red and tumid, or yellowish-red, relaxed and ulcer- ated ; the tonsils are ulcerated in spots, or red, tumefied and threatening suppuration; ulcers when visible show an uneven yellowish base and red borders; one is struck by the apparent lack of vital reaction against the morbid condition. Sanguinaria may be of benefit, though its symptoms pertain- ing to the throat are not very characteristic. Headache, vertigo, tinnitus, pain in the throat and ears; dry, raw throat; fulness and choking sensation while swallowing; inflammation and ulcer- ation of the mucous membrane, with pearly diphtheritic exuda- tions; dry cough and dyspnoea; chilliness and fever, and torpid languor and weakness, are regarded as characteristic symptoms for the employment of the medicine. Hepar sulph. calc. is of secondary value in the early stages of pharyngitis to some of the medicines already mentioned, but is generally required when suppuration threatens. It should be considered, when there is lassitude, fainting spells, great sensi- tiveness in the open air, chilly sensations and flushes of heat fol- lowed by easy sweating, stitching pains over the body, swelling of the glands, vertigo, and headache. The eyes may be irritated or sore; the nose affected by catarrh, and the larynx, trachea and bronchi inflamed, causing dyspnoea, hoarseness, and harsh cough. The throat has a dry, scraped, sore feeling; the mucous mem- brane is red and granular or ulcerated; sharp pains shoot through the throat and neck, and extend along the Eustachian tube to the ear; the submaxillary glands are tumefied, and the ton- sils swollen. The whole tonsil or the part over the abscess forms a pyramidal or rounded prominence, projecting into the fauces; but sometimes the swelling is very irregular, and the abscess out of sight behind it. It is desirable to abort a suppuration, or, if this cannot be done, to hasten the process. The former work can be best accomplished TREATMENT OF CHRONIC NASAL CATARRH. 379 by some of the above remedies ; the latter by the administration of Hepar, which has a specific influence upon the formation of pus. Incision.—When the tonsil is enormously swollen, the swallow- ing very difficult or impossible, and suffocative spells frequent, the tonsil ought to be incised in several places, so that it may bleed freely; but the abscess should be opened by preference in all cases, when possible without too much risk. A long-handled bistoury, having the blade wound by tape so that only half an inch of the point is uncovered, is safe and effi- cient for scarification. Seat the patient with the head against a support; illuminate the throat by direct or reflected light; depress the tongue, and put a cork between the teeth to hold the jaws apart if necessary ; pass the knife directly backwards, with the cutting edge directed imcards upon the affected side; push the point into the tumor inside the palato-glossus muscle, preferably into the inner half of the swelling, and cut towards the middle line of the body. Make two or three incisions a little distance apart, or push the knife into an abscess; then give the patient warm water as a gargle, and let him hold his head forward, so the blood or pus may run out anteriorly. The only danger is of wounding the carotid artery, which courses upwards just at the base of the ton- sil. Swelling sometimes displaces the vessel and renders its exact relation to the tonsil doubtful, but, if the above directions are followed, no disaster need be apprehended. Treatment of Chronic Nasal Catarrh.—This is one of the most obstinate diseases the physician is called upon to treat. In many cases of aural disease, the Schneiderian mucous membrane must be brought to a healthier state, or the ear trouble cannot be removed. © / The frequent partial as well as total interruption to respiration through the nose, and the almost constant irritation maintained in the naso-pharynx by the morbid discharge, prevent the normal action of the Eustachian tubes in aerating the tympanum, and support the diseased condition of the tubal and tympanic mucous membrane. Proper treatment of the nose and pharynx will do more good, than neglect of these, and the most thorough measures directed to 380 THE HUMAN EAR AND ITS DISEASES. the ear. The patient must observe all the hygienic measures, which long observation and experience have shown to be sensible, scientific, and conducive to the best health of man. Everything calculated to cause frequent irritation in the nasal mucous mem- brane ought to be avoided; therefore, working daily in a dusty atmosphere, using catarrh snuffs, and smoking cubebs and tobacco should be forbidden. In the early stage, a great deal can be done by preventing colds, and treating those that occur gently but per- sistently. After the mucous membrane has become thickened, atrophied, and ulcerated in places, I think colds in the head are not frequent, exposure being more likely to cause inflammation of the larynx and bronchi. I can only account for this by suppos- ing, that the morbid state of the Schneiderian membrane renders it incapable of those profuse sero-mucous fluxes to which it is so sub- ject when healthy, and, that a moderately increased mucous discharge occurs in the nose from a cold, but the major work of elimination— if cold causes elimination of some morbid product of the blood— is done by healthier mucous membrane in the larynx and bronchi. When acute attacks have subsided, and the nasal lining keeps up a rather free discharge too long; especially, if the discharge shows a little bloody, or the patient has occasional attacks of ep- istaxis from slight causes, then is the golden opportunity to nip the affection in the bud. These patients are generally children or adolescents, adults presenting more advanced disease; but occasionally a middle-aged person, who is in feeble health, furnishes evidence of this incipient stage. In the mildest phases, I direct a warm solution of an even teaspoonful of salt to a pint of water to be snuffed well into the nose, and used as a gargle every day. Pulsatilla is the most valuable remedy in the materia medica for this state, but ought to be given in tincture. If the patient is strumous, or of very light sanguine temperament, Calcarea carb. may be given, but I prefer the Calcarea phos., which in my experience has proved very efficient in all cases where the car- bonate seemed indicated. If the symptoms do not improve, it is advisable to give Arseni- cum iod., and have the patient, in addition to the usual salt-water douches, draw in the nose twice or three times a week, the steam TREATMENT OF CHRONIC NASAL CATARRH. 381 from a pint bowl of hot water, in which a teaspoonful of Tere- binthina tincture has been diffused. After carefully following this treatment for some weeks, if the catarrh and bloody show still continue, I believe it advisable to spray or douche the nose twice a week with a warm mixture of a teaspoonful of Tar tincture in a pint of salted water. Generally these measures will restore the integrity of the mucous membrane, but in obstinate cases, besides constitutional medica- tion, it may be necessary to use a spray or douche of five grains of Alumen or of Zinc sulphate to a fluid ounce of warm water, to astringe and tone up the relaxed mucous membrane. These mild cases, which generally precede for awhile the graver ones, are seen by the general practitioner much more frequently than by the specialist; and the former, therefore, should be more in- terested in prophylaxis against the severe nasal catarrhs. When chronic nasal catarrh has reached the secondary stage, characterized by thick discharge and some degeneration of the Schneiderian membrane, the most important measure for the com- fort of the patient, for improving or curing the disease, and pre- venting or curing Eustachian tube or middle ear complications, is to keep the nasal labyrinth and naso-pharynx clean and free from Fig. 91. Post-nasal Syringe. the morbid secretions of the parts. At the same time certain local medicaments must be applied secundum artem, while the proper internal remedy is taken continuously. There are several ways of cleansing the nasal meatus. Fluid may be snuffed into the nose from the hollow hand or from a vessel. The patient should be directed to breathe only through the mouth, and to hold it very wide open during the procedure, to prevent washing secretions down the throat. This method fails to cleanse the devious passages in a thorough 382 THE HUMAN EAR AND ITS DISEASES. manner, and, hence, is only applicable alone, when the disease is mild, and confined to the inferior and middle meatus of the nose. It is very useful, however, to combine this, in many cases, with injections through each side of the nose from the posterior nares, by means of the post-nasal syringe already mentioned. It is not needed when the douche is employed. The post-nasal syringe is of hard rubber, has a spool-shaped butt, so that it can be readily held between the index and middle fingers, while the thumb in the ring works the piston. The in- strument is operated with one hand, the curved and much-per- forated nozzle is passed up and hooked behind the palatine arch of each side in succession, while the tongue is depressed, and the throat is kept in view under direct or reflected light. When the injections are made, it is well to cover the patient's chest with a long towel, and direct him to incline the head a little Fig. 92. The Posterior Nares, Etc (Seiler).—1, The nasal septum; 2, inferior meatus; 3, superior meatus; 4, middle meatus; 5, superior turbinated bone; 6, middle turbinated bone ; 7, inferior turbinated bone ; 8, mouth of Eustachian tube; 9, Eosenmuller's fossa; 10, side of the pharynx; 11, the pharyngeal tonsil; 12, velum of the palate. forwards, so that the fluid from the nose may run into a vessel, and not over his clothes and the floor. He must be directed to keep his mouth open, and to breathe through it, and be cautioned not to start back when the injection is in progress. If deftly done, the whole fluid drawn up by the syringe and injected, should run out of the anterior naris of the side upon which the injection TREATMENT OF CHRONIC NASAL CATARRH. 383 has been made. Sometimes owing to contraction of the pharynx and displacement of the nozzle, the fluid will escape from both nostrils. This is generally the case, when the fluid is injected merely into the naso-pharynx, and indicates the necessity of carrying the nozzle higher, in order to effectually clean both meatuses. If the reader will note the direction of the turbinated bones, and the passages of the upper portion of the nose, he will see that an injection from behind will pass into places that cannot be reached from the anterior nares except with the douche, and then only when the upper part of the nose is harmoniously developed and the passages large. The superior meatus of the nose is directed obliquely down- ward and backward towards the pharynx ; it communicates above with the middle and posterior ethmoidal sinuses, and behind with the sphenoidal sinus. Its anterior communication with the middle meatus is frequently closed by irregularity in osseous development and by disease. The middle meatus is directed backward and a little downward. The anterior ethmoidal, and the frontal sinuses open into its upper anterior portion, and the maxillary sinus into its middle part beneath the middle turbinated bone. The inferior meatus below the true turbinated bone is directed horizontally backward, and receives in its anterior portion the lachrymo-nasal duct. The problem in chronic catarrh is to cleanse and medicate all this labyrinth. It is apparent that fluid introduced by the anterior nares will readily flow into the inferior and middle meatuses, but will pass with difficulty, or not at all, into the superior meatus and its diverticula. It is evident that a stream of fluid thrown forward and upward from behind will reach the superior meatus and its sinuses very easily, and it is because this fact is not remembered, and the post-nasal syringe is hot used in conjunction with the douche, that so many cases of chronic nasal catarrh resist treat- ment. I recommend, therefore, the use of the syringe to cleanse these upper passages, in all but the mildest cases of chronic catarrh, and consider it a sine qua non for severe ones. In conjunction with snuffing and anterior injections, it may suffice and the douche 384 THE HUMAN EAR AND ITS DISEASES. may be neglected, in cases where the use of the latter is not con- sidered advisable. Fig. 93. Vertical Section of the Face and Neck (Leidy).—1, Oval cartilage of left nostril; 2, triangular cartilage; 3, line of separation ; 4, prolongation of oval cartilage along the nasal columni; 5, superior nasal meatus; 6, middle meatus; 7, inferior meatus; 8, sphenoidal sinus; 9, side of posterior naris ; 10, mouth of Eustachian tube; 11, naso-pharynx; 12, soft palate and uvula; 13, post-labial region; 14, roof of mouth and hard palate; 15, communication be- tween the bucco-dental space and mouth; 16, tongue; 17, fibrous septum of tongue; 18, genio-glossal muscle; 19, genio-hyoid muscle; 20, mylo-hyoid mus- cle; 21, anterior half arch of the palate; 22, posterior half arch of the palate; 23, tonsil; 24, 25, floor of the fauces ; 26, 27, pharynx; 28, cavity of the larynx ; 29, ventricle of the larynx and vocal cords; 30, epiglottis ; 31, hyoid bone; 32, 33, thyroid cartilage ; 34, thyro-hyoid membrane ; 35, 36, cricoid cartilage ; 37, sterno-thyroid muscle. Gruber has given directions for injecting the nose anteriorly, for the purpose of cleansing the naso-pharyngeal space and medicat- TREATMENT OF CHRONIC NASAL CATARRH. 385 ing the Eustachian tubes. A two-ounce syringe with a rounded nozzle is filled with the fluid desired, pressed into one nostril, and quickly injected. If it is required merely to cleanse the naso- pharynx, the other nostril is left open, and the fluid escapes there- by ; if to force the fluid into the tubes, it is partially or wholly closed for an instant. No directions are given the patient about breathing, reliance being placed on the instinctive action of the base of the tongue and soft palate to shut off the upper pharynx from the throat. I think the patient should be instructed to keep his mouth weli open, and to breathe through it, as I have tried the method of the distinguished professor several times, and in- stinct failed so ignominiously, that the whole injection went into the stomach. There is considerable difference of opinion among authors in regard to the advisability of using the nasal douche. From ob- servation and experience, I am inclined to the belief, that the instrument is not injurious to the ear when used in a proper manner. I have known many cases of naso-pharyngeal catarrh treated by the douche, without injury to the ears, even when diseased, and I use it frequently in my practice with the best results. There are several kinds of douche, in the market, but I shall allude to only two, the siphon, and the modified Thudicum douches. The siphon douche consists of a piece of simple rubber tubing, fitted with a good sized nipple or olive-shaped, hollow nose-piece at one end, and a perforated, hemispherical, nickel-plated weight at the other. The base of the latter has an elevated scolloped rim around the circumference, so that when it rests base down- wards, the fluid can flow freely to the central hole, which com- municates with the tube upon the upper side. Any vessel, pre- ferably a pint tincup, completes the apparatus. The vessel should be filled with the desired solution; then put the instrument into it until the tube is filled, close the nose-piece tightly with the finger, and remove all of the tube except enough to leave the weight upon the bottom of the receptacle, and it is ready for use. The modified Thudicum douche, as recommended by Dr. Seiler, 386 THE HUMAN EAR AND ITS DISEASES. consists of a nose-piece and length of rubber tubing, connected with a pint tincup by a tube soldered into a hole near the bottom. When fluid is placed in the cup, and the tube is held below, the flow from the nose-piece immediately begins. A tincup is preferable to a crockery or glass bowl, because it will not break, and is inexpensive. I prefer the siphon apparatus and a glass bowl, however, for medicated solutions, as the tin be- comes oxidized and the iron rusty from the chemical action of certain remedies. The physician before applying the nasal douche should note if the patient can breathe freely through both sides of the nose, and Fig. 94. Fig. 95. Siphon Douche. Siphon Douche Complete. examine both nasal fossae anterior and posterior, to be certain there is no obstruction sufficient to prevent the flow of fluid both ways. If obstruction is found, the douche should not be tried. If no obstacle exists, he should then instruct the patient to breathe through his mouth, keep this wide open, and incline his head a very little forwards above a receptacle. The clothes should be covered with a towel or rubber apron, and the patient encouraged to keep quiet and obey orders. The solution having been prepared and put in the cup, the nose- piece is pushed into the nostril and held so as to close it, the pa- tient cautioned to watch his breathing, and the cup steadily raised till its bottom is upon a level with the eyebrows. As the fluid flows through the meatus, around the naso-pharynx and septum, and out of the other nostril, and the patient gets accustomed to the new sensations, the cup may be elevated one or two inches higher; but under no circumstances should it be raised above the TREATMENT OF CHRONIC NASAL CATARRH. 387 head, as the increased pressure will force the fluid into the Eus- tachian tubes, frontal sinuses, and even farther, and produce serious consequences. The first application should be short, and half a pint of fluid is sufficient for it. The quantity may be increased, as the patient becomes accustomed to the treatment, until a pint or more is passed through the circuit. The patient may be instructed how to use the douche by one or two office applications, and then cleansing and topical medicinal treatment may be carried on by him at home; the physician, however, should not remit his attentions on this account, but use the instrument upon the patient several times a week, in conjunction with the posterior nasal syringe, in order to insure thorough work. All fluids introduced into the nose ought to be raised to a tem- perature agreeable to the patient. This will be a little below blood heat, and may be approximately determined by dipping the back of the hand in the solution, or putting a few drops in the palm. The first filling of the syringe or douche should be wasted, especially in cold weather, as its heat is abstracted by the cold instrument. Another important matter is the specific gravity of the fluid. Simple warm water as advised by many persons is positively in- jurious to the nasal mucous membrane. The douche must be of the same density as the serum of the blood, or osmotic effects will be produced. When warm water, or a fluid of less density than the blood serum, is brought in contact with the nasal lining, endosmosis will take place, the numerous capillaries will become engorged, and pain induced. When a fluid of greater density than the blood serum is em- ployed, exosmosis will occur, the blood corpuscles, deprived of part of the liquor sanguinis in which they float, will accumulate and stagnate in the capillaries, and cause irritation and burning pain. A solution of 56 grains of common table salt in a pint of water will neither swell nor crenate the red blood corpuscles, and is, therefore, of the same density as the blood serum. This prop- erty, and the well-known antiseptic nature of chloride of sodium, 388 THE HUMAN EAR AND ITS DISEASES. render this liquid excellent for cleaning purposes, and it may be used as a vehicle for medicinal substances with which it is not chemically incompatible. In such instances, the quantity of salt must be diminished in proportion, as other substances are added, in order to preserve a specific gravity of 1030. The solution may be made near enough for practical purposes by adding an even teaspoonful of table salt to a pint of warm water. Sea salt, sold by druggists for bathing purposes, is agree- able for nasal applications, and may be substituted for the com- mon article. After warm douches and warm spraying, a patient ought not to go out of doors for some time, especially, in the cold season; and in all seasons he should be careful of exposure to drafts and damp places. I have seen sweat stand in great beads upon the forehead after a moderately warm nasal douche, and one of my patieuts took a severe cold from making a call soon after an ap- plication, having been obliged to stand some minutes waiting at the door for a lazy servant to let him in. The post-nasal syringe and the nasal douche are to be used with the salt solution to cleanse the nose and pharynx whenever required. It may be necessary at first to do this twice a day, but once daily is generally sufficient. The patient must co-oper- ate in the treatment by blowing the nose hard, and by taking forced nasal inhalations, in order to remove all morbid secretions. A good deal of trouble is necessary occasionally, particularly when the patient is first seen, to dislodge the foul crusts and scabs, which cling to the narrow passages of the nose; but by repeated snuffing, blowing, syringing, and douching success is gained, and if proper measures are adopted, they will not accumulate in quantity again. Inflation with the air-bag aids in clearing the passages, and will often remove the dreadful frontal headache that comes from stuffed sinuses. After the nasal passages are clear and clean, it is desirable at least once a day to apply antiseptic and medicinal solutions to the mucous membrane. This may be done with the syringe, douche or atomizer. One of the best lotions after cleansing is a warm solution of Muriate of ammonium (Ammonii murias5ij, Aqua Oj), TREATMENT OF CHRONIC NASAL CATARRH. 389 applied with the post-nasal syringe, or by the hand atomizer through the nostrils and the throat. The same solution may be injected through the cathether into the Eustachian tubes, if they are much affected. Borax, bicarbonate of sodium, and chlorate of potas- sium are used in the same proportion, and are nearly as efficient. If there is ulceration and a very foul odor to the discharge, Chlorine water (Aq. Chlorini), one tablespoonful to a pint of warm water, sprayed into the pharynx and nasal fossae, will prove valuable. The dilution may be used often as a gargle, when the throat is foul and diseased,-as in diphtheria and malig- nant scarlatina. It deodorizes and disinfects the morbid exu- dates and the mucous membrane, and stimulates the tissues towards healthy action. A solution of Permanganate of potassium (Potassii perman- ganas gr. x to xx, Aqua f5j) is antiseptic and mildly stimulating, and may often be used with advantage. Severe cases of chronic catarrh, denominated Ozaena, some- times have a sickening smell, and require a stronger deodorizing, disinfecting, and stimulating remedy. This is found in Carbolic acid, which should be used as a spray and gargle in the propor- tion of five grains to the fluid ounce of water. A teaspoonful of glycerine added to the solution will make it more agreeable and more effective, especially, when the crusts and certain parts of the Schneiderian membrane are rather dry, and the former cling tenaciously. Many practitioners may be content to rest the local treatment here, keeping the nasal fossae and pharynx scrupulously clean and sweet, and relying upon the vis medicatrix naturce and internal medication to effect a cure. Some patients may recover after awhile; others will be greatly improved, but will need astringent and stimulating applications applied to the naso-pharyngeal mu- cous membrane. Tannic acid, commonly called tannin, is a pure astringent, having stimulating or irritant properties according to the strength of the solution of it employed. It is much superior to Hydrastis and Hamamelis for topical use, as these contain deleterious vegetable matters mixed with the tannic acid upon which their value depends. 390 THE HUMAN EAR AND ITS DISEASES. The mucous membrane of the nose and pharynx, in the very humid cases of chronic catarrh, becomes relaxed and cedematous, upon the anterior and posterior ends of the inferior turbinated bones, it is soft, moist, glistening, swollen, and bags downwards, so that it is sometimes difficult to differentiate the cushions from mucous polypi. This condition is generally coincident with elongated uvula, low-drooping arches of the palate, and hypertrophic pharyngitis. A solution of tannin (Acid. Tannici gr. xx to xxx, Aqua dest. foj), applied to the parts with the atomizer, sometimes supple- mented by the post-nasal syringe, contracts the distended capilla- ries, promotes absorption of the submucous effusion, and stimu- lates to healthy action. This solution is excellent for mild cases of epistaxis, occurring during the course of the disease. Tannin in glycerine is much employed in throat practice, and is frequently beneficial, but should not be used for the above symptoms. The aqueous solution is better adapted to the con- ditions, and it suits sore throat in general better than the glyc- erite. Sulphate of zinc is preferable to tannin, when there is no hemorrhage, and rather more stimulation is desirable. It may be employed for the cedematous symptoms of nasal catarrh, as well as for an atonic, granular, and ulcerated state of the Schnei- derian membrane. When cleansing and the above applications seem to have done all the good they will, and the mucous lining appears here pale, there red and rough, perhaps, in another place showing shallow, broad ulceration, a zinc solution (Zinci Sulphas gr. x to xx, Aqua dest. f§j), applied twice or three times a week, awakens the dormant energy of the tissues and promotes healthier action. The tar-water before mentioned is a mild and agreeable stim- ulant, that may be used alone or in alternation with an astrin- gent remedy. It can be added to the officinal salt solution for daily cleansing purposes with advantage. If the mucous mem- brane is very dry, a dressing of equal parts of glycerine and water is demanded. Glycerine may be added to some of the medicated solutions when deemed advisable. TREATMENT OF CHRONIC NASAL CATARRH. 391 Nitrate of silver is a better topical application for this disease than anything yet discovered. It suits all the stages admirably. It is soothing and antiphlogistic to active inflammation; it astringes and tones up relaxation, causing vessels to contract and resume their wonted activity; it burns a superficial slough upon spots of ulceration, and exercises a mysterious alterative power over tissues morbidly astray; it starts all the parts into active nutritive change, which, aided and guided, will lead to a condi- tion so closely approximating health, that both patient and phy- sician will be satisfied. For general stimulating, astringing, and alterative purposes, a five or ten grain solution of nitrate of silver (Argent, nit. gr. v to x, Aqua dest. f§j), should be sprayed into the anterior and posterior nares every second or third day, according to the severity of the case, after the parts have been thoroughly cleansed, and a last wash of Sodium bicarbonate has been used. Solutions of twenty, thirty or forty grains to the ounce of water may be applied by a camel-hair brush, a special flexible throat-brush, a light tuft of cotton on the holder, or, rarely, by a small bit of sponge in a sponge-holder. These strengths stim- ulate strongly, and cauterize tender spots and ulcers superficially. Fig. 96. Wagner's Handle and Brushes. If it is desired to apply the solid caustic, melt some crystals of the pure salt in a little porcelain capsule or a platinum cup such as is used in chemistry and metallurgy, dip into it when melted the end of a flexible silver probe, then withdraw it and let it cool. The probe can be bent to any desired angle, and ulcerated surfaces cauterized. Several useful but expensive porte-caus- tiques have been invented for this purpose. In these applications to particular spots, good illumination 392 THE HUMAN EAR AND ITS DISEASES. must be had with the head-mirror, and the throat-mirror when necessary, and a speculum may be needed to dilate the anterior nares. It is difficult to make limited applications in the poste- rior nares and naso-pharynx, because the palate muscles contract easily, push back the mirror, and, grasping the instrument, the mucous membrane gets well cauterized when it is withdrawn. To obviate this, pass a loop of silk around the uvula, draw it forward, fasten the silk between the patient's front teeth, and have the patient breathe entirely through the nose. If this cannot be endured, or is not successful in keeping the palate away from the pharynx, and one cannot guide a sheathed caustic holder to the spot upon the index finger, the cotton wisp or sponge in the holder Fig. 97. Granger's Sponge-Holder. must be used with mild cauterizing solutions. I have been obliged to depend upon the sponge-holder oftener than desirable. For the sake of precaution, after applying a very strong solution or the solid caustic, and waiting a few minutes, the patient should gargle the throat and douche the nose with the usual salt solu- tion, in order to neutralize any excess of silver nitrate that is likely to flow down the pharynx and do injury in its course. Spraying or syringing with the same will suffice, if the other measures are inoperative. Certain powders are sometimes beneficial in ozaena, but I have had too little experience with them to warrant giving an opinion. Bismuth subnitrate, Boracic acid, Cubebs powder, Iodoform, and Magnesium carb. may be snuffed or blown into the nose after cleansing it. Two very convenient powder blowers are figured. They are useful in this connection, and for applying powders to a suppurating tympanum. A recent writer claims to have cured several cases of ozaena in TREATMENT OF CHRONIC NASAL CATARRH. 393 two weeks, with snuff composed of Iodoform two parts and Acacia powder ten parts, applied three to six times a day. Others praise Iodoform, Mercury, etc., combined with vaseline or cold cream. Dr. Woakes recommends the use of various kinds of medicated cotton, packed in the nasal fossae. Hemorrhage of a mild degree is frequent in nasal catarrh, and can be arrested generally by the salt water or one of the astrin- Fig. 98. Tiemann's Powder-blower. gent solutions. Sometimes the bleeding persists in spite of these, and other remedies must be tried. The patient should be assured there is no danger, and be kept quiet and calm, sitting erect in an armchair. If fainting occurs, the chair and patient can easily be inclined backwards awhile. When the usual domestic methods Fig. 99. Sexton's Powder-blower. for arresting nosebleed have not been tried, if the flow is not excessive, they may be tested. Hold the right arm up perpen- dicular, put a piece of coarse paper under the tongue, dash cold water in the face, and snuff it up the nose, put a wet compress or a piece of ice wrapped in a towel upon the nape of the neck, and hold ice in the mouth. These failing, press the sides of the nose firmly together, and apply pressure over the facial arteries upon the superior maxillaries, just outside the alae of the nose. Should these proceedings fail, dilate the nostrils with a Frankel's speculum, and examine the illuminated fossae for the source of 26 394 THE HUMAN EAR AND ITS DISEASES. the hemorrhage. If this is visible in ruptured or ulcerated ves- sels, or fungous granulations, wipe the part clean and blow pow- dered tannin upon it, or apply a point of nitrate of silver. I stopped immediately and permanently an obstinate, recur- rent, and alarming hemorrhage from granulations, in a case of ozaena, by one application of lunar caustic to a fungoid excres- cence. If the source can only be approximately determined, stuff the affected side firmly by a probe and finger writh non-absorbent cot- ton. An intelligent patient can materially assist in packing this into the crevices and crannies of the nose. Let the patient now incline the face a little forward and await results. If blood escapes by the side of the cotton or goes into the throat, remove the cotton, and douche and syringe the nose thoroughly with ice- water. Hot water may be tried instead of the cold in anaemic persons. If this does not succeed, substitute a cold saturated solution of tannin for the water, aad wait. I have great faith in this; it does not stain nor excite inflammation, and I have suc- ceeded in stopping dangerous epistaxis with it in two cases, after strong iron solutions had failed. I deprecate the use of iron solu- tions ; they stain everything with which they come in contact, and cause inflammation and much distress to the patient. Mon- sel's solution (Liq. Ferri subsulphatis) is usually employed in this country, and may be sprayed, syringed or douched into the nose in various dilutions. One teaspoonful to an ounce of water should be tried at first, and then if necessary the strength may be increased until equal parts are used. Tincture of iron (TV. Ferri chloridi) and water, equal parts, is highly praised, and has the advantage of being easily procured. A pledget of lint wet with spirits of turpentine and introduced into the nose has arrested epistaxis after many other methods have failed. Rolls of cotton or linen, moistened with water, rolled in tannin, and packed into the nose, have been very effectual in some cases. During this active local treatment, there may be opportunity and necessity for internal medication. Vascular excitement and tendency of blood to the head require Aconite, Belladonna or Veratrum viride. Depressed circulation and debility demand TREATMENT OF CHRONIC NASAL CATARRH. 395 Ammonium carb., Camphora, Cinchona, Digitalis, Ferrum, Nux vomica, and Phosphorus. In rare instances, the hemorrhage will continue in spite of everything mentioned, and the anterior and posterior nares must be plugged. Make two cotton roller bandages an inch long and three-quarters of an inch in diameter, and tie a strong string around the middle of each. Make two smaller rollers, but large enough to close the anterior nares. Introduce Bellocq's canula through the one side of the nose to the pharynx, push in the piston, and the knobbed spring will appear curving forward in the mouth. Fig. 100. Bellocq's Canula. Secure the string of one roller to the hole in the knob, draw in the spring, withdraw the canula and thread. Proceed in the same manner with the other side of the nose. There will now be a string from each nostril, with the other ends to which the rolls are attached hanging out of the mouth. Now pull upon the strings from the nose, and draw the rolls into the throat, and then firmly into the posterior nares. Guide them in the throat with the index finger, so the length will be vertical. To the strings from the nostrils fasten the small rolls, so as to make each nasal fossa a closed cavity. It may be necessary to plug only one side, if the bleeding is confined to it. In cases of doubt, or when the septum is per- forated, both must be closed up. Remove the plugs in from one to three days, wash out the clots and secretions, and apply car- bolized water for a day or two to correct fetor and decomposition, then go on with the usual treatment of the case. Internal medication in chronic nasal catarrh is an important part of the treatment, and should be persistently kept up as long as the disease exists. It may be sufficient to effect a cure in mild 396 THE HUMAN EAR AND ITS DISEASES. and recent cases without the aid of local treatment, but in severe and long-standing ones, it will not succeed alone, and the physi- cian should not delay to institute the local treatment described. The selection of the medicine is made from a careful consider- ation of the constitutional and local symptoms. A great many remedies are recommended for the treatment of chronic catarrh, which are practically useless and consumers of valuable time. Half the agents of the materia medica may be necessary to treat disorders that arise in the system of a patient with nasal catarrh; but the same necessity obtains in other patients without catarrh, and the medicines should not therefore be classed under catarrhal remedies. A large majority of the patients are strumous, a few are syph- ilitic, and the balance rheumatic or gouty. These diathetic con- ditions furnish bold indications for certain groups of medicines, and from each group may be selected the one especially adapted to the local symptoms. The following list embraces most of the medicines, whose reli- able pathogeneses and clinical histories show them to be valuable in this disease: Arsenicum iod., Aurum mur., Calcarea phos., Ferrum iod., Hepar sulph. calc, Iodinium, Kali bichrom., Kali hydriod., Mercurius, Acid. Nitricum, Pulsatilla, Sanguinaria, Silicea, and Sulphur. Arsenicum iod. I prefer to any other preparation of the metal for strumous patients, with pale mucous membranes, and scaly eruptions upon the face or head. The discharge from the nose is rather watery and irritating; the upper lip and nostrils are reddened and excoriated; the Schneiderian membrane is relaxed, cedematous, granular, insensitive and, perhaps, ulcerated. The pharynx usually shows the granular or hypertrophic changes ; there is burning rawness and slight soreness in the throat; the tonsils are enlarged ; hawking to clear the throat is frequent; tinnitus and pain in the ear not infrequent. The face has a muddy color; the patient is weak and easily exhausted; fugitive pains in the chest, soreness at the root of the lungs, and occa- sional hoarseness show a tendency to tubercular deposition. I have seen these symptoms ameliorated in a wonderful manner by steady administration of this medicine. TREATMENT OF CHRONIC NASAL CATARRH. 397 Hepar sulph. calc. suits cases of less active symptoms, in much the same constitutions. When indicated, the naso-pharyngeal membrane feels raw and rough, and smarts sharply during inspi- ration of wintry air; the discharge is muco-purulent, sometimes bloody, and not very copious; the sense of smell is frequently very acute; the nose becomes.stopped by swelling and crusts of bad odor; the eyes are irritable; there is pain and tension in the frontal sinuses ; the nasal bones are sore to the touch ; the upper lip is excoriated and swollen; the nostrils and inside of the nose are often covered with many layers of scab, which make the parts rigid and the passages impervious; the tonsils and submax- illary glands are indurated by chronic hyperplasia; the Eusta- chian tubes are affected, as the ears feel full and there is rattling on blowing the nose; ravenous hunger alternates with indifferent appetite, and the patient presents a picture of malnutrition and feebleness. Kali bichrom. is demanded, when there is frontal headache, pain across the bridge of the nose, pressure and soreness of the nasal bones; sore nostrils, diminished power of smell, irritability of the eyes; thick, tenacious, mucous discharge, with occasional crusts and blood ; considerable dryness and great soreness of the naso-pharyngeal mucous membrane, with chiselled-out ulcers here and there; ulcers covered by scabs upon the septum, with perfo- ration or widespread destruction of the cartilage; swelling of the lymphatic glands; mucous rattling in the Eustachian tubes, and tinnitus; roughness of the throat with hoarseness. The remedy is lauded for its antisyphilitic virtues, but Kali hydriod. is probably more efficacious. The potash salts must be used sparingly in anaemia, as they are very destructive to the blood plasma. Aurum mur. is used in graver states of ulceration of the mu- cous membrane and cartilage, and in caries of the nasal bones from syphilis. The discharge is greenish-yellow or yellow, con- taining dark particles; foul strings, crusts, and scabs are removed from the anterior and posterior nares; respiration is often im- peded ; the sense of smell is hypersensitive or lost; the nose is swollen both inside and out; the bones are very sensitive to pres- sure ; disease of the lachrymal apparatus occurs from obstruction 398 THE HUMAN EAR AND ITS DISEASES. of the downward flow of tears; the ears are affected by chronic catarrh or purulent disease; and the patient is apprehensive and morose. Why should gold cure disease? Nothing in its phys- ical properties would lead us to suppose it would. So we might say of mercury, zinc, and copper, yet, experience has proved the value of all four metals in disease. Mercurius may be necessary in grave destruction of the nasal mucous membrane, cartilage and bones. It suits milder cases, besides, when the mucous membrane is pale, gray, flabby, ulcer- ated and bleeds easily, and the nostrils are scurfy and sore; the nasal bones are tender, the Eustachian tubes filled with mucus; the throat slimy, and the mucous discharge grayish, fetid, and metallic. Acid. Nitricum.—It was an old joke, that the professor at the University of Pennsylvania related annually to the class about the elimination of nitric acid. He said a country doctor gave nitric acid to his patient so strong, that when he blew his nose the mucus burned holes in his handkerchief. That's a peg for truth to hang upon. Nitric acid is required, when there is copious acrid, bloody discharge from the nose; the mucous membrane is raw, granular and ulcerated; thick mucus streaked with blood is blown from the nose or hawked out of the throat; false, easily exfoliating membranes form in the throat and nose; the bones of the nose and face are sore; the ears are in a condition of chronic catarrh, and there is deafness and occasional otalgia. There may be destructive ulceration of the cartilages and bones of the nose from syphilis ; and the patient may be suffering from the mercurio-syphilitic cachexia, and be weak, peevish and de- pressed. In such cases, nitric acid, by furnishing oxygen to the system, stimulates the morbid tissues to healthier action, tones up the general system, and aids in eliminating both the syphilitic and the metallic poisons. Kali hydriod. is not used half enough in nasal catarrh. In good constitutions, having a rheumatic or gouty diathesis, it is required for nasal catarrh, with alternations of acrid watery dis- charge, and of thick yellow mucus. The mucous membrane of the throat is usually in the hypertrophic or granular stage; that of the nose is deep red, glistening and cedematous; nasal respira- TREATMENT OF CHRONIC NASAL CATARRH. 399 tion is alternately obstructed and free; the Eustachian tubes and ears are somewhat affected ; the patient is fond of the table, and, if a man, smokes and, perhaps, drinks liquors. A man I was treating for Bright's disease, received Kali hy- driod. for some weeks, and was cured of a chronic nasal catarrh, and obstruction of the right side of the nose, which he assured me he had had for twenty-two years. The man's character was such as to render his evidence perfectly reliable. The remedy may be used sparingly in struma with swollen glands, and will be found very efficacious in all syphilitic cases. Iodine is suitable to the strumous and syphilitic patients, but not to the rheumatic or gouty. Pulsatilla has been mentioned, as suited to mild cases of chronic catarrh. It is especially adapted to leuco-phlegmatic patients, with pale, atonic, and ulcerated mucous membrane; a bland yel- lowish-green mucous discharge of offensive cheesy odor; fulness at the root of the nose; rawness of the throat; fulness of the ears, and occasional tinnitus with headache. In women, the nasal catarrh is better during menstruation, and the discharge almost ceases, only to be greatly increased during the interval. When the discharge is profuse, the patient feels hungry all the time, and will want something to eat a few minutes after finishing a hearty dinner. Such cases are greatly benefited by this medi- cine. Calcarea phos. is probably the most useful remedy for strumous cases. It combines the nourishing and alterative properties of lime, and the nutritive and stimulating properties of phosphorus, and may be employed where the symptoms correspond with those of Calcarea carb. and Phosphorus. In many cases of disease, where Calcarea carb. seems appropriate, and, yet, there exists a great deal of anaemia and nervous irritability, the phos- phate will do much better than the carbonate. The symptoms calling for its administration are : malnutrition of the osseous tissues; imperfect digestion; frontal headache ; pressure at the root of the nose; supra-orbital pain on one or both sides; a mild mucous discharge, mixed with crusts and, oc- casionally, with blood; roughness of the throat; downward pas- sage of scabs in the pharynx; more or less obstruction of the 400 THE HUMAN EAR AND ITS DISEASES. Eustachian tubes, with tinnitus and deafness. The nasal mem- brane is pale, fungous, flabby and ulcerated; the throat shows the atrophic pharyngitis ; the palate is frequently relaxed, and the ears full and ringing. Ferrum iod. is a medicine applicable to the same class of cases as Calcarea phos., but more particularly indicated, when the anaemia is profound, and the powers of digestion and assimilation are much weakened. There is not a shadow of a doubt about iron enriching the blood, when administered in small doses. When the system will not abstract iron from food, it will re- ceive and retain it from minute doses, because of some myste- rious tonic influence the metal seems to exert upon the stomach and absorbent system. The iodine in this preparation exercises its usual alterative influence upon morbid tissues and glandular infiltration, so that the remedy is suited to chronic nasal catarrh in strumous persons. It should be administered when there is anaemia, weakness, glandular enlargement, roughness of the throat, hoarseness, raw sore feeling in the nose, continuous thin mucous discharge from the nose and throat, relaxation and ulceration of the Schneiderian mucous membrane, and the variable symptoms of the nasal disease. Sanguinaria has a limited range of action in this disease, but is better for the acute stage. It is said to promote the absorption of polypus, but the evidence of this power is not voluminous. Sulphur may be needed as an intercurrent remedy, but cannot be regarded as having any specific action upon the disease or the constitutional state which accompanies it. Silicea has an imposing pathogenesis, but it is difficult to say how much is reliable. The symptoms calling for silicea are: headache, bruised pain over the eyes, irritation and inflammation of the eyes; sneezing, with dryness of the nasal mucous membrane or an acrid corroding discharge; occasional bleeding of the nose; pricking and soreness of the throat; tinnitus, fulness, and pain in the ears; hoarseness, and dry hacking cough. I cannot recom- mend silicea enthusiastically, as it has disappointed me frequently. I think some of the other medicines mentioned above will prove more satisfactory. TREATMENT OF POLYPUS. 401 Treatment of Polypus.—These tumors never exist in the nose or pharynx without some degree of catarrh, and, indeed, are generally preceded by it, so that the proper medicine for the catarrh will be the most appropriate for the removal of the polypus. Calcarea carb., Kali bichrom., Pulsatilla, Phosphorus, Sanguinaria, Sulphur, and Teucriurn are considered powerful remedies for removing the excrescences. That internal medicinal treatment has cured polypi seems to be well established, and in all cases one may treat the patient in- ternally, while carrying on the local treatment indicated. When means for the speedy cure of polypus are at hand, I think it would be improper, to say the least, to postpone their use until a long course of internal medication has been tried. In addition to the cleansing and medicated fluids employed for the condition accompanying polypoid tumors, I would advise the application of strong solutions, and, even, crude substances di- rectly to the morbid growth, whenever it can be seen or felt. The fluid applications should be made with a brush or a small piece of sponge in a holder. The handle should be flexible, so it can be bent to reach the growth through the nostril or up be- hind the palate as desired. In the latter case, it will be necessary to use the throat-mirror to direct the instrument, or to employ the finger as a guide for a special instrument. I have devised one, which I call the Guarded Sponge-holder; it terminates in a tiny cup, holding a small sponge attached to a disk, that can be projected and retracted at pleasure by a piston working in the hollow stem. The cup limits the application to the part touched by the sponge; the sponge is pulled back into the cup after its fluid is squeezed out by the piston, and the whole is withdrawn without medicating any other than the part intended. Acetic acid (Acid. Aceticum), Tincture of iron (Tr. Ferrichlor.), solution of Subsulphate of iron (Liq. Ferri subsulph.), solution of Zinc sulphate (Zinci sulph. 3), Aqua dest. f5j), and solution of Nitrate of silver (Argent, nit. gr. xl, Aqua dest. fgj) are the fluids I employ for polypus and the peculiar adenoid tumors of the naso-pharynx. One must be careful not to take up too much fluid upon the 402 THE HUMAN EAR AND ITS DISEASES. instrument, and then drop it upon other parts than those desired. It is sufficient to apply one of these to the tumor, twice or three times a week, and the other local measures should be carried on as usual. The hypodermic syringe may be employed to inject one of the above remedies, preferably the Acetic acid, when the tumor is easily reached; there is risk of causing embolism if the tumor is very vascular, and the method is not recommended in such cases. Dr. C. R. Upson, of Atlanta, Ga., has invented a very useful svringe for injecting and destroying tumors in the naso-pharynx and larynx. " It consists of an ordinary hypodermic syringe, provided with a long hollow needle, which is passed through a silver canula properly curved at its extremity. The outer surface of the needle, Fig. 101. Upson's Tumor Syringe. a short distance from its attachment to the syringe, has cut upon its surface a screw-thread, which is fitted with a traverse nut, to regulate the depth of puncture of the growth. Two shanks, with finger-rests at one end, are passed through rings on the side of the syringe, and attached at their other extremity by means of set-screws to the canula, to enable the surgeon to operate the instrument with one hand. The flat wings at the end of the syringe serve as thumb-rests. The tip of the canula is made to unscrew, and in its place can be fitted the fine spray-jet which accompanies the instrument. With this jet, applications of any desired medicament can be made either to the pharynx or larynx. " The modus operandi of the instrument is briefly described. First charge the syringe with the desired quantity of the solution to be injected—say Acetic acid, gtt. x-xv ; then place the patient in a good light—either direct or reflected—draw forward and TREATMENT OF POLYPUS. 403 depress the tongue with a proper instrument, which may be in- trusted to the patient to hold, or the tip of the tongue may be covered with a napkin, drawn forward, and held out of the way by the patient. After cautioning the patient to breathe quietly through the nose, introduce the rhinoscopic mirror below and a little back of the palate, and, as soon as you secure a good image of the growth in the mirror, introduce the canula with the free hand, project the needle the desired depth into the growth, move the thumb back from its rest to the piston, and slowly inject the contents of the syringe into the tumor." Tannin, Alumen exsiccatum, Cubebs, Sanguinaria, and Teu- crium are often used in powder, and snuffed in the nose or blown upon the excrescence. The latter is much the better method of procedure, as the substance can thus be in a measure limited to the growth. A powder-blower is the best to use for this purpose. Ascertain first that the tumor can be reached, then take a little of the powder in the tube, place its distal end against the tumor, and blow the powder out. It does not matter whether you do Fig. 102. Nasal Polypus Canula. this by connecting a rubber tube or an air-bag with the blower, though the latter is more agreeable. After such an application, it is best to suspend other local treatment for a day or two and watch its effect. When the tumor is quite large, and local measures and internal medication have been fairly tried without success, surgical treat- ment must be essayed. The problem is to remove mechanically a tumor from the nasal fossa or upper pharynx. The usual methods are by ligature and by forceps. Whenever the polypus is within reach, and of such a shape that a ligature can be thrown around it, I prefer the cord or wire to the forceps. In applying a ligature, a great deal of patience and manceu- vering is often necessary. In some cases, the wire loop of the Wilde- 404 THE HUMAN EAR AND ITS DISEASES. Blake snare or of the nasal polypus canula can be slipped over the growth and the thing cut off in a trice. In others, a silk or wire ligature must be passed around the tumor by the aid of probe, forceps, aneurism needle or Bellocq's canula. One must look, and work, and poke carefully, in order to be successful. , When the ligature is once around, it should be pushed near the pedicle, drawn tight, and twisted and pulled until the growth comes away. It is not agreeable to tie and leave it in position until sloughing occurs. Hemorrhage is usually slight, and easily controlled by cold water or an astringent. Some years ago, I had a large pyriform polypus to remove from the posterior nares. The growth sprang from the sphenoidal region, and hung down into the naso-pharynx. I failed to pass a loop around it, and nipped it with forceps so that it bled pro- fusely. I did not like that nor the prospect of abundant hemor- rhage in the region, so I worked away with a ligature. Finally I passed Bellocq's instrument upon the outer side of the tumor, and drew a string through the nose ; then having reintroduced the instrument, I succeeded by turning the beak of the canula around the vomer in getting another cord through the same meatus inside the morbid growth. I knotted the two cords from the mouth together, drew the loop backward and upward by pulling upon the other ends, and slipped it over the tumor. Then I twisted the cords together hard, pulled moderately, and had the satisfaction of drawing a rather firm mucous polypus out of the nose. Many surgeons prefer to use the forceps for the removal of cysts and polypi, and this is the speediest and most brilliant method of operating. The patient should be seated in a good direct or reflected light with the head thrown a little back against a firm support. In operating through the throat, a slip-noose should be put around the uvula, the soft palate drawn forward by it, the string fastened between the front teeth, and a cork placed between the jaws to keep them open. Removal of a piece of the inferior turbinated bone and a projecting side of the septum has been advised. The patient should be required during the operation to breathe through the nose if possible. This will give TREATMENT OF POLYPUS. 405 more room to work. The throat-mirror and index finger are used to guide the forceps when operating behind the palate. The location of the tumor having been ascertained, a pair of properly shaped forcepsshould be introduced into the nasal meatus, Fig. 104. Tiemann's Flexible Throat Forceps. the nostril of which is dilated by a speculum, or else up behind the palate; the growth should be seized firmly, twisted as much as possible with the instrument, torn off, and removed. Fig. 105. Fauvel's Forceps. Various shaped instruments are necessary to meet the require- ments of all cases, but the most generally useful is Simrock's forceps. 406 THE HUMAN EAR AND ITS DISEASES. These are angular at the junction of the blades and handles, and have fenestrated, serrated blades. Fauvel's polypus forceps are strongly curved and adapted to both naso-pharynx and larynx. Fig. 106. Noyes's Polypus Forceps. After the tumor has been removed as thoroughly as possible, control the bleeding by gargling, syringing, and douching with cold water or astringents when necessary, and continue the treat- ment proper for the diseased mucous membrane. For the surgical treatment of severe or complicated cases, the reader must refer to works upon general surgery. Dr. Helmuth has a full exposition of the subject in his System of Surgery, and gives an excellent resume of an operation for resection of the nose for the removal of polypus. Treatment of Adenoid Tumors.—These growths in the naso- pharynx are treated much the same as polypi, for which they are generally mistaken. Having made out the size, shape, color, consistency, position, and attachment of the morbid growths by palpation and inspection with the mirror, the condition of the mu- cous membrane of the choanae should be observed, and the treat- ment determined. The medicines used for polypus, and some of those under chronic nasal catarrh should be studied, and those indicated tried awhile. They will probably prove useless, and local treatment must be adopted to effect a cure. When the tumors are flat, sessile, rather smooth, and numer- ous, they must be treated by astringents and escharotics, as at- tempts to remove them by instruments would injure the mucous membrane and cause unfortunate cicatrices. The nasal douche, post-nasal syringe, and atomizer, with the solutions of salt, muriate of ammonium or chlorate of potas- sium should be used daily to cleanse the parts from the morbid discharge generally present; then a solution of Zinc sulphate gr. TREATMENT OF ADENOID TUMORS. 407 xxx, of Silver nitrate gr. xx, or a dilution of tincture of Chloride of iron, foj, to fSj of water, should be sprayed into the pharyngeal vault upon the tumors every day, and a gargle of an even tea- spoonful of salt to a pint of water used soon afterwards. Twice a week the morbid growths should be touched with a brush or the sponge in its holder, wet with Silver nitrate gr. xl in distilled water f§j, or with the pure tincture of Chloride of iron, and after waiting five minutes for the remedy to act, a salt water gargling and syringing or douching must be had to limit extension of the active agent employed. If these measures with hygienic regulations and internal medi- cines do not make the adenoid hypertrophy diminish, and give signs of disappearing in a few weeks, it would be proper to apply pure lunar caustic to the outgrowths. A silver probe bent to the desired degree should be dipped in fused pure nitrate of silver and cooled. Then the uvula should be drawn forward and fastened, the patient instructed to breathe through the nose, the tongue held down, the throat-mirror warmed and introduced, the probe carried into proper position as seen in the illuminated mirror, and its caustic rubbed briskly upon the tumors. It is important to use a gargle and douche of salt water five minutes after this application, as the caustic dissolves in the mucous discharge about it, and, unless neutralized, will run down the pharynx and excite inflammation in it, the oesophagus, and, perhaps, the larynx. In the intervals between the caustic appli- cations, the same cleansing and astringent treatment should be followed as described above. AVhen the tumors are nodular, pedunculated, pyriform or rough and jagged like the comb of the cock, and astringent and caustic treatment does not remove them, it will be necessary to resort to Upson's injecting, to ligation, crushing, and twisting oft with forceps, or to ablation with cutting instruments. Large tumors may be injected with acetic acid by Upson's sy- ringe. The ligature and snare are seldom applicable, and their use requires no description beyond that given under the treat- ment of polypi. Forceps of proper shape guided by the finger or mirror may be passed through the nasal meatus or up behind the palate, and a tumor seized and twisted out of the pharyn- 408 THE HUMAN EAR AND ITS DISEASES. geal vault, or crushed so that it will slough away; but the operation is difficult unless the excrescence is quite large and easily reached. A cutting instrument is generally necessary. Loewenberg re- commends a suitably curved curette, with which the tumors can frequently be scraped away. The use, however, is difficult, and he prefers a cutting forceps of his own invention. I translate his description of the instrument and his method of using it. Fig.107. Lcewenberg's Curved Cutting Forceps. " It is a forceps terminated by two cutting blades of which the sharp edges are applied against each other when the instru- ment is closed. It possesses a double curvature in S. The joint Fig. 108. Lxewenberg's Angular Cutting Forceps. is placed near the bite in order to preserve a great length of branches, which gives a powerful leverage and permits easy cut- ting. The beaks cut by closing. They are slightly rounded and excavated on their inner face. "This is how we employ our instrument: Guided by the rhi- noscopic mirror or by the left index finger, one introduces the forceps closed, then one opens them and cuts the vegetation the nearest possible to its base. "A single cut is sufficient for a slender pedicle or the base of a sessile vegetation of small dimensions; the voluminous tumors demand naturally more cuts of the instrument. It is the same for TREATMENT OF ENLARGED TONSILS. 409 the true polypi, that one can operate upon equally well by means of our instrument." * There is always more or less hemorrhage after instrumental removal of these tumors, and a cold water or astringent douche or injection must be employed. In severe cases, tannin or pow- dered alum may be blown upon the bleeding surface, or a large moist compress rolled in either might be held against the vault of the pharynx by a string passed through the nose. When the adenoid tumors or polypi prevent respiration through the nose after the passages are cleared, the Eustachian tubes and middle ear must be opened, and the mucus driven out by repeated strong inflations with the air-bag. The same system of cleansing the pharynx and making topical applications suit- able to the morbid conditions must be continued, according to principles already laid down. Treatment of Enlarged Tonsils.—This is generally associated with that of chronic pharyngitis, but I think it better to keep the affections distinct. Hypertrophy of the tonsil is easily cured in children, is said to disappear spontaneously with the advent of puberty, but is refractory in adults. Glandular hypertrophy indicates debility, and every means ought to be used to improve the general health of the patient. The throat should be gargled every morning and evening with a solution of an even teaspoonful of common salt in a pint of water. If the patient is too small to gargle, the solution may be applied to the throat with an atomizer. When the tonsils are red, tender, and ulcerated, a solution of chlorate of potassium, gr. xvi in an ounce of water, will prove much more efficient than the salt, and may be sprayed upon the glands three or four times daily. Another topical application of decided value is tar tincture, f3j in an ounce of water, used in the same manner. A solution of nitrate of silver, gr. xx in an ounce of distilled water, applied to the tonsils by a brush or tuft of cotton on the holder, * Les Tumeurs Adenoi'des du Pharynx Nasal; Leur Influence Sur l'Audi- tion, la Respiration et la Phonation, Leur Traitement. Par Le Dr. B. Loew- enberg ; V. Adrien Delahaye et Cie. Libraires-Editeurs, Place de I'Ecole de Medecine, Paris, 1879. 27 410 THE HUMAN EAR AND ITS DISEASES. every other day for many weeks, will cause a diminution in size. The tongue should be held down for a few minutes, and then a salt solution applied to neutralize and limit the action of the remedy. Equal parts of glycerine and tincture of iodine or of glycerine and tincture of the chloride of iron, applied in the same manner, are as efficient and rather more agreeable to the patient and physician than the silver solution. A short time after the application the mouth should be rinsed with water. A recent writer asserts, that enlarged tonsils may be caused to undergo shrinking by applying to them every day or two crude bicarbonate of sodium. Another method of inducing retrograde metamorphosis is to inject iodine into the gland. This is the most effectual way of shrinking an enlarged tonsil, and may be tried before resorting to ablation. Mix five parts of tincture of iodine with fifteen of alcohol, draw three or four drops into a hypodermic or the Upson syringe, push the syringe needle half an inch into the tonsil, then withdraw one-fourth of an inch, and inject the contents into the tissue. Three or four injections in a month will be sufficient, and improvement may be confidently expected except in the oldest and worst cases. The administration of medicines should commence with the gargling and spraying, and the silver or iodine ought not to be resorted to until the internal remedies have had a fair chance to cure, and have failed. Two or three months treatment will show whether the tonsillar disease is yielding to the secret and insid- ious action of the internal agent. Sulphur is recommended for recent hypertrophy, when the tonsil is swollen by the remains of inflammatory exudation, rather than by hypertrophy of the proper tissue elements. Mercurius is more valuable than Sulphur in this same condi- tion, especially, in young subjects, and should be given for a time in the early treatment of all but the old cases. Baryta carb. is highly praised by authors, for patients with a tendency to acute exacerbations of tonsillitis, considerable hard- ness of the gland, and paresis of the throat muscles. I believe its virtues are very much overestimated. Calcarea phos. has a decidedly beneficial action upon enlarged tonsils, as upon swollen glands elsewhere. It is indicated when TREATMENT OF ENLARGED TONSILS. 411 the gland is large, pale, flabby and, perhaps, ulcerated in places. In all strumous cases in young persons, a course of Phosphate of lime diminishes glandular hypertrophy and improves the general health in a surprising manner. Calcarea iod. is a valuable medicine for hypertrophied tonsils, when they form red, nodular tumors of considerable hardness, and there is much catarrh of the throat, with frequent attacks of hoarseness. When local measures and internal medication have had a fair trial, and have failed to diminish tonsillar hypertrophy to a size consistent with comfort and health; when one or both of the tonsils is quite large, very firm, and a serious obstacle to the physiological action of the throat, then a surgical operation is demanded. It is not necessary to remove the whole tonsil. Experience has proved, that if a liberal slice be taken from the gland, the re- mainder will shrivel and shrink to a moderate size. The patient should be seated erect in a good light, the mouth held wide open by a eork between the molar teeth of one side, and the tongue held down by a depressor. Then pass Fahnestock's tonsillotome back to the tonsil; carry its ring over the gland until as much is through as it is considered desirable to cut off; push the sharp retainer through the tonsil; draw the circular knife outwards, and remove the instrument. The piece removed will be spitted upon the retainer. The pain from the procedure is very little, and children bear it very well. Fig. 109. There are two movements connected with the instrumental manipulation, pushing in the retaining needle, and drawing back the annular knife. To simplify the manoeuvre, Billing's tonsil- lotome was invented. It consists of a pair of rake-tooth forceps, placed over the oval opening for the amygdala. A chisel-like 412 THE HUMAN EAR AND ITS DISEASES. knife slides lengthwise of the oval, between the claws and the body of the instrument. The first two fingers are passed into side rings upon the body, and the thumb into the ring upon the proximal end. The in- strument is applied with the claws inwards; enough tonsil is worked through the oval; the instrument is held steadily, and the thumb pushes the chisel blade backwards and home. This movement causes the claws to grasp the tonsil, and drag it through somewhat, so that the chisel knife cuts it off with a slope out- ward and backward, corresponding with the natural outline of the throat in this part. Thus one movement secures and removes the piece of tonsil, and fashions the remainder; the instrument is, therefore, preferable to Fahnestock's. Fig. 110. The hemorrhage from the operation is generally slight and easily arrested by a gargle of cold water; or, in case of necessity, by a solution of tannin. When it continues notwithstanding these, a tuft of absorbent cotton or a camel-hair brush should be dipped in iron tincture or a xx gr. solution of nitrate of silver, and the cut surface painted freely. Dr. Seiler says, " I am in the habit of always painting the cut surface with nitrate of silver solution, since it seems to start the process of repair at once, and at the same time protects the wound from the influence of the air."* In very rare cases, it may be necessary to make pressure upon the cut surface with the finger, or, even, to twist the open end of a rigid vessel to arrest obstinate hemorrhage. There is no danger in removing a piece of the tonsil, if the instruments are used according to directions. The carotid artery ascends just outside the tonsil, and a very deep cut or an attempt to operate with a tenaculum and bistoury might be dangerous. * Hand-Book of Diagnosis and Treatment of Diseases of the Throat and Nasal Cavities. By Carl Seiler, M.D., etc. H. C. Lea & Co., Philadelphia, 1879, p. 116. TREATMENT OF CHRONIC PHARYNGITIS. 413 The wound glazes over soon and heals generally within a week, during which time the patient should take fluid and soft food, and abstain from irritants. Medicines may be given according to any special indications present. Treatment of Chronic Pharyngitis.—This must be general for all varieties, including every hygienic measure for improving the health of the patient; and special, including local and inter- nal remedies for the three phases of the disease which I have presented. The disease may be cured; but, failing in curing, it may be so greatly diminished, that no discomfort or injury will be experienced through life. Nearly every one in the temperate zone has some pharyngitis. Until it reaches a certain grade it does little harm. It must be kept within narrow limits. The subject of chronic pharyngitis ought to live in a dry cli- mate, preferably upon high ground, in a well-ventilated and properly heated dwelling. He should keep the skin active by frequent baths; bathe the neck every morning and evening in cold water, and rub dry with a crash towel; wear merino underclothes in summer, and flannel in winter; avoid drafts and needless ex- posure to bad weather, and take proper exercise in the open air daily. Respiration should be through the nose when possible; the mouth ought to be kept closed the most of the time, especially, in foul, dusty or cold air; the swallowing of very hot and very cold things at the same meal must be forbidden ; good plain food only should be permitted ; spices, strong liquors and tobacco are very irritating to the throat and should be avoided; and using the voice in either singing or speaking reduced to a minimum. It is beneficial for every person afflicted with pharyngitis to gargle thoroughly every time he takes a drink of water. This removes superfluous mucus, cools and stimulates the mucous membrane, and improves the state of the throat and Eustachian tubes by the muscular action that ensues. The Eustachian tubes and middle ears ought to be inflated by the air-bag or Valsalvian method, as often as the symptoms of fulness, rales, and tinnitus indicate obstruction to the entrance of air. The frequency of the demand will vary from once or twice 414 THE HUMAN EAR AND ITS DISEASES. a day, to once or twice a week, according to the extent and se- verity of the disease. Treatment of Hypertrophic Pharyngitis includes other gargles besides cold water. An even teaspoonful of salt to a pint of water is one of the best. It should be used as agargle the first thing in the morning and the last thing at night, and continued many weeks, or until the pharyngitis is altered in character or cured. Chlo- rate of potassium in the same proportion is better than the salt, if there is much sensitiveness. The pharynx should be sprayed daily with tar-water (TV. Picis liq. f5j, Aqua f5J), and the atom- izing tube must be passed deeply into the throat, and through each nostril, in order to reach all parts of the vault. If the condition of the mucous membrane does not improve in time under these topical applications and the internal medica- tion, a solution of sulphate of zinc (Zinci sulph. gr. x, Aqua dest. f 5j) should be substituted for the tar-water, and the treatment continued. This failing, nitrate of silver solution (Argent, nit. gr. x, Aqua f Sj) should in turn replace the zinc, and care be taken Fig. 111. Uvula Scissors. to limit the application to the diseased parts, and not to stain normal tissues or the clothes. It is well soon afterwards to have the throat gargled with salt water, in order to prevent the silver getting down the oesophagus and into the mouth. If there is swelling about the Eustachian tubes, the silver so- lution may be applied with a throat-brush or sponge in holder, arid a drop or two of this or some other agent can be injected through the catheter. Inflation with the air-bag should not be forgotten in case of obstruction to the entrance of air to the tympanum. When the uvula is elongated so that it rests upon the base of TREATMENT OF CHRONIC PHARYNGITIS. 415 the tongue and causes frequent coughing and gagging, if it does not retract under the zinc or silver applications, it should be seized and its cedematous point cut off with the uvula scissors. The latter have the handles bent so the hand will not obstruct the sight, and beneath the blades, a rake-tooth forceps is attached which seizes the amputated piece. Calcarea phos. is the best medicine for hypertrophic phar- yngitis, in young persons of strumous or lymphatic constitutions, especially, when the tonsils are enlarged and the ear affected. Under its continuous administration, and daily spraying with the tar-water, I have seen the mucous lining of the throat become lighter and thinner, and the glands much diminished in volume. Ferrum iod. is a most valuable agent for the same class of pa- tients, when lymphatic glands harden a little, and anaemia and debility are noticeable. A few drops should be given in water after meals, in order to avoid any unpleasant stomach sensations. Mercurius is very useful, when the gums and tongue are flabby and softened; the tongue is coated at the base; a thick sticky secretion clings in the throat; there are, perhaps, spots of ulcera- tion ; the tonsils are enlarged and submaxillary glands swollen; the appetite and digestion are impaired ; the taste and breath are foul, and the patient is in bad health. It is frequently indicated in the early stages of a case, when there is tinnitus and tubal ob- struction, but other medicines suit later stages better. I give usually the Mercurius sol. in powders or Mercurius corros. dis- solved in water. Merc, iod is preferable, if there is suspicion of syphilis. Kali hydriod. is a capital remedy for hypertrophic pharyngitis, in stout plethoric persons, who are bons vivants and do not curb their epicurean desires. Sometimes there is a persistent soreness of the throat, and moist mucous rales in the tubes and ears, connected with the congestion and hypertrophy, which is supposed to de- pend upon a rheumatic or gouty diathesis. There may be stiff- ness of some of the joints, and dull pain in the muscles. In such cases, the potash salt is very efficient in removing the general morbid symptoms, and curing the pharyngitis. Nux vomica is indicated, when the appetite and digestion are poor; the throat is full and slimy; there is decided tinnitus and 416 THE HUMAN EAR AND ITS DISEASES. occasional otalgia; mucus clings to the posterior wall of the palate and pharynx, causing frequent hawking and gagging, and the patient may have been in the habit of using liquors or tobacco in excess. Treatment of Atrophic Pharyngitis differs from the hypertro- phic considerably. The usual salt gargle agrees very well with some patients, but is too irritating and drying for others. If the mucous membrane is humid and the secretion active, it will prove beneficial. When there is only a moderate secretion of mucus, and the mucous membrane is here and there dry and glazed, a glycerine gargle (Glycerinum f.—Kathode, Dauer, Klingen. 3. Ka. O — Kathode, Oeffhung. 4. An. S.—Anode, Schliessing. 5. An. D.—Anode, Dauer. 6. An. O. Kl. >.—Anode, Oeffhung, Klingen. 468 THE HUMAN EAR AND ITS DISEASES. Translated: 1. Ca. CI. R'.—Cathode, closing, ringing loud. 2. Ca. D. K. >.—Cathode, duration, ringing. 3. Ca. O.—Cathode, opening. 4. An. CI.—Anode, closing. 5. An. D.—Anode, duration. 6. An. O. R. >.—Anode, opening, ringing. This requires further explanation in order to be understood by the uninitiated. 1. When the cathode is at the ear, the anode being some dis- tance away from it beyond the middle line of the body, and the current closed, the subject hears a loud noise, generally a ringing sound. 2. In the duration of this current, the ringing gradually di- minishes and finally ceases altogether. 3. When this circuit is broken by removing the cathode, no sound is caused. 4. When the current is reversed, and the circuit is closed by applying the anode to the ear, no sound is produced. When the electricity is of high intensity, a slight ringing may be experi- enced. 5. In the duration of this current, no sound is heard. 6. When this circuit is broken by removing the anode, a slight and transient ringing is experienced, corresponding to that of No. 2. It is well to remember that the ringing may be replaced by the various sounds already mentioned, so that the term noise would express the reaction more accurately for all cases. The reactions are modified by the experiment alone. Ka. S. is stronger after An. S., and continued some time in- creases the reaction of the nerve. An. O. ringing increases with the intensity of the current a»nd its longer duration. Dr. Butler says, " This formula is nothing more than the Gal- vanic reaction upon healthy auditory nerves. Why its cor- rectness should ever be questioned by any one who has thoroughly and honestly tested it, I am at a loss to discern." It is evident the Galvanic current furnishes another means of diagnosing disease of the ear. Any alteration in the formula signifies a morbid condition of the auditory apparatus. The Galvanic reaction serves to confirm aural disease, which is ap- SYMPTOMS OF AURAL ELECTRIZATION. 469 parent by other methods of examination, but it is especially val- uable in diagnosis of morbid conditions of the labyrinth, auditory nerve, and brain. It is curious that in some cases, when the cathode is applied to one ear and the formula is tested, the other ear responds by sen- sations at the time when the first ear gives no reaction, just as if it were under the influence of the anode. This second series is called an inverted, or paradoxical formula. I present an exam- ple given by Brenner. Nine cells were used: Right Ear Healthy, with Cathode. Left Ear Diseased. Ka. S. KF.—Loud ringing. Ka. S.—No sound. Ka. D. Kl. >.—Ringing gradually Ka. D.—No sound. ceasing. Ka. O.—No sound. Ka. O. Kl.—Ringing. An. S.—No sound. An. S. KF.—Loud ringing. An. D.—No sound. An. D. Kl. >. — Ringing gradually ceasing. An. O. Kl.—Slight ringing. An. O.—No sound. This inversion is frequently presented, when there is hyperaes- thesia of the nerve submitted to the cathode, with exaggeration of its normal reactions. A case of chronic inflammation of the tympanum with deaf- ness and much tinnitus, subjected to twenty cells, gave the fol- lowing : Ka. S. KF.—Loud ringing. Ka. D. Kl. oo.—Ringing continuous. Ka. O.—No sound. An. S.—No sound. An. D.—No sound. An. O. Kl. >.—Ringing gradually diminishing. A similar case tested with ten cells gave: Ka. S. KF.—Loud ringing. Ka. D. Kl. oo .—Ringing continuous. Ka. O.—Battling. An. S.—Rattling. An. D.—Rattling continuous. An. O. Kl. >.—Ringing gradually ceasing. Another case with chronic inflammation of the tympana, opacity of the membranes, and deafness of many years duration, under twenty cells gave: 470 THE HUMAN EAR AND ITS DISEASES. Ka. S.—Chirping. Ka. D.—Short chirping. Ka. O.—No sound {slight and short roaring in left ear). An. S.—Roaring. An. D.—Short roaring. An. O.—Indefinite sounds. Beard and Rockwell report testing an ear, that had been cured of perforation of the membrana tympani and purulent inflam- mation of the middle ear, with restoration of normal hearing. The patient was a young man, and eight cells were employed. Ka. S.—Some rumbling. Ka. D.—Some rumbling. Ka. O.—No sensation. An. S.—Rumbling. An. D.—Rumbling. An. O.—No sensation. This reaction proves that the ear was not fully restored. In these examples, the deviations from the normal formula have been mostly printed in italics. Brenner and others consider the Faradic current useless for these tests, and recommend the Galvanic current of two to twenty cells. The rheostat is necessary, if a current of high intensity is employed, and the external method of applying the electrodes is preferable. Notwithstanding the apparent simplicity of Brenner's method of diagnosis, its practice is beset with many difficulties. Success will attend only the most careful and scientific manipulators and the coolest and closest observers. Whether the electric current acts upon the auditory nerve through reflection from the trifacial, through the tympanic mus- cles or by direct, deep passage of the electricity, I shall not stop to discuss. Probably the nerve is influenced in all these ways, but the last is the most potent in awakening sensations. Electricity in Disease.—There is considerable difference of opinion among aural surgeons in regard to the value of elec- tricity in diseases of the ear. French and German physicians look upon it as almost indis- pensable, but I heard a German, even, in one of the most cele- brated aural clinics in the world, say, " Eine Galvanische Batterie ist ein schbnes Spielzeug fiir Kinder." English and American ELECTRICITY IN AURAL DISEASE. 471 doctors employ it sparingly, and many of them speak about it con- temptuously. The differences are individual rather than national, and the use of the powerful agent is restricted, because medical men have been deterred from a careful study of electrical apparatus and electro-therapeutics by imaginary difficulties and dangers, and by their disgust at the charlatanism displayed by peripatetic quacks and impostors. One has only to compare electricity with other forces to appre- ciate its extraordinary power. An electric discharge that endures but the millionth of a second is sufficiently powerful to split the proudest tree of the forest into splinters, and to shatter and de- stroy the largest edifice of man. Nerve currents that seem to us almost instantaneous, move at a speed of 26 to 30 meters, and light travels at the rate of about 300,000,000 meters in a second, but electricity has the wonderful velocity of 464,000,000 meters in the same space of time. This intangible manifestation of force, that enables us to talk with people at the antipodes, is too valuable to be relegated to the ignorant and dishonest. It must be appropriated by all scientific physicians, and become a valuable addition to the armamentarium medicorum. The use of electricity in aural disease has been too limited, and it will ever remain so, unless we all take hold of our batteries and work and write it into deserved prominence. Electricity is of considerable value in idiopathic otalgia, tin- nitus, paralysis of the facial and chorda tympani nerves; hyper- aesthesia, torpor or paralysis of the auditory nerve; labyrinthine disease, with partial or total deafness; chronic inflammation of the tympanum, with adventitious bands, and anchylosis of the ossicles; and in spastic contraction and paresis or paralysis of the tympanic and palato-tubal muscles. Otalgia, when not relieved by the usual measures, is sometimes promptly cured by the continuous Galvanic current applied by the external method, the anode being in the auditory meatus. Tinnitus may be treated by the same current, with the anode in the Eustachian tube, and the cathode in the meatus, upon the mastoid, or over the superior cervical sympathetic ganglion. 472 THE HUMAN EAR AND ITS DISEASES. Paralysis of the facial nerve and chorda require the Gal van ic cur- rent, with the electrodes applied nearly in the course of the main trunk. The anode may be placed over the stylo-mastoid foramen or in the auditory meatus, and the cathode in front of the masseter muscle. The current may be reversed occasionally. Hyperaesthesia, torpor, and paralysis of the auditory nerve are best treated by the Galvanic current, with the cathode in the meatus, and the anode upon some part of the other side of the body. Labyrinthine disease with deafness should be subjected to the same treatment. The so-called nervous deafness belongs under torpor of the auditory nerve, though generally there is more or less disease of the tympanum. Chronic inflammation of the tympanum with attendant changes may be experimented upon with both the Galvanic and Faradic currents. The anode should be in the Eustachian tube, and the cathode in the meatus or upon the mastoid process. The current may frequently be reversed to advantage. Contraction, paresis, and paralysis of muscles demand the Far- adic current, with the cathode upon the velum or in the Eusta- chian tube, and the anode in the meatus. If symptoms are not ameliorated, the current should be reversed, and in obstinate cases the Galvanic current tried. Dr. Houghton, of New York city, reports a case of paresis cured by the Galvanic current. The anode was placed in front of the auricle and the cathode behind the angle of the lower jaw. These directions will serve to guide the novice somewhat in his use of electricity in aural diseases. If no improvement follow a given method of application, it would be advisable to reverse the current by turning the rheotrope, and should one kind of electricity prove useless, the other ought to be tried before aban- doning an agent that has proved so potent for good in the hands of trustworthy and able physicians. The reader can follow up this subject with pleasure and profit in A Text Book of Electro-Therapeutics and Electro-Surgery, by John Butler, M.D., L.R.C.P.E., etc.; and in A Practical Trea- tise on the Medical and Surgical Uses of Electricity, by Drs. Beard and Rockwell. THE INTERNAL EAR. 473 CHAPTER X. THE INTERNAL EAR. The Internal Ear is more delicate and complex than any other portion of the auditory apparatus, and almost inappreciable path- ological changes in its soft tissues are sufficient to diminish or destroy audition, and to cause decided constitutional disturbances. There is no doubt that the labyrinth has its own primary diseases, but a larger proportion are secondary to affections of contiguous tissues in the tympanum and the cranial cavity. The labyrinth is situated so secluded from sight and touch, that it is difficult and in some cases impossible to arrive at an accurate diagnosis of its morbid conditions. In consequence of this, some writers upon aural diseases either pass over this divi- sion of the subject hastily and discreditably, or mix their descrip- tions, to the confusion of the student, and the demoralization of classification. It is important to rescue this department of otiatrics from neg- lect and confusion, and, by avoiding profuse speculative theories, to make scientific facts more prominent. Allusions to labyrinthine and intracranial affections have been made frequently in connection with diseases of other parts of the ear in previous chapters. It will be necessary for the reader to refer to these for information upon the slight disorders of func- tion of the auditory nerve and brain, often sympathetic and tran- sient, and for fracture, hyperostosis, and caries of the temporal bone. Diseases of the internal ear are rare, relative to those of the middle and external ear, and one may practice many years and only see a few cases. The observer must be well read in general medicine, particularly in nervous diseases, in order to appreciate the significance of symptoms belonging in common to the audi- tory nerve and brain. Diseases of the internal ear I have classified as follows: Anae- 31 474 THE HUMAN EAR AND ITS DISEASES. mia, Hyperaemia, and Inflammation, including nervous deafness, Meniere's disease, and paralysis from concussion. Anaemia.—This condition of the labyrinth may exist alone or be associated with the same disorder in the brain and general system. There is a deficient supply of blood to the internal ear, or the blood is deficient in red corpuscles and other nutritive ele- ments. This latter state would be better expressed as hydraemia, but this word has not been permitted to replace the former term, which holds right of possession in all our medical works, and still conveys an exact meaning. Anaemia of the labyrinth has a variety of causes. It may be a consequence of pressure upon the fluid contents by depression or thickening of the membranes of the round and oval windows from tympanic disease ; of narrowing of the auditory artery by end- arteritis, pressure from hyperostosis of the temporal bone, or intracranial tumors; of occlusion of the artery by an embolus; of aneurism of the basilar or carotid artery; of reflex action through the sympathetic, or vaso-motor nerves, from disease of the spinal cord and other organs; or of general anaemia and debility, arising from mental exertion, anxiety, hemorrhage, and severe constitutional disease. Some of these causes will ultimately induce more serious dis- orders in the ear than simple anaemia, which is either temporary or antecedent to other morbid states. A symptom of anaemia of the labyrinth is tinnitus like the soughing of wind through the trees, the distant roar of the ocean, the murmurs of a conch shell, and sometimes like sharper and rougher sounds. The sounds are generally low and continuous, but may be aug- mented with every heart-throb by sounds of arterial pulsation. In general anaemia, the well-known bruit of the jugulars causes a characteristic humming tinnitus when there is disease of the tympanum, but the tinnitus of labyrinthine anaemia is different. Those who become insensible from syncope, suffocation, and anaesthesia experience and can describe it. In such cases, it is loud and tumultuous; in anaemia of the ear per se, it is softer and less constant. Another aural symptom is temporary or permanent impair- ANAEMIA OF THE INTERNAL EAR. 475 ment of hearing. The auditory nerve is not adequately nour- ished and its sensibility is diminished ; the subjective noises over- power vibrations transmitted from without, and the patient can- not hear well. The degree of impairment of audition depends upon the cause of the anaemia; if the deafness is great and the tympanum healthy, there is serious general debility or some grave local lesion existing. Vertigo accompanies most cases. It comes and goes with sud- den movements of the body, and, also, when quiet is maintained. It does not cause turning or falling impulses, but a swaying and hovering sensation, as if the head were too light, and went side- ways now and then. Vertigo, tinnitus, and deafness are common symptoms in aural disease, and their existence is not presumptive evidence of anaemia. The diagnosis of the condition must be made by exclu- sion, and a careful estimate of all the subjective symptoms; the objective cannot aid it much. The history of the case; habits of the patient; healthy condition of the tympanum, external canal and Eustachian tube; the character of the tinnitus and vertigo; the impairment of hearing; the defective reaction to the tuning-fork, and modifications of Brenner's formula will enable one to make a proper diagnosis. Other symptoms and examinations will be necessary in suspected cerebral disease, particularly an inspection of the optic nerve. Schwartze says : ' The anatomical recognition of anaemia of the labyrinth is very difficult; it is still doubtful whether these aural symptoms cannot be referred with equal justice to changes in the intracranial circulation, and a consequent imperfect percep- tive power in the central organ, the brain.'* Treatment.—The patient's physical and mental state should be fully investigated ; his health improved by every means possible ; the mind relieved of strain or anxiety, and intellectual work di- minished and regulated. The existence of disorder or disease in any part of the body, especially in the brain, should be treated secundum artem, and such medicines administered as the totality of symptoms may in- dicate. * The Pathological Anatomy of the Ear. Schwartze, p. 156. 476 THE HUMAN EAR AND ITS DISEASES. Ferrum will prove efficacious in general anaemia and chlorosis; Arsenicum when there is a dartrous diathesis, accompanied by much irritation and debility ; Calcarea phos. for strumous and delicate constitutions; Mercurius and Kali hydriod. for syphilis; and Cinchona in malarial cachexia, and great debility following hemorrhage and constitutional diseases. Inflation ought to be performed occasionally, and every two or three days a little vapor of sulphuric ether sent through a catheter into the tympanum to stimulate the local circulation. The hot aural douche may be employed a few times, and benefit may be derived in some cases from keeping the patient at rest in a recumbent position. The Galvanic continuous current ought to be used daily for five minutes, placing the cathode in the meatus and the anode upon the other side of the neck or in the opposite ear. The current must be very weak at first, and then gradually in- creased as the patient can bear it. It is safest in such cases to use a rheostat in the circuit. I have had two cases of anaemia of the labyrinth in which the diagnosis could not be questioned, though probably in both there was coexisting anaemia of the brain. Case I.—A lady, who had a good constitution and excellent health, and was on the shady side of sixty years, went through a severe attack of diphtheria, and suffered during several months following from the consequent debility. The patient came to me for peculiar sensations in her ears. She said when she went about and went up and down stairs, she frequently experienced a sensation as if something fell in her ears, then a distressing roaring would intervene, and a slight de- gree of vertigo ensue. The first attack startled her so that she threw herself forwards upon a sofa, and the symptoms immedi- ately ceased. She said she did not feel faint or nauseated, and did not lose consciousness in the least. The experience gained the first time enabled her to conquer subsequent attacks. When- ever the same symptoms returned, she would bend herself for- wards until the trunk was horizontal and relief would immedi- ately follow. The patient said she felt tolerably strong and went about, not- ANEMIA OF THE INTERNAL EAR. 477 withstanding the unpleasant consequences, and so she was very frequently making profound salaams to the furniture and people at unexpected moments. The nose, pharynx, and Eustachian tubes were healthy; inflation of both tympana was easy; the ex- ternal canals and membranes were a little dry, and the tympana seemed only affected by the desiccation and contractions of se- nility. The fork was heard equally well by both ears per ossam, and Hw. |£ upon either side. Her health seemed good, but there were some symptoms of dyspepsia, and the circulation was feeble. I blew ether into the tympana, applied diluted glycerine to the drum-heads, and gave Nux vom. to be taken before, and a powder of Quinia sulphate after meals. Improvement was rapid, and the aural sensations ceased within two weeks. Case II.—A man, about fifty years old, of fairxlevelopment, and good constitution, had a severe attack of typhoid fever, ac- companied by much deafness of the labyrinthine variety. There was roaring in the ears, but there had been no acute affection of the tympanic structures as far as known. Convalescence from the fever was slow, and the patient was confined to his room in bed most of the time for four weeks after the disease had ruii a typical course. Tinnitus had then ceased in the right ear, but persisted in the left, whenever he took a vertical position. This would come on as soon as he sat up in bed, or got out in his easy chair. It was of the character of a steady roaring, which he compared to that produced by wagons rolling over a paved street. There was a very little vertigo, but he complained of the noises as very dis- tressing. The patient was anaemic and feeble; his pulse was thready and weak, and his appetite poor. Both ears presented the typical symptoms of chronic inflammation of the tympanum. The drum-heads were yellowish-gray, thickened, and opaque; the malleus handles were slightly drawn inwards; the pharynx was tolerably healthy; the tubes opened well to inflation, which moved the drum-heads out moderately. The right ear had 478 THE HUMAN EAR AND ITS DISEASES. Hw. g-§; the fork upon the vertex was heard by both ears, but better upon the right side. I prescribed Cinchona tincture, ten drops in water four times a day. There was very little change in the condition after a week's treatments, and I then ordered Quinia sulphate % gr. four times a day. In one week, the aural symptoms had ceased, and the patient was discharged. Hyperaemia.—This condition of the internal ear frequently coexists with tympanic disease, and with disorders of circulation in the cerebrum. The amount of blood in the labyrinth is in- creased beyond the normal; the blood may be in active circula- tion, coming in and passing out rapidly, or the currents may move slowly, leaving stagnant foci here and there. Both condi- tions may produce pressure upon the filaments of the auditory nerve, and thus give rise to nearly similar symptoms. The congestion supervenes frequently from slight causes, and passes away without doing more damage, than temporarily alter- ing the functions of the apparatus. Again, it remains constant, induces slow or rapid pathological changes in the membranous labyrinth, and causes partial or total deafness. It is the condi- tion antecedent to the grave affections of the internal ear, which occur as a consequence of certain constitutional diseases, and should always be regarded with suspicion. Labyrinthine congestion of a mild grade is produced by both acute and chronic disease of the tympanum. Anastomosis of the vessels of the mucous membrane of the middle and internal ear has been demonstrated by the researches of Politzer. Anything that causes hyperaemia of the middle ear, such as impacted cerumen, furuncles of the canal, injuries of the drum-head, sore throat, obstruction of the Eustachian tube, etc., will induce corresponding congestion in the deeper structures. On the other hand, hyperaemia of the brain from mental states, hysteria, general debility, mental worry and ex- haustion, indulgence in alcoholic beverages, large doses of qui- nine, and some other medicines, cause congestion in the labyrinth very soon, because of the direct and copious supply of blood to the parts through the internal auditory artery. Graver degrees of labyrinthine congestion, those which often HYPEREMIA OF THE INTERNAL EAR. 479 lead to profound organic change, occur from disease of the tem- poral bone, fracture of the skull, meningitis, apoplexia, cerebral abscess, tumors, aneurisms, obstruction of the venous circulation, heart disease, poisoning by carbolic acid, and various constitutional diseases. The symptoms of uncomplicated and moderate hyperaemia of the labyrinth are, at first, exaltation of hearing, a sort of hyper- aesthesia of the nerve, and sounds of moderate intensity cause discomfort and annoyance to the patient, especially when he is in a quiet place or if he tries to go to sleep. A fine ringing tinnitus usually accompanies this state, and vertigo is not very uncommon. The mild cases if continuous soon merge into severe ones. When the labyrinth becomes much congested, the auditory power declines rapidly, ranging from an inability to hear medium voice to total deafness. The tinnitus then becomes louder; coarser and rougher sounds of hissing, rumbling, cracking, etc., are ex- perienced ; transient spells of vertigo occur, sometimes becoming so severe as to cause falling, and the patient feels insecure and alarmed. The symptoms are all aggravated by mental excitement and anxiety, by voluntary exercise of the auditory power, and by general systemic fatigue and debility. Toynbee relates a typical case. " I had for a long while a pa- tient under my care, who, when perfectly tranquil, could dis- tinctly 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." I had a young lady under treatment for a mild tinnitus, with unobstructed tubes, and nearly normal tympana. She was in- clined to plethora, and had considerable cerebral congestion and nervous disturbance during menstruation. The deafness varied from low to loud voice. In spite of treatment, she grew worse. I found that she was taking a glass of ale at lunch every day. I stopped this, her head became clear, vertigo and tinnitus ceased, the hearing improved much, and remained good. Hyperaemia can be recognized by its history, subjective symp- 480 THE HUMAN EAR AND ITS DISEASES. toms, and response to certain tests. The Galvanic current will give an abnormal formula; the fork in most cases will not be heard clearly, and the other parts of the ear will show conditions not potent to cause such great impairment of auditory power. Treatment.—The cause of the hyperaemia should first receive at- tention, and when this consists of morbid conditions of the middle or external ear, of the brain or interior structures, they should be removed if possible by treatment of the ear, and by the adminis- tration of general constitutional remedies, according to the princi- ples already given, and others belonging to general medical art. The general health and strength should be raised to the highest degree by careful regulation of the physical and mental labor, diet, exercise, recreation, and personal habits. Of the medicines appropriate for ordinary cases, Belladonna is very efficient. It diminishes the hyperaemia of the labyrinth and brain often in a surprisingly short space of time. Cinchona has a specific action upon the auditory apparatus, and is suitable for patients of nervous temperament, who have been subjected to mental strain and worry, and, perhaps, exposure to a malarial atmosphere. Kali bromidum relieves congestion, dulness of hearing, tin- nitus, and the uncomfortable, strained, confused feeling of the head very promptly. Nux vomica suits passive congestion in spirit-drinkers. It stimulates the vaso-motor nerves, causes contraction of the blood- vessels, and thus relieves the labyrinthine disorder. Salicylic acid has been recommended in tinnitus dependent upon hyperaemia, and has proved curative in some cases. Conium and Pulsatilla are excellent medicines for a female patient with hyperaemia depending upon menstrual disturbance. Bryonia and Colchicum may prove valuable, when the affection is connected with rheumatic or gouty manifestations. Kali hydriod. ought to be given, when the history or symp- toms point to a possible syphilitic lesion. The Galvanic current may be tried as a last resort, when other measures are unsuccessful, provided there are no cerebral or other contraindications. The anode should be placed in the auditory canal and only a weak current employed. INFLAMMATION OF THE LABYRINTH. 481 Inflammation of the Labyrinth.—Tissues cannot remain long in a state of vascular turgescence without undergoing alter- ation and proliferation, and the delicate structures of the laby- rinth are no exception to the rule. The slightest causes change normal cells into pathological ones, and inaugurate processes which unchecked go on to pervert function and destroy structure. Inflammation is excited in the labyrinth by its local nutritional changes, and by morbid influences transmitted from other parts of the ear and from within the brain case, and once well started in this confined space, its results are most disastrous to audition. Congestion, effusion of serum, exudation of plastic lymph, ecchy- mosis and hemorrhage, proliferation, fatty degeneration, and for- mation of pus occur here, as elsewhere, and lead to unique local and general symptoms. A study of the scanty literature upon labyrinthine disease will produce the conviction, that the relation between cause and effect cannot be so clearly defined, as in morbid processes in other parts of the body. The causes of inflammation in the labyrinth are multiple, the effects are not constant for the same cause, nor can they be deter- mined with certainty in any case without a post-mortem exami- nation of the temporal bone and brain. Disease of the tympanum, excessive use of quinine, exposure to severe cold, concussions and falls; caries, fracture, rheumatic periostitis, calcareous degeneration of vessels, the concretions of gout, and syphilitic deposits; obstruction of the circulation from aneurism, embolus, tumors, and heart disease; apoplectic attacks; the shocks of parturition ; acute tuberculosis, mumps, diphtheria, erysipelas, measles, scarlatina, variola, typhus and typhoid fever ; hydrocephalus, convulsions, meningitis, and cerebro-spinal men- ingitis are all enumerated as causes of internal ear disease. One group of causes generally induces congestion and subacute inflammation in the labyrinth, which creeps on slowly and insid- iously, and gradually diminishes the hearing. The so-called nervous deafness from rheumatic periostitis, gouty concretions, atheromatous vessels, continuous avocation-noises, large doses of quinine, intemperate use of alcoholic beverages, syphilitic de- posits, aneurisms, tumors, heart disease, repeated shocks from 482 THE HUMAN EAR AND ITS DISEASES. parturition, and, probably, some of the fevers, is often depen- dent upon subacute inflammation in one or all parts of the labyrinth. There is at first increased sensibility of the nerve to sounds; the hearing seems very acute, so that the patient is annoyed at some tones, but the ability to hear the voice, watch and fork is really below the standard. There is tinnitus of a mild ringing, singing, hissing or rushing character at the beginning of the dis- order, accompanied by slight attacks of vertigo, and an empty feeling in the head. As the disease advances, the hearing grad- ually declines; the voice and watch are no longer perceived ; the fork upon the vertex is barely distinguished as a muffled tone, and the facial nerve gradually alters the tonus of the muscles of the face, so that it presents that wistful look so apparent in deaf persons. The symptoms will vary somewhat with the stage of the disease, the degree of moisture, the electrical state of the atmosphere, the amount of blood in, the head, and the health of the patient. Before and during storms the hearing power will be depressed or lost. Hyperaemia of the brain will aggravate the aural disease and diminish audition, while an anaemic state of the cerebral circulation will improve it temporarily. Vertigi- nous attacks belong to the morbid condition of the labyrinth, but they are rendered severe and more frequent by gastric disorders. A person without any aural disease, or with one of mild degree, is liable to have sudden and transient attacks of loud tinnitus and severe vertigo, owing to reflex action from the stomach through the sympathetic nerves. Subacute inflammation in some cases, after doing a certain amount of damage to the labyrinth, becomes arrested by removal of the cause, by exhaustion of its irritation, or by the superven- tion of senile atrophy. I know no other explanation for condi- tions that one meets so frequently in practice, where the tympa- num is but little if any affected, and the fork is heard very faintly, yet, the patient affirms that there has been no increase in the deafness for years. A woman, twenty-five years of age, enjoying good general health, was deaf to loud shouts, but heard faintly the sound of a large tuning-fork. She said she had had noises in her ears and INFLAMMATION OF THE LABYRINTH. 483 began to lose her hearing, during a severe attack of measles, twelve years before. In six weeks, she could not hear loud voice, and she remained locked up from external sounds, until to her surprise she heard the fork upon the vertex. The tubes opened readily, the membranes were a little opaque, but the tympana were apparently healthy. This seems to be an illustrative case of arrest of the labyrinthine inflammation from exhaustion of the irritation. When the cause continues active, total deafness generally re- sults, as in the case of a lusty blacksmith who applied to me for an opinion. He had suffered from proliferative inflammation of the tympana, with the usual symptoms of tinnitus, slight vertigo, and gradual loss of hearing. The membranes were like chamois skin, and adherent to the inner tympanic wall; the manubria were strongly retracted, so that they were nearly " end-on," and inflation caused no movement or sensation in the ears. There was total aural and cranial deafness. The man was and had been very healthy otherwise all his life. His history was clean, and no diathesis could be established. When a patient has tympanic disease, it is not necessary to seek further for a cause of labyrinthine mischief unless very extraor- dinary symptoms ensue. When the history and symptoms lead to some one of the causes enumerated, it is rational to accept it, but one should bear in mind that several may be associated in the same case, as atheroma of vessels in gouty persons with heart disease; syphilis in those subjected to avocation-noises; and qui- nine poisoning in those who are habitually intemperate. The causes in this first group generally excite the subacute form of inflammation of the labyrinth, which may be finally as damaging to the hearing as a more severe disease, but some of these causes may, also, start an acute inflammation or a destruc- tive morbid process of great severity. Another group of causes is more likely to excite acute inflam- mation, attended by effusion, exudation, hemorrhage, and grave pathological lesions. They are purulent inflammation of the tympanum ; caries of the bony labyrinth, and fractures through its walls; violent concussions, severe cold, embolism, aneurism, apoplexia, parturition, syphilis, mumps, diphtheria, erysipelas, 484 THE HUMAN EAR AND ITS DISEASES. measles, scarlatina, and variola; malarial, typhus and typhoid fevers; hydrocephalus, convulsions, meningitis, and cerebro-spinal meningitis. In purulent inflammation of the tympanum, the membranes of the round and oval windows may be destroyed by ulceration or accidental puncture, and air and pus gain access to the laby- rinth to cause inflammation. Caries and fracture of the bony labyrinth generally induce purulent disease in the cavity. Con- cussions from reports of firearms, blows, falls, etc., cause sudden deafness by paralysis of the nerve from shock, and by causing ecchymosis and hemorrhage in the labyrinth. Loss of taste and smell, and affections of the ocular muscles have been observed in this connection. Exposure to severe cold has caused sudden and grave decline of auditory power. In most cases, the disorder has been in the tympanum instead of the middle ear. Embolism of the internal auditory and of the basilar arteries has produced sudden deafness and atrophic changes in the labyrinth. Aneurism of the basilar artery, and intracranial tumors occasionally destroy hearing by pressure upon the auditory artery or nerve. An apoplectic clot along the course of the auditory nerve or within the labyrinth has destroyed the hearing and the integrity of the membranous structures. Severe parturition is accompa- nied by congestion of the cerebral vessels, and may produce in- flammation, effusion or hemorrhage in the labyrinth. A patient during a rather severe bearing-down pain, felt or heard a loud snap in her right ear, and this was followed by loss of hearing, tinnitus, and vertigo. The labor terminated safely, the aural symptoms soon disappeared, and hearing gradually im- proved. Fifteen years later, I found Hw. gc0, and the fork was heard moderately. The membrana tympani was opaque and de- pressed, and other symptoms confirmed catarrhal otitis of long standing. Syphilitic exudations, thickenings or gummata sometimes occur in the labyrinth and at the base of the brain, and damage the auditory apparatus. There is sometimes paralysis of the facial and chorda tympani nerves. I have a man under treatment, who has upon the right side a healthy tympunum and drum-head, open Eustachian tube, deafness, paralysis of the facial, chorda INFLAMMATION OF THE LABYRINTH. 485 tympani, and abducens nerves. Mv diagnosis is syphilitic gum- ma near the posterior border of the pons varolii. Mumps is charged with setting up labyrinthine disease, though it oftener affects the tympanum. A lad came under my observa- tion who had lost his hearing in one ear from the disease. The membrane was opaque and everywhere adherent to the inner wall of the tympanum, inflation was nugatory, and the fork could not be heard when vibrating upon the mastoid or vertex. Perhaps the labyrinthine disease was secondary, and a consequence of that in the tympanum. Diphtheria has in some instances been followed by total deaf- ness, whether from labyrinthine disease or paralysis of the audi- tory nerve trunk, clinical experience has failed to establish. A treacherous poison that strikes down the proudest manhood by paralysis of the heart, would easily destroy the nervous power of the labyrinthine filaments. The erythematous, malarial, and continued fevers, though more liable to affect the tympanum, sometimes cause great deafness, effusion, hemorrhage, and inflammation in the labyrinth. Many cases of labyrinthine disease following malarial fevers must be charged to the inordinate use of quinine. Deafness occurs very frequently in typhus and typhoid fevers, but the hearing often returns with convalescence, which is proof that the loss of power has been occasioned by vitiation of the cerebro-spinal fluid and the peri- and endo-lymph, as well, as by the poisoned, torpid condition of the sensorium. Hydrocephalus affects the labyrinth by effusion into its cavities. Children are liable to attacks of convulsions with rapid loss of hearing. Convulsions frequently produce effusion into the sub- arachnoid spaces and ventricles of the brain, and it is probable the labyrinth participates, since there is free communication of the sub-arachnoid spaces through the foramen acustica and aquae- ductus vestibuli, with the endo- and peri-lymph cavities. Primary inflammation occurs in the labyrinth, as several fully reported cases substantiate, and it is an open question, whether some con- vulsive attacks are not brought on by mischief therein. Menin- gitis is both cause and consequence of disease of the labyrinth. Purulent inflammation and probably milder diseases of the laby- 486 THE HUMAN EAR AND ITS DISEASES. rinth excite meningitis and cerebral abscess, and meningitis fre- quently extends to the labyrinth and induces grave pathological changes. Cerebro-spinal meningitis has become such a common disease, and it so frequently affects the internal ear, that abundant oppor- tunity has been afforded to study the relations of the disease and its complications. Through routes already described, the inflam- mation of the meninges passes to the labyrinth and excites a morbid process, which advances rapidly, destroys the delicate ap- paratus, and causes total deafness at once; or it creeps on slowly, and makes its presence apparent during convalescence by slightly impaired hearing, then audition diminishes as the disease of the labyrinth progresses, until, perhaps, when the general health has been fully established, the patient is shut out from all worldly sounds forever. Sometimes certain tones can be heard, though the patient may be considered totally deaf. This indicates that a few terminal filaments of the auditory nerve have escaped de- struction. Disease of the tympanum, paralysis of nerves and muscles, and blindness are occasionally associated with cerebro-spinal and labyrinthine disease, and post-mortem examination has in some cases revealed purulent inflammation of the labyrinth and pia mater. The symptoms of acute disease of the internal ear are gener- ally very decided. There is sudden impairment of hearing in one or both ears, and this may be partial or complete; at the same time, hissing, whizzing, buzzing, rasping or thumping tin- nitus, continuous or intermittent, comes on to distress the pa- tient ; he becomes giddy, objects seem to move about him in ver- tical or horizontal planes; he feels as if he were moving side- ways, turning or falling, and may grasp things for support; he may walk unsteadily, whirl around, and, even, fall down. Great anxiety and fear of immediate death seize him; the face becomes pallid, cold, and moist; the pulse feeble, nausea is felt, and vom- iting of the contents of the stomach and regurgitated bile fre- quently occurs. There may be spasm of the facial muscles, pho- tophobia, oscillation of the eyeballs, diplopia from irregular action of the recti muscles, and dimness of vision on account of Meniere's disease. 487 dilated pupils. In rare cases, faintness and, even, unconscious- ness ensue. Other symptoms may be present or some of these may be absent, but the clinical picture is unmistakable. Meniere's Disease is a title that has been applied to this group of symptoms regardless of their cause. This is an improper ap- plication, because Meniere associated them with a definite path- ology. The celebrated Frenchman advanced the following prop- ositions, which I quote from Burnett: " 1. An auditory apparatus, hitherto perfectly normal, may be- come suddenly the seat of functional disturbances, consisting in noises of a variable nature, continuous or intermittent, and which may be accompanied, sooner or later, by a diminution in hear- ing. " 2. These functional troubles having their seat in the internal auditory apparatus, may give rise to symptoms which have been considered cerebral, such as intense vertigo, uncertainty of gait, turnings to the right or left, and falling, and they may be attended with nausea, vomiting, and syncope. " 3. These accidents, which are of intermittent type, are at last followed by deafness gradually growing worse, and often the hearing is at last suddenly and totally lost. " 4. All this tends to confirm the belief that the lesion, which is the cause of these functional troubles, is in the semicircular canals." Burnett says : " Meniere's description of an aural disease con- tained in these four propositions is extremely comprehensive, but from the subsequent researches of many observers it cannot be applied to a solitary lesion in the semicircular canals."* Meniere subsequently restricted the pathological lesion to the vestibule and semicircular canals, and Knapp believes it to con- sist in a serous exudative inflammation. It is well known that the peculiar symptoms occasionally ap- pear from irritation in the external auditory canal, various dis- eases of the tympanum, gastric disorders, and, rarely, from epi- leptic attacks and other cerebral diseases, without there being any * The Ear, Its Anatomy, Physiology and Diseases. Burnett, p. 554. 488 ' THE HUMAN EAR AND ITS DISEASES. lesion in the labyrinth. It may be stated in general that, when the group of symptoms mentioned is present in a patient, it should be considered an indication of irritation of the semicir- cular canals, not necessarily, but, perhaps, involving a pathologi- cal lesion. The decline in hearing often makes the patient appear stupid ; hallucinations of hearing occur sometimes, and the patient can hardly be convinced that the sensation has no external objective cause; a tone may be heard double, i. e., as two tones in the same ear, several lines and spaces apart (diplacusis monauricularis), or one in each ear (diplacusis binauricularis); one or two peculiar sounds may be all that can be distinguished ; the lower tones are often heard when the upper are lost; or the patient may be locked in eternal silence. A boy had slight inflammation of the tympanum from sea-bathing, and knocking a flat stone placed over his ear with another stone, in order to get rid of the water in the canal. He had paroxysms of pain the same night, during which he distinctly heard the knocking sounds repeated over and over again, exactly as he had heard them when he had used the stones. Recovery followed soon, but left imperfect hearing, though the cranial perception was fair. The vertigo, tinnitus and loss of equilibrium may be great, but the mind remain perfectly clear and active. Again, tempo- rary unconsciousness may rapidly follow the aural symptoms. Both conditions are seen in mild as well as in severe cases, and one cannot base a reliable prognosis upon either. The graver cases are occasionally associated with delirium and opisthotonos, generally, though not always, indicative of meningitis. The feel- ing which impels the patient to turn or fall varies much. If the right ear is affected he generally turns towards the left; if the left, towards the right. Cyon says : " The semicircular canals are peripherical organs of the sense of space. The disturbances manifested after a lesion of the semicircular canals are due, " (a.) To visual vertigo, produced by the discord between the space seen and the ideal space. " (b.) To the false notions engendered as to the position of the body. INFLAMMATION OF THE LABYRINTH. 489 " (c.) To disorders in the distribution of the innervating force to the muscles." The immediate cause is variation in pressure of the labyrin- thine fluid, whether induced by external forces or intralabyrin- thine processes. Longhi says: "The semicircular canals, on account of their great sensibility and of their contiguity to the cerebral centres, regulate the normal function of the muscular sense of the head, and in this way its equilibrium." When they are irritated or diseased, the equilibrium of the head and body is destroyed, the sense of space deranged, and the body is unstable. This instability is intensified when there is irregular action of the ocular muscles. The relation between the sense of space and the apparent space is disturbed in certain oculara flections, notably in astigmatism, and some persons with this anomaly suffer from vertigo and incoordination of muscles, though aural symptoms may be entirely absent. The pathology of diseases of the internal ear has been well worked up by aural specialists. Simple irritation induces hyperaemia and probably slight ef- fusions, which disappear and leave the hearing about normal. Total inactivity of the conducting apparatus is said to cause atrophy of the auditory nerve. Light attacks of inflammation produce an infiltration of lymphoid corpuscles, described by Moos in caries of the bone and in affections of the tympanum during the continued and eruptive fevers. Chronic inflammation causes thickening and atrophy of the membranous labyrinth, connective tissue development on the sac- cule and utricle, stuffing of the cavities with a thick yellowish- white or soft reddish mass, deposits of corpora amylaceaand lime crystals, decrease or increase of otoliths, the occurrence of calci- fication, ossification and hyperostosis, collections of pigment and cholesterine, diminution or increase of the endo-lymph sometimes changed into a hemorrhagic fluid or an opaque jelly-like sub- stance, atrophy of the auditory nerve, and fatty degeneration of the organ of Corti. Acute inflammation induces effusion, ecchymosis, hemorrhage, and purulent infiltration. Pus passes from the brain to the laby- rinth and vice versd. Ecchymoses in the membranous labyrinth 32 490 THE HUMAN EAR AND ITS DISEASES. have been found after continued fevers, variola, and acute tuber- culosis. Hemorrhages have been noted after fracture of the bone, severe contusion of the skull, atheroma of the arteries, heart and kidney disease, acute tuberculosis, typhoid and typhus fevers, scarlatina, measles, mumps, gout, and syphilis. Intracranial diseases destroy the integrity of the nerve. Atrophy of its fibres results secondarily from disease of the cere- bellum, fourth ventricle, medulla oblongata, spinal cord, and from cerebral apoplexia, atrophy, softening, and hydrocephalus. Tumors of various kinds occur in the labyrinth and upon and along the trunk of the auditory nerve. Tubercle, psam- moma, neuroma, fibroma, sarcoma, and gumma are occasionally found pressing upon the nerve and invading its neurilemma either in the labyrinth or within the cranial cavity. " In seventy-seven cases of tumor of the cerebellum, disturb- ances of hearing occurred seven times; in twenty-six cases of tumor of the pons, they occurred seven times; in twenty-seven cases of tumors of the middle lobes, three times; on the other hand, no disturbances of hearing occurred in twenty-seven cases of tumors of the anterior lobes, in fourteen of the posterior lobes, and in four of the fourth ventricle. "Tumors of the cerebellum not infrequently produce bilateral total deafness, beginning first on the side corresponding to the tumor; and this bilateral deafness may occur even in cases where a direct pressure of the tumor on the nerve trunk of the second ear, or on its nucleus in the medulla oblongata, is utterly impos- sible, and where other symptoms of paralysis of other nerves of the brain or spinal cord on the second side are, also, wanting. " Very continuous and laborious work is still needed in order to throw more light anatomically on cerebral deafness. After previous hardening of the brain, the whole region where the cen- tral ganglia lie from which the fibres of the acusticus arise must be successively dissected."* Diagnosis of inflammation of the labyrinth and its complica- tions is made from the history, the subjective and objective symp- toms. In mild cases, the symptoms may leave one in doubt * The Pathological Anatomy of the Ear. Schwartze, pp. 172-174. INFLAMMATION OF THE LABYRINTH. 491 whether there is anaemia, hyperaemia, slight effusion or moderate inflammation; the history will often aid materially in coming to a conclusion. Yet, functional disorders have symptoms so aggra- vated that the inexperienced are often misled. The degree of deafness is a most important consideration; in general, the greater the diminution of hearing, the more certainty of grave disease. It should be remembered, however, that re- coverable cases of deafness are encountered sometimes, though rarely, as results of hysteria, concussion, exposure to cold, mental exhaustion, anxiety, and general debility. The hearing per vias naturales will be partially, and, in severe cases, totally lost. A careful examination of the external canal, tympanum, and Eus- tachian tubes should be made in all cases. The sensations of the patient, when the tuning-fork is vibrating upon the vertex or mastoid, will show the degree of activity in the auditory nerve. In nerve deafness, the sound will not be increased by stopping the external meatus. In severe cases, the fork will not be heard at all, and a pistol-shot behind the patient will not attract any attention. Brenner's formula should be compared with the aural reaction to the Galvanic current. The nature of the vertigo and tinnitus should be studied; the defects of equilibrium carefully noted; the nausea and vomiting considered with reference to the condition of the stomach, and the cerebral functions examined critically. The cause is often as important as some of the symptoms in arriving at a conclusion, and so remote an organ as the heart or uterus may be the fons et origo mail The early history throws a vivid light upon some cases. Only by a careful, scientific exclusion of some cere- bral and other affections, and a calm survey of the important phenomena, can the lesion be located in the labyrinth or along the nerve trunk. A stout, plethoric woman, 53 years of age, came to me for treatment. She had been doctored much by many physicians.. She had progressive bilateral deafness, with loud tinnitus in the right ear, none in the left; she suffered from attacks of vertigo and nausea, occasional loss of equilibrium, and falling. She had taken much quinine, which had made her worse. No cachexia 492 THE HUMAN EAR AND ITS DISEASES. was present, but I suspected syphilis. The right ear heard loud voice, left ear heard nothing. The right drum-head was depressed, opaque, non-adherent; the ear was easily inflated through its tube, and the tuning-fork was heard moderately well upon the mastoid, but not on the vertex. The left drum-head was opaque and partially adherent; inflation was impossible; the fork was not heard upon the vertex or mastoid. A diagnosis of chronic inflammation of both tympana and of the left labyrinth was easy, and the connection between the loss of equilibrium, the gastric symptoms, and the aural affection was much more evident than in most cases. I saw a young lady, in 1875, in consultation with Dr. F. F. Rowland, of Media, Pa. She had had transient attacks of ver- tigo and staggering gait, with declining health for months. Amen- orrhcea, nausea, vomiting, and great general debility were present. She had been treated for amenorrhoea and supposed gastric ulcer. Finally she took to her bed, the vomiting was frequent, the dis- turbance of equilibrium was great, but the mind continued clear. She had hyperaesthesia of the auditory nerves, could not bear noise, became distressed at some young ladies singing across the street, and had temporary attacks of diplopia. I was impressed with the fact that the significant aural anp ocular symptoms had not received the consideration they deserved, on account of the prominence of the gastric symptoms and the accompanying anaemia and amenorrhoea. Investigation revealed slight deafness and tinnitus, and a deviation of the axes of the eyes to the right side, and a study of the gastric phenomena convinced me that the frequent attacks of vomiting were of cerebral origin. The lady had inherited a strumous constitution, and this in connection with the other phenomena led me to make a diagnosis of tuberculous tumor at the base of the brain. I suggested an ophthalmoscopic examination of the eyes, but never had an op- portunity of making it, as my diagnosis was not accepted. The post-mortem examination revealed a glioma the size of a pullet's egg, snugly ensconced in a depression in the base of the left lobe of the cerebellum. The prognosis in inflammation of the internal ear and its com- plications should always be guarded. The lighter affections may INFLAMMATION OF THE LABYRINTH. 493 pass away, even, when the characteristic symptoms of Meniere have been violent. The prognosis is favorable, when deafness has resulted from hysteria, mental exhaustion, anxiety or general debility. The effects of quinine, parturition strain, moderate concussion, exposure to cold, diphtheria, mumps, gout, and syphilis are not necessarily permanent, and scientific treatment may restore the labyrinth nearly to its wonted functional activity. Nervous deafness from the eruptive and continued fevers fre- quently disappears under treatment, and the labyrinth returns to nearly a normal state. When the inflammation is secondary to tympanic, cranial or visceral disease, the result will depend upon the success in treat- ing the primary affection. Chronic proliferative and purulent inflammation of the tympanum, periostitis and hyperostosis of the temporal bone, atheroma of the vessels, and heart disease, are likely to cause permanent lesions. The sudden occurrence of total deafness indicates effusion or hemorrhage in the labyrinth, or a grave cerebral apoplexia, and is of bad omen. Inflammation from fracture, caries, purulent in- filtration, acute tuberculosis, peculiar convulsions, and simple and cerebro-spinal meningitis, are generally destructive of hearing, as well as dangerous to life. Lastly, when there is embolism, aneur- ism, cerebral tumor, apoplexia, hydrocephalus, cerebral mollifies, in connection with great deafness and other aural symptoms, no just expectation of improvement in audition can be entertained. Treatment.—The therapeutics of internal ear diseases will fur- nish the solidist and the humoral and neuro-pathologist with a limitless field for investigation and experiment. As in all other morbid affections of the body, it is more important to regulate the patient's diet and personal hygiene. The weak and anaemic must be well nourished and stimulated, the strong and plethoric dieted and depleted. Both should be protected from everything known to aggravate aural diseases, as cold, dampness, imprudent sea- bathing, continuous loud noises, excessive mental labor, excite- rnent, anxiety, the inordinate use of tobacco and alcoholics, fre- quent child-bearing, residence in a malarial region, and taking large doses of quinine. 494 THE HUMAN EAR AND ITS DISEASES. The sudden occurrence of Meniere's characteristic symptoms, without any demonstrable disease of the ear, may be regarded as functional, and treated with a small blister upon the mastoid, and the administration of Kali bromide, Conium, Amyl nitrate, Phy- sostigma or Cinchona, according to the special indications. The slowly progressive subacute inflammation of the internal ear from disease of the tympanum demands treatment of the latter condition, according to directions already given. If the patient has a gouty diathesis, and periostitis of the tem- poral bone is suspected, nitrogenous food ought to be restricted, much out-of-door exercise taken, and Bryonia, Colchicum, Kali hydriod., Lycopodium, and Natrum salicylicum tried successively. When quinine, menstruation, parturition, and other causes have brought on or increased labyrinthine congestion and deafness, Belladonna, Kali brom., Natrum brom., Acid, hydrobromic. will prove effective medicines. Sudden deafness from exposure to severe cold and from con- cussion and convulsions should be treated at first by hot aural douches, and Aconite or Belladonna. After awhile, Kali hy- driod., Strychnia sulph., and the Galvanic current may promote absorption and stimulate the nervous apparatus. When the aural affection seems to be connected with disturb- ance of the circulation from heart disease, the patient should be kept quiet, and Aconite, Cactus grand., Digitalis, and Spigelia used pro re nata. Disease of the labyrinth caused by embolism, syphilis, apo- plexia or tumor requires the steady administration of palpable doses of Kali hydriod. and occasional intercurrent remedies.. If syphilitic affection has been recent, Mercurius should be given in place of the former, which suits the latter stages better. Aneurism can rarely be diagnosed as a cause of aural disease. I saw a case of suspected aneurism of the carotid at its junction with the circle of Willis. A squeaking sound synchronous with the pulse distressed the patient, and was heard by auscultating the temporal region. There were no other symptoms apparent. No treatment was advised, the sound gradually ceased, and the child grew and remained well some years, until I finally lost sight of him. INFLAMMATION OF THE LABYRINTH. 495 Roosa quotes Griesenger's symptoms of disease of the nerve from aneurism. They are: " difficulty in swallowing ; occasion- ally spasmodic deglutition ; impairment of hearing, or even com- plete deafness, often appearing at intervals, with great tinnitus ; difficulty of respiration and articulation ; interference with the excretion of urine; without any impairment of the intellectual functions; and finally paraplegia." " Von Troltsch states that, a constant sensation of knocking in the back of the head is also a suspicious symptom."* If the diagnosis were certain and relief imperative, compression of the carotid, or ligation of it or the vertebral artery might be performed with a prospect of cure. I should however be loth to recommend such a procedure. Arsenicum, Kali hydriod., Phosphorus, and some of the cardiac sedatives might be adminis- tered with some prospect of improvement. When total deafness comes on suddenly without apparent cause, it is usually due to effusion or hemorrhage in the labyrinth, or to cerebral apoplexia. The latter will easily be recognized from the former by other than the aural symptoms depending upon the cerebral lesion. In either case, keep the patient's head elevated, permit no muscular movements, apply ice to the head and warmth to the feet,.and give Veratrum vir. tincture in five- drop doses, every half hour, until the heart and pulse become a little weakened. This medicine is a powerful vascular depres- sant, and is not so dangerous as Aconite, because nausea and vomiting occur early to warn the physician when the limit of tolerance for it has been reached. It is probable the aurist will not see these cases until the pri- mary symptoms have passed, and the family physician consigns them to his care for special treatment of the ear. Then Kali hydriod. will promote absorption if any medicine will, and this may be aided by frequent applications of the Galvanic current. The results of treatment of hemorrhage in the labyrinth so far have not been brilliant. When the internal ear is affected by tuberculous ulceration or deposition, little can be expected from local treatment, but the * A Practical Treatise on the Diseases of the Ear. Roosa, p. 507. 496 THE HUMAN EAR AND ITS DISEASES. general treatment by means of careful alimentation and the ad- ministration of 01. Morrhuee and Calcarea phos. holds out the only hope of improvement. Hydrocephalus causes a slow accumulation of fluid in the labyrinth and the sheath of the optic nerve, and deafness and blindness are sometimes late sequelae of the disease. Anything that will diminish the intracranial dropsy will improve the-aural condition. Apis, Apocynum, Bryonia, Digitalis, Kali hydriod., Mercurius, and Pilocarpin will probably do all that any medi- cines can. The torpor caused by the effusions or vitiations of typhoid and typhus fevers requires Cinchona, Nux vomica, and the Gal- vanic current. Mumps, measles, scarlatina, erysipelas, and diphtheria cause disease of the labyrinth rarely, through a morbid process set up in the tympanum, though it is not unusual that the impulse comes from cerebral states accompanying the diseases. The middle ear if in a morbid state should be restored to as healthy a condition as possible. Any cerebral hyperaemia present must be reduced by cold applications to the head, and the administration of medi- cines. If the loss of hearing is sudden, use cold applications and Veratrum viride as already stated, when the constitutional disease does not prohibit them. When the deafness and labyrinthine mischief have become stationary, after the systemic affection has terminated, Mercu- rius, Kali hydriod., Kali brom., Cinchona, Strychnia sulph., and stimulation by the Galvanic current offer the most available means of relief. Electricity ought to have a trial when the nerve responds slightly to the tuning-fork, especially after an at- tack of diphtheria. Primary inflammation of the labyrinth simulating meningitis, and secondary inflammation arising from meningitis, generally cause such destruction of the delicate apparatus of the labyrinth that little hope can be entertained of successful treatment. When not contraindicated, the early stage is best treated by cold appli- cations and full doses of Aconite, Belladonna or Kali brom. After the acute disease has terminated and the patient is totally deaf, it would be rational practice to produce and maintain for DEAF-MUTISM. 497 some time a suppurating sore upon the mastoid, and give Mer- curius, Kali hydriod., Quinia sulph., Strychnia sulph., and appli- cations of the Galvanic current a fair trial. Charcot cured a case of this character by giving Quinia sulph., 15 grains three times a day for several months. The toxic effects of this powerful remedy must, however, be watched and the medicine stopped, if any symptoms of amaurosis supervene, since Dr. Griining, of New York, reports a case in which eighty grains, administered in ten-grain doses, in a period of thirty hours, caused temporary blindness. Though good central vision w7as ultimately regained, the visual fields remained permanently contracted. It would be better to give much smaller doses, than to risk so terrible a disaster as loss of sight, and it is altogether probable that two grains taken three times daily would do as much good as a more ponderable dose. The effect of caries of the temporal bone has already been fully described, and no special treatment for labyrinthine lesion connected with it can do much good. The caries requires all our surgical skill and therapeutic resources, because it is not merely a question of danger of loss of hearing, but of death, if not im- mediately by shock or laceration, a little later, by reactive inflam- mation and great degeneration. The pathognomonic signs of fracture of the temporal bone are, hemorrhage from the ear, a flow of serum, and paralysis of the facial nerve. Rupture of the round or oval membrane or a punc- ture through the outer labyrinth wall may, however, furnish the first two symptoms. The patient should be kept quiet with the head elevated, the external ear must be cleansed with water, a compress wet with dilute Arnica placed over the seat of injury, and Arnica given internally. When reaction and inflammation ensue, Aconite or Belladonna should be substituted for the Arnica, and the case treated according to general surgical principles. Deaf-Mutism.—Consideration of the graver diseases of the auditory apparatus naturally leads to some account of that sad state of abolition of hearing denominated deaf-mutism. This term is not used in its strictest sense, but is understood to include cases in which the hearing is so defective, that the individual can- not distinguish articulate sounds well enough to understand 498 THE HUMAN EAR AND ITS DISEASES. speech. Examination of the auditory power in many persons who are commonly regarded as deaf and dumb will prove a variable amount of hearing, some auditory nerves responding to one kind of noise and some to another, but the power of discrim- inating between words is always lost. Some of these afflicted ones can hear a few notes of the piano, the noise made by clap- ping the hands, the cracking of a whip, the rumbling of a car- riage, railroad train or thunder; a loud shout in the ear, and the report of firearms. A shout in the ear or the report of a pistol near the head causes many deaf and dumb persons to shrink and express by their features some discomfort. Several that I have examined have complained that noise hurt their ears, though they presented no signs of disease to indicate hyperaesthesia. The auditory nerve, after it becomes incapable of distinguishing the quality of sound, still reacts in some degree to intensity. Recent experiments with the dentaphone and audiphone teach one not to be rash in deciding, that there is inability to appreciate the quality of sound, until these new inventions have been tried; because there is no doubt, that some so-called deaf mutes by their use have been made to hear speech and enjoy vocal and instru- mental music. It requires examination by an expert to determine the condi- tion of the auditory nerve, and though some sensibility may be revealed in many cases, there are others in which the hearing is totally abolished, and the patient lives in a realm as silent as the environs of the Sleeping Princess. The voice of a person unable to hear himself speak'is strangely modulated and harsh. Spoken language is regulated in pitch and rhythm, according to the sounds that the ear transmits to the consciousness. The hearing has an influence over speech anal- ogous to that of sight over bodily movements. Deafness causes imperfect pronunciation, blindness irregular locomotion. When a person of mature age becomes gravely deaf, he retains his power of speech, but little by little the manner of speaking be- comes altered, so that the voice is disagreeable to those with good hearing, though the patient is unconscious of the defect. When young children lose their hearing for voice, they cease to progress in spoken language, soon forget their slender vocabu- DEAF-MUTISM. 499 lary, and finally become in a certain sense mute. Older children with great deafness are liable to lose their knowledge of spoken language unless great care is taken by associates to keep them in systematic exercise of the vocal organs. Loss of voice and abolition of the movements of the throat and chest organs in vocalization induce weakness of the pulmon- ary circulation, and general systemic disorders, which frequently lead to fatal disease of the lungs. Congenital cases of deaf-mutism give utterance only to gib- berish, unless they have passed through a long and laborious training in vocalization, whereby some intelligent students are enabled to use spoken language. The defects of this are, how- ever, marked, and the importance of the hearing as a regulator of speech is made manifest. The vocal organs are in a nor- mal condition in ninety-nine per cent, of deaf mutes, and only require proper exercise and training to acquire the power of speech. Deaf-mutism is acquired or congenital. The records of asylums for the deaf and dumb show, that from forty to sixty per cent, of the inmates have lost their hearing through disease of the middle and internal ears. From the history of many cases it becomes evident, that the sad results might have been prevented had proper treatment been applied during the progress of the aural disease. More exact observation is constantly relegating cases that have been classed as congenital to the acquired group. The jelly-like mucus in the tympana of the new-born, the perturbations and exposures to which they are subject in the first months of life, and the difficulty of recognizing ear disease during this period, render it probable, that many infants acquire an aural lesion early, which when later discovered is considered congenital. The congenital cases proper are those in which the auditory apparatus and associate parts are well developed, but the physio- logical action of which is impeded by some disease that has occurred during intra-uterine existence; and other cases, showing defective development, and absence of parts essential to audition. The causes of deaf-mutism are, inflammation of the tympa- num, disease of the labyrinth, intracranial disease affecting the 500 THE HUMAN EAR AND ITS DISEASES. roots or trunk of the auditory nerve, and defective development of the auditory apparatus. The following pathological conditions have been found in cases of deaf-mutism : ceruminosis; thick- ened, depressed, adherent, shrivelled, perforated, and destroyed membrana tympani; adventitious bands, thickenings, granula- tions, tumors, and purulent products in the tympanum ; anchy- losis of the ossicles or absence of one or more of them; hyperos- tosis of the inner tympanic wall, and occlusion of the foramina; organic occlusion of the Eustachian tubes; cleft palate; caries and sclerosis of the temporal bone; fracture through the laby- rinth ; the vestibule full of morbid lymph, pus, caseous matter, blood, tubercle, and fibrin ; increase in the quantity of otoliths; hyperostosis of the semicircular canals and cochlea; calcification of the lamina spiralis; the auditory nerve softened, hardened, degenerated, atrophied, and compressed by exostosis and tumors; and disease of the optic thalamus and posterior cerebral lobes. Defective development is represented in this connection by the external canal stopping short in a cul-de-sac ; the meatus entirely closed by bone; contraction and absence of one or more of the osseous semicircular canals; absence of the membranous semicir- cular canals; rudimentary state of the cochlea; absence of the whole labyrinth; and shortening and defect of the auditory nerve. Diagnosis of deaf-mutism requires some care, and it is more difficult in children than in intelligent adults. Taken in a re- stricted sense, there should be inability to hear speech or to use it to express ideas. Some so-called deaf and dumb can hear words shouted into an ear trumpet, and express themselves in spoken language, if they have learned it before becoming deaf or have been educated in an asylum. A degree of deafness in a child, that would not hinder an adult from hearing and using speech, will make the former speechless. Parents or guardians present a child for examination, with or without a history of aural disease, and say, they believe he cannot hear, and they wonder why he does not learn to talk, or why he begins to mumble his words and speak indistinctly. The auditory apparatus should be carefully examined and any DEAF-MUTISM. 501 abnormalities noted. Seat the child and have its attention at- tracted in one direction by the attendant. Then shout aloud, clap the hands, blow a sharp whistle, ring a bell, and snap a cap upon a toy pistol behind the patient, taking care to prevent any commotion of the air from reaching him, and note the effect of these manoeuvres. If he starts or looks around suddenly, it may be taken as evidence that some hearing exists; if not, he may be considered totally deaf. An infant suffering from severe scarlatinal otitis was very rest- less, and did not respond to shouting and clapping the hands. I placed a vibrating tuning-fork of large size to one ear and then to the other, the child stopped its movements, " kept as still as a mouse," and a pleased expression swept over the countenance. I accepted these effects as conclusive that the sound was heard. With older patients, an ear trumpet and dentaphone should be tried ; the electrical formulae compared; the tuning-fork made to vibrate upon the vertex and mastoid process, and questions asked and answered in writing or by speech if possible. Mutes ought to be silent, but they often use meaningless sounds. Children that are totally deaf may utter aloud a few monosyllables, but no more importance should attach to this act, than to the speech of the educated mute. Neither can be accepted as evidence of hearing. Older persons who have learned to speak before their affliction, and those who have been educated in deaf and dumb institutions, will furnish a history of their disease and describe the symptoms accurately. Treatment.—Any disease of the ear that is amenable to treat- ment should receive careful attention at the hands of the aurist, according to the principles presented in preceding pages. Every means of relief should be tried, not only to have all the chances of restoring or saving some hearing, but in certain cases to save the patient's life. When the vowel sounds or words can be heard even faintly by artificial aid, the patient should be furnished with a conversa- tion-tube, and the friends directed to exercise the patient's audi- tory apparatus daily by shouting into the instrument, and by en- couraging him to repeat the sounds into the tube himself, in order to modulate the voice and retain speech, or learn it if necessary. 502 THE HUMAN EAR AND ITS DISEASES. All attempts to use signs should be discouraged, and the voice should be exercised as much as possible. There is no doubt that the dormant power of some ears can be awakened in this manner to sonorous vibrations and both hearing and speech improved. Stimulation of muscles and nerves of a paralyzed limb will some- times restore physiological action, and it is reasonable to suppose the same effects may be produced in the muscles and nerves of the ear by systematic and persistent efforts. The audiphone should, also, be brought into use, because it is in just such cases that it has proved valuable. It has one advan- tage over the trumpet. Sound vibrations from it act upon the auditory nerve through the bones of the head, as in fishes, and thus it relieves the strain upon the tympanic muscles, which is very fatiguing. It would be rational to use it in connection with the ear trumpet. A training seance may in this way be continued longer than when only the trumpet is used. When a patient cannot be made to hear the vowel sounds by means of a trumpet or audiphone, and it is evident that the auditory apparatus is greatly disorganized, or not properly devel- oped, the parents should be informed that there is no hope of improving the hearing, and that measures should be taken to have the patient educated in an asylum. It ought to be the province of the aural surgeon to advise the public in regard to methods of education of deaf mutes, but persons are not willing to accord him this right; they take the advice of the laity in preference to his, and often fail to send their wards to the best institution. A deaf mute should possess a normal throat and vocal organs, a fair degree of intelligence, and good health, in order to master the details of the best system of education. The special training should commence not later than seven years of age, and about eight to ten years will be required to learn to speak, and to rec- ognize what others are saying, by lip reading and observation of the act of vocalization. There are three systems of educating deaf mutes : 1. Finger talking, or dactylology, and sense of sight. 2. Imitation of articulation, and lip reading. DEAF-MUTISM. 503 3. Visible speech, or phonetic writing, and observation of the parts employed in speaking. Dactylology is the system of communicating by signs; each letter of the alphabet is represented by a different position of the fingers, and by combining these, words are spelled rapidly. This system was until recently the only one taught in England and the United States. Arery few people understand the finger signs, and the mute is, therefore, unable to communicate with many persons except by writing, which is often inconvenient. The vocal organs remain inactive, and this predisposes to disease of the lungs. Imitation and lip reading is a method of educating the deaf and dumb, which, though first originating in England, has been most extensively employed in Germany for many years. It is now taught to some extent in all European countries and in the United States, and is considered by those who have made the education of these unfortunates a study, as the best system ex- tant. Children are early taught by imitation and observation to employ spoken language, and to understand it by watching the movements of the lips of the speaker. All artificial signs are forbidden, as tending to distract atten- tion and hinder the progress of the student. Close attention, and cultivation of the inherent power of imitation in the child are requisite to success, and Dalby says, " The mute's alphabet is more correct and less arbitrary than our own." The great advantage that one educated by this system possesses is, that he can go out into the world and understand what is said to him, while he is able to converse in language common to all. Burnett affirms that "English mutes thus instructed have learned to talk not only their own language, but the French and German."'* Visible speech, or phonetic writing, and observation, advocated by Dr. Bell, consists in an amplification of the lip method, which the student is made to understand by drawings of the lips, tongue, palate, and larynx, in the various positions in which they must * The Ear, Its Anatomy, Physiology and Diseases, p. 603. 504 THE HUMAN EAR AND ITS DISEASES. be placed to utter vocal sounds. With this knowledge, comes the ability to recognize spoken language by observation of the face and throat, and the deaf mute is thus brought into commu- nication with his fellow-men. It is thought by those qualified to judge, that this system is more easily taught and more capable of developing the vocal organs and the faculty of speech, than the German method. It is looked upon with favor in this country, and has already been adopted in several of our asylums. Instruments to Assist the Hearing'.—Nature is frequently assisted and improved by art. The practice of art, the mode of applying its principles, belongs properly to artists. Physicians are artists in many of their functions, but the public has not been educated sufficiently, yet, to accord them all their rights. The public suffers from this disregard, and assuming judgment upon things of which it is ignorant, unwittingly increases the physician's business. Striking illustrations of these statements are furnished by the numerous patients, suffering from functional disturbances and organic diseases of the eyes, caused by improperly fitted spectacles, who are constantly applying to the oculist for relief. Fitting spectacles involves so many nice questions in physio- logical optics, that neither the person most interested nor the so- called " scientific optician " ought to assume the responsibility of a decision. I maintain that it is just as reprehensible, and almost as perni- cious) for the deaf person or the shopkeeper to select an instru- ment to assist the hearing. The auditory apparatus of mankind was not cast in a common mould, and no two cases of aural disease present the same char- acteristics. It is, therefore, necessary for the good of the patient, that the aurist should decide what instrument is best adapted to his case. The aural surgeon should find out by proper tests the amount of hearing power that remains after the resources of treat- ment have been exhausted. He should notice the length of the external auditory canal, its diameter at different depths, its curves and pockets, and the state of its dermic lining and glands. The two ears should be compared, the reaction of the auditory nerves to the tuning-fork noticed, and the probability of improvement INSTRUMENTS TO ASSIST THE HEARING. 505 in one or the other ear from treatment considered. Instruments of proper dimensions should be selected and various shapes tried, in order to determine which one transmits sound the clearest and strongest. The audiphone or dentaphone should then be adjusted and compared with the most efficient auricular instrument, and one or both ordered, according to the resultvof the examination and the finances of the patient. The educated aurist will readily appre- ciate the necessities of a given case, and I will present only a few points for consideration. The ear-piece of the ear trumpet should be smooth, fit the meatus closely, and not penetrate farther than the junction of the cartilage with the osseous canal. Preference should be given to small instruments, when they will enable the person to hear tolerably, as they are easier carried and manipu- lated. The instrument should be used alternately in each ear when feasible, in order that they may be stimulated by the con- centrated vibrations, and be kept in as active a condition as pos- sible. When one ear is affected by ceruminosis or purulent inflammation, the other should be used if possible, and treatment of the disease advised. The audiphone or dentaphone should be tried in all cases where applicable. They are convenient instruments to manage, and the patient feels that his defect is not so apparent to the public with either, as when a trumpet is used. Their value for hearing gen- eral conversation and vocal and instrumental music has been fre- quently demonstrated. Vibrations are transmitted to the head best through the upper natural teeth, but with artificial upper teeth or the hardened gums, these instruments act tolerably well. 1. Toynbee's Artificial Drum-head consists of a disk of soft rubber about a centimeter in diameter, held between two small metal disks, which are fastened centrally at right angles to a small wire an inch long and terminating in a loop. The rubber disk is pushed in against the membrana tympani, its re- mains, the osseous ring or the ossicles, and the wire rests upon the lower wall of the canal within reach, so that the instrument can be withdrawn easily. The patient can apply and remove this at pleasure, and he should keep the rubber and the canal scrupulously clean. 33 506 THE HUMAN EAR AND ITS DISEASES. This appliance and the cornet had better be removed and left in a cup of water during the night, as constant use irritates the canal and often renders them unbearable. The artificial membrana tympani is adapted to some cases of relaxed or contracted and depressed drum-head, perforation or destruction of it, and absence of one or more of the ossicles. It is an excellent protective of an exposed middle ear, occasionally favors reparation of the natural drum-head, and greatly improves the hearing. Fig. 126. j^ Jk §—° ale B.TIEMANNiCO.N.Y. Cornets and Artificial Drum-head. 2. Cornets.—These are little funnel-shaped instruments with oddly contorted mouths. The ear-piece is made to fit the external auditory canal, and the mouth rests in the concha against the auri- cle. They are made of silver to resist corrosion, and should be made to order to fit individual cases. The wearer can introduce and remove them easily, and this is fortunate because they re- quire cleaning frequently. Cornets assist the hearing by keeping the meatus open and the canal straight. They are useful when the meatus is relaxed as in old age, the canal is unusually crooked or narrowed by malformation, cicatricial contraction, periosteal thickening or osseous growths. Fig. 127. G.TIEMANN&CO. N.Y. . Artificial Auricles. 3. Artificial Auricles are made of vulcanite or metal, in INSTRUMENTS TO ASSIST THE HEARING. 507 the shape of a whorl with one side flattened, and have an ear- piece projecting from the inside. They are made rights and lefts, one for each ear, and are united by an adjustable spring which passes over the crown of the head. They fit closely to the anterior surface of the auricle, the mouth. piece is pointed forward and upward, and they can be easily con- cealed by ladies who dress their hair low in the old-fa-hioned way. The instrument is very handy and useful for moderately deaf persons, who are obliged to hear and converse a great deal every day. 4. The Conversation Tube is composed of an ear-piece to fit into the external canal, a mouth-piece of hard rubber, two inches in diameter, and a tube a yard long connecting these, made Fig. 128. Conversation Tube. of a spiral wire, covered with rubber, and overspun with silk. Sometimes the tube is made much longer, so that the mouth-piece can be passed around a circle and general conversation carried on without any one leaving his seat. This instrument is much less clumsy than the trumpet, does not attract so much attention, and can be snugly stowed away in the pocket. It is an efficient aid to hearing a single voice close by, but does not transmit sound as well as a full flaring ear trumpet. Fig. 129. 5. Ear Trumpets are manufactured of many shapes and sizes. 508 THE HUMAN EAR AND ITS DISEASES. They are made of tin, copper, and silver, and present smooth, firm, curved inner surfaces for the reflection and concentration of sound vibrations. The parts of a trumpet are the ear-piece, Fig. 130. neck, and mouth. The ear-piece is only an inch or two long, makes a gentle curve with the longer neck, and terminates in a perforated knob. The neck is straight, slightly curved, or Fig. 131. doubled upon itself, or it makes a complete oval, and increases in diameter towards the mouth. These departures from a direct line do not hinder the passage of vibrations. Sometimes the Fig. 132. neck is beaded to the detriment of the instrument; sometimes it is made in sections to shut up like a telescope, and again it is elongated to serve as a walking-cane. INSTRUMENTS TO ASSIST THE HEARING. 509 The mouth is made according to various patterns. In some instruments, it forms a slightly expanding handle for the cane- neck, and is fixed at right angles to it; in others, it consists of the prolonged neck, terminating in an obliquely cut lip ; again, Fig. 133. there is a well-marked, bell-shaped end, continuing in a right line with the neck, or forming a curve more or less pronounced; and, lastly, it is made in the shape of a flaring cup, with the Fig. 134. mouth closed by a perforated plate, and the bottom like a para- bolic curve to reflect sound vibrations into the end of the neck, which perforates the side and bends towards it. Fig. 135. These different shapes are called the cane, the cone, the horn, the bugle, the telescope, the trumpet, and the dipper ear trum- pets. They vary as much in power as in shape; the greater the 510. THE HUMAN EAR AND ITS DISEASES. expansion of the mouth, and the larger the instrument, the better are vibrations of sound heard. The bugle is most agreeable for persons of delicate organization with rather sensitive ears. The horn is adapted to persons of coarser constitution and insen- sitive ears. The dipper is best for very deaf persons, who cannot hear well with the other kinds, and it is particularly valuable for use at concerts and public lectures. Directions how to hold a trumpet would be superfluous. Fig. 136. Long Dipper. 6. The Audiphone was invented by R. S. Rhodes, of Chi- cago, 111., an able and honest publisher, who had been quite deaf for twenty years. He happened one day to place his watch be- tween his teeth, and was surprised at the clearness with which he heard its ticking. He seized immediately upon the idea of con- structing an instrument to assist the hearing by application to the teeth. His experiments led him finally to adopt and patent an instrument of vulcanite, shaped nearly like a quadrangle with rounded corners, and with a handle in the middle of the base, the whole having much the appearance of a fan. Four silk cords are fastened at the upper border, then united about half way towards the handle with a double cord, which is drawn tight and fastened under a wedge in the handle, so as to curve the fan towards the base. This constitutes the single audiphone. A double instrument of the same general shape is now offered. It has two similar and parallel disks, with their bases united and inserted in the handle. The upper edges are notched and sep- arated about a quarter of an inch by a row of beads. When in position, the voice of the holder vibrates between the disks and the sounds return intensified to the teeth. This makes the double audiphone more valuable than the single one as a means for the self-education of mutes. INSTRUMENTS TO ASSIST THE HEARING. 511 When the audiphone is curved towards the base by drawing and securing the silk cords, it is taken by the handle, the convex surface turned outwards, the upper edge pressed firmly against the upper incisor or other teeth, and it is ready for use. Mr. Rhodes says : " Experience will regulate the exact tension needed Fig. 137. The Audiphone Adjusted. for each person, and that necessary for different voices, music, distant speaking, etc. The audiphone is adjusted to suit sound, as an opera glass is focussed to suit distance." The vibrations which constitute sound impinge upon the convex disk, are trans- mitted to the teeth, the bones of the face, and base of the skull, and through these to the auditory nerve. When the Eustachian tubes are easily opened, some sound reaches the labyrinth through them. The audiphone is best adapted to cases of severe deafness, depending upon middle ear disease, in which the internal ear and auditory nerve are normal or nearly in a normal condition. The audiphone does not attract so much attention as an ear trumpet, as many persons suppose it is a black fan, and when not in use it can be hung by a loop to a button inside the coat. I have examined the evidence presented in favor of this inven- tion, have read the reports of well-known and honorable business men, of physicians of prominence, of superintendents of asylums 512 THE HUMAN EAR AND ITS DISEASES. for the deaf and dumb, and have made numerous experiments with my aural patients, and I consider it established beyond cavil, that the audiphone is a useful invention. It helps a certain class of deaf patients to hear, who by middle ear disease are shut out from ordinary sounds, and it deserves a trial by aural surgeons and others in every case of severe deafness. The Dentaphone is an instrument identical in principle and similar in shape to the audiphone. It is made of three thin sheets of vulcanite, which are united by brass hinges to form a nearly quadrangular-shaped fan with rounded top and corners, fixed firmly in a handle at the middle of the base. The hinged wings can be closed right and left, and the instrument can then be easily carried in the coat pocket. When the wings are unfolded, an elastic cord, connected with them upon the opposite side to the hinges, is drawn tight and slipped over a peg upon the handle to keep them open. There are no silk cords from the top of the disk to the handle to maintain a fixed curvature; this varies with the pressure against the upper teeth. The tension is not a fixed one, as in the audiphone with its cord fastened, and this is a dis- advantage. The patient is liable to maintain improper tension, to vary it, and to twist and injure the instrument. Instruction and practice are necessary at first, in order to know how to hold the instrument. There are two sizes of the instrument denominated the " Ordi- nary Conversational Dentaphone" and the " Lecture and Concert Dentaphone." The latter is larger and better for hearing lec- tures, concerts, and distant sounds; the former is well adapted for conversation and home use. The vibrations of sound are collected by the dentaphone and transmitted through the bones of the face and base of the skull to the auditory nerve, as with the audiphone, and both inven- tions are adapted to the same class of cases. The application of the dentaphone merits a few words. Un- fold the dentaphone leaves, draw down the elastic cord and slip it over the knob upon the handle to keep them open. Hold the hinged side towards the face, place the upper edge of the disk firmly against the front of the canine teeth, or others near to their position if they are absent, and by upward pressure bend the fan INSTRUMENTS TO ASSIST THE HEARING. 513 in an arc. Sometimes it is necessary to bend the disk to a half circle; the handle should always be held rather near the breast. The deafer the person, the greater should be the degree of curva- ture. Do not twist or strain the instrument; bend evenly and steadily, and keep the lips and lower teeth away from it. Fig. 138. The Dentaphone. When a person hears in the usual way through the external meatus, there is tension of the tympanic muscles of the ear; if there is disease in the tympanum, considerable voluntary power must be concentrated upon these muscles, and muscular fatigue will result. It is not uncommon to find deaf persons, who hear readily when first addressed, but soon are unable to understand unless the voice is raised considerably. They are not able to maintain the muscular tension with which they first began, and relaxation ensues. This effort to hear is fatiguing, not only to the ear, but to the whole system, and patients show symptoms of debility. This is apparent in robust persons, but, of course, is much more noticeable in those whose general health is below par. The use of a conversation tube or trumpet does not relieve the necessity for voluntary effort, but rather increases it, because they imply a degree of impairment of conduction in the middle ear, requiring more tension to overcome resistance, and greater nicety of adjustment to transmit the various tones. The volun- 514 THE HUMAN EAR AND ITS DISEASES. tary effort is probably made with the trumpet in all cases, though the tympanic muscles be much hampered or even destroyed by disease. The audiphone and dentaphone have the merit of relieving the patient from this voluntary effort, the muscular strain, and the consequent fatigue, by transmitting sound to the auditory nerve through rigid parts which cannot be accommodated. The patient hears passively, as he sees at a distance without accommodating when his eyes are emmetropic. This superiority of the new inventions over the auricular instruments is so impor- tant, that they should have the preference whenever possible. Dr. Knapp has made some comparative experiments with the dipper trumpet and audiphone upon very deaf persons. He asserts that the trumpet increases the hearing more than the audiphone, and gives the latter faint praise.* The duration of the improved hearing in each case ought to have been considered, because as trumpets do and osteophones do not cause aural fatigue, the dura- tion of hearing by the former should be shorter than by the latter. The different notes of a piano are generally heard readily by very deaf persons through the audiphone and dentaphone. The handle of the instrument may be rested at first upon a piano, and, as the patient becomes accustomed to the new sensation, he may withdraw farther and farther from the instrument, A majority of those who know the sounds of spoken lan- guage distinguish words readily. Mutes and others, who do not know how words should sound, often hear them, but do not rec- ognize them. Very deaf persons hear words imperfectly, and must learn to recognize them shorn of their labials and aspirates. Regular systematic training is necessary to enable very deaf persons to understand with these instruments. It is advisable to have some one read aloud at first, while the listener is shown what words are being read. In this way he will soon learn to recognize spoken language. Mutes with some degree of hearing can learn to speak by re- peating, with the instrument against the teeth, the sounds of letters and words uttered by the teacher. A mute who has * Archives of Otology, New York, 1880. INSTRUMENTS TO ASSIST THE HEARING. 515 never heard has no idea of the meaning of sound words. He may be able to read and write, understand what is said by watch- ing the speaker's lips, and, even, speak in the mechanical way taught in some asylums, yet, not be able to connect the sounds he utters or those he hears from others, with the printed characters which represent them in every language. The audiphone or dentaphone will enable him to connect visi- ble with articulate language, and persistent practice will rescue him from that unhappy band of persons, whose afflictions are re- garded by some individuals as reproaches to our art, and by others as direct visitations of God. Finis. INDEX. Abscess, cerebral, 298 of the external ear, 138 treatment of, 139 post-pharyngeal, 332 Act of hearing, 75 Acumeter, testing the hearing by the, 94 Acute dermatitis of the external audi- tory canal, 164 treatment of, 166 inflammation of the tympanum, 215 treatment of, 226 pharyngitis, 319 treatment of, 369 Adenoid tumors in naso-pharynx, 324 treatment of, 406 Air-bag, inflation with the, 101 Politzer's, 101 Amoeba, the, 9 Ampullae of the semicircular canals, 47 Analogy of the eye and ear, 76 Anatomy, comparative, 9 Anaemia of the internal ear, 474 treatment of, 475 Angiomas, 281 Angiomata, simple and cavernous, of the external ear, 140 treatment of, 141 Angular ear forceps, 95 Anthrax of the external ear, 136 treatment of, 137 Apparatus, steaming, 432 Appearance of the membrana tympani, 186 Application of the cotton drum-head, 276 of Toynbee's artificial membrana tympani, 277 Aquaeductus cochleae, 54 Fallopii, 58 vestibuli, 45 Arches of Corti, 57 Articulates, sense capsules of, 11 Artificial auricles, 506 membrana tympani, Tovnbee's, 275, 505 Atomizer, Knight's, 369 Newman's, 370 perfume, 369 reversible, 370 Richardson's, 370 steam, 372 Atrophic pharyngitis, 329 treatment of, 416 Atrophy of the membrana tvmpani, 200 treatment of, 201 Audiphone, the, 510, 511 Auditory nerve filaments, foramina of the, 59 process, fracture of the, 149 treatment of, 150 Aural disease, electricity in, 458, 470: electrization, symptoms of, 467 Auricle, the, 13 a resonator of sound ,67 comedones of the, 143 defective development of the, 124 eczema of the, 130 erysipelas of the, 128 erythema of the, 127 hypertrophy of the, 124 ligaments of the, 14 malformations of the, 123 malformed, 124 muscles of the, 14 othcematomata of the, 142 other tumors of the, 143 physiology of the, 66 rudimentary, 123 tophi of the, 143 Auricles, artificial, 506 frostbitten, 130 Auricular cartilage, 14 Auricularus magnus nerve, 19 Auriculo-temporal nerve, 18 Auscultation and inflation of the ear, 101 sounds in, 105 518 INDEX. Auscultation tube, 102 Auscultatory catheterization, 116 B. Batrachians, organ of hearing in, 12 Bellocq's canula, 395 Billings's tonsillotome, 411 Birds, organ of hearing in, 12 Blake's middle ear syringe, 442 mirror, 88 Bougies, 118 Bowl, ear, 99 Brenner's electric formula, 467 Brunton's otoscope, 83 Brushes, Wagner's handle and, 391 Butler's inhaler, 421 C. Caisson disease, 189 Canalis reuniens, 52 spiralis modioli, 51 Canula, Bellocq's, 395 nasal polypus, 403 Carcinoma in the tympanum, 288 Caries of the temporal bone, 305 treatment of, 309 Catarrhal inflammation of the tube and tympanum, 316 Catheter, examination with the Eusta- chian, 111 holder, Bonnafont's, 117 Catheterization, auscultatory, 117 Causes of ear disease, 120 Cerebral abscess, 298 surface of the temporal bone, 64 Cerumen, 68 Ceruminosis, 159 treatment of, 161 • Cholesteatoma of the membrana tym- pani, 206 Cholesteatoma of the tympanum, 287 Chorda tympani nerve, 35, 71 Chronic adenoid dermatitis of the ex- ternal auditory canal, 172 treatment of, 173 dermatitis of the external auditory canal, 168 treatment of, 170 inflammation of the Eustachian tube, 333 treatment of, 419 inflammation of the Eustachian tube and tympanum, 316 general treatment of, 364 inflammation of the tympanum, 339 Chronic inflammation of the tympa- num, treatment of, 434 nasal catarrh, 321 treatment of, 379 pharyngitis, 327 treatment of, 413 purulent inflammation of the tym- panum, 229 treatment of, 245 Ciliated cells of the organ of Corti, 56 Cleansing the ear, 94 instruments for, 95 Cleborne's tongue spatula and spray apparatus, 371 Cochlea, the, 49 Cochlear aqueduct, 54, 61 canal, divisions of the, 54 duct, 55 nerve, 63 physiology of the, 73 or spiral canal, 50 vessels, 60 walls, 73 Coelenterate radiates with special sense organs, 10 Color of the membrana tympani, 23 Comedones of the auricle, 143 treatment of, 143 Comparative anatomy, 9 Compressed air, injury of membrane from, 189 Concha, 14 Concussions, injuries of the membrana tympani from, 190 Conversation tube, 507 Constant battery, 458 Cornets, 506 Corti, organ of, 55 Coryza, 319 treatment of, 366 Cotton drum-head, application of, 276 holder, 95 Cribriform spots of the vestibule, 59 Crista acustica, 48 spiralis, 52 vestibuli, 44 Cupola, 54 D. Deaf-mutism, 497 treatment of, 501 Defective development of the auricle, 124 Definition of sound, 68 Dentaphone, 512,513 Depressors, tongue, 108 Diagnosis of ear disease, 121 Direction of sound, 75 of the external auditory canal, 15 Divisions of the cochlear canal, 54 INDEX. 519 Douche, siphon, 385 Drum, the, or middle ear, 19 Drum-head, 20 Toynbee's artificial, 505 Ductus cochlearis, 52, 55 E. Ear, auscultation and inflation of the,101 bowl, 99 cleansing the, 94 disea>e, causes of, 120 diagnosis of, 121 symptoms of, 119 treatment of, 122 examination of the, 78 extrinsic muscles of the, 14 intrinsic muscles of the, 14 lobule of the, 14 physiology of the, 66 specula, 85 spoon and hook, 95 spout, 99 stones, 49 syringes, 96 syringing the, 98 the human, 13 the infant's, 65 the internal, 473 Ear trumpets, 507 Echinoderm radiates with ocelli, 10 Eczema of the auricle, 130 treatment of, 132 Eminentia stapedii, or pyramid, 28 Enchondromata of the external ear, 144 treatment of, 144 Endolymph, 49 physiology of the, 74 Enlarged tonsils, 326 treatment of, 409 Entotic test of hearing, 119 Electric currents, qualities of, 464 formula, Brenner's, 467 Electricity in aural disease, 458, 470 method of application of, 466 Electrization, svmptoms of aural, 467 Electrodes, 463" Epithelium of the membranous laby- rinth, 48 Epithelioma in the tympanum, 288 of the membrana tympani, 206 Epitheliomata of the external ear, 147 treatment of, 147 Equilibrium, sense of, 74 Erysipelas of the auricle, 128 treatment of, 128 Erythema of the auricle, 127 treatment of, 128 Eustachian catheter, examination with the, 111 Eustachian tube, the, 36 catarrhal inflammation of the, 316 chronic inflammation of the, 333 muscles of the, 38 nerves of the, 42 physiology of the, 72 vessels of the, 40 Examination of the ear, 78 naso-pharynx, 107 nose, 110 throat, 106 with the Eustachian catheter, 111 Exostoses in the tympanum, 288 treatment of, 291 Exostosis of the external auditory ca- nal, 181 treatment of, 183 Explorer, Toynbee's, 117 External auditory canal, acute derma- titis of the, 164 chronic dermatitis of the, 168 adenoid dermatitis of the, 172 foreign bodies in the, 150 osteo-periostitis and ex- ostosis of the, 181 phlegmonous inflamma- tion of the, 176 physiology of the, 68 meatus, 15 ear, abscess of the, 138 anthrax of the, 136 enchondromata of the, 144 epitheliomata of the, 147 fibromata of the, 144 furuncles of the, 134 glands of the, 16 injuries of the, 148 malformation of the, 123 nerves of the, 18 sarcomata of the, 145 sebaceous cysts of the, 143 simple and cavernous an- giomata of the, 140 skin diseases of the, 133 skin of the, 16 sympathetic nerves of the, 19 vessels of the, 16 Extrinsic muscles of the ear, 14 Eyelet and forceps, Politzer's, 441 F. Face and neck, vertical section of the, 384 Facial nerve, 24, 42, 61 520 INDEX. Facial nerve filaments in the tym- panum, 35 paralysis of the, 291 Fahnestock's tonsillotome, 411 Fallopian aqueduct, 58 Fauvel's forceps, 405 Fibromas in the tympanum, 282 Fibromata of the external ear, 144 treatment of, 145 Fishes, organ of hearing in, 11 Fixator basis stapedis muscle, 33 physiology of the, 70 Foot-plate of the stapes, 31 Foramen rotundum, or round window, 27 ovale, or oval window, 27 Foramina of the internal auditory nerve filaments, 59 Forceps, angular ear, 95 Fauvel's, 405 Loewenberg's curved cutting, 408 angular cutting, 408 Noyes's polypus, 406 Pomeroy's ear, 96 Simrock's, 405 Tiemann's flexible throat, 405 Forehead mirror, or otoscope, 82 Foreign bodies in the external auditory canal, 150 treatment of, 155 Fountain ear syringe, 96 Fracture of the auditory process, 149 treatment of, 150 Frankel's nasal speculum, 110 Frostbitten auricles, 130 treatment of, 130 Furuncles of the external ear, 134 treatment of, 134 G. Galvano-faradic apparatus, 460 General definition of an organ of hear- ing, 11 General treatment of chronic inflam- mation of the tube and tympanum, 364 Glands of the external ear, 16 pharynx, 40 Granger's sponge-holder, 392 Granular pharyngitis, 332 treatment of, 418 Green's tenotome, 447 Gruber's tenotome, 447 II. Habenula perforata, 52 Hairs of the external meatus, physiol- ogy of the, 68 Hand mirror, or otoscope, 81 Hard-rubber ear syringe, 97 Harmonics and overtones, 73 Hassenstine's otoscope, 83 Hearing, the act of, 75 Helicotrema, 52 Hemorrhages in the membrana tym- pani, 205 treatment of, 206 Holder, the cotton, 95 Human ear, 13 Hyperaemia of the internal ear, 478 treatment of, 480 membrana tympani, 196 treatment of, 197 Hypertrophic pharyngitis, 328 treatment of, 414 Hypertrophy of the auricle, 124 membrana tympani, 202 treatment of, 204 I. Illuminating the ear, 84 Incision of the tonsil, 379 Inconstant battery, 459 Incus, the, 30 ligaments of the, 30 Infant's ear, the, 65 inflation of the, 106 Inflammation of the Eustachian tube, chronic, 333 Inflammation of the Eustachian tube and tympanum, catarrhal, 316 Inflammation of the Eustachian tube and tympanum, chronic, 316 Inflammation of the labyrinth, 481 treatment of, 493 tympanum, acute, 215 chronic, 339 chronic purulent, 229 Inflation and auscultation of the ear, 101 by Politzer's air-bag, 101 by Valsalva's- method, 104 of the infant's ear, 1U6 vertigo after, 106 Infundibuluni, or helicotrema of the organ of Corti, 51 Inhaler, Butler's, 421 nozzle, 421 Injuries of the external ear, 148 treatment of, 148 membrana tympani, 188 from compressed air, 189 from concussion, 190 treatment of, 195 INDEX. 521 Instruments for cleansing the ear, 95 to assist the hearing, 504 Intensity, or loudness of sound, 68 Interlamellar abscess of the membrana tympani, 199 Internal auditory artery, 60 meatus, 58 nerve, 62 physiology of the, 75 car, 43, 473 anaemia of the, 474 hyperaemia of the, 478 vessels of the, 60 vestibule of the, 44 Internal pterygoid muscle, 40 Intrinsic muscles of the ear, 14 Invertebrates, organ of hearing in the, 11 position of the otic capsule in the, 11 Jacobson's nerve, 34, 43 K. Knapp's ear specula, 86 Knight's atomizer, 369 Kramer's bivalve speculum, 87 ear syringe, 97 Labyrinth, osseous, 44 membranous, 47 inflammation of the, 481 Lamina denticulata, 52 spiralis ossea, 51 membranacea, 52 Laryngeal lancet, Tobold's, 428 Larynx, the, 429 Laxator tympani (muscle?), 32 physiology of the, 70 Levator palati muscle, 38 Ligaments of the auricle, 14 incus, 30 malleus, 29 stapes, 31 Ligamentum spirale, 52 Light triangle, or cone of light, 23 Lining of the tympanum, 33 Lobule of the ear, 14 Loewenberg's curved cutting forceps, 408 angular cutting forceps, 408 Loudness, or intensity of sound, 68 Lymphatics of the tympanum and Eustachian tube, 41 Lymph currents, movements of, 74, 75 Lymph spaces and lymphatics of the internal ear, 61 M. Macula acustica, 48 cribrosa inferior, 45 media, 45 posterior, 45 superior, 45 Malformation of the external ear, 123 Malformed auricle, 124 Malleus, the, 29 ligaments of the, 29 Mammalia, organ of hearing in, 12 Mastoid cells, physiology of the, 71 disease, 293 treatment of, 299 process, 24 Measures, metric and English, com- pared, 30 Meatus auditorius externus, 15 internus, 58 external auditory, 15 internal auditory, 58 Membrana basilaris, 52 reticularis, 57 tectoria, 52 tympani, 20 appearance of the, 186 atrophy of the, 200 cholesteatoma of the, 206 color of the, 23 epithelioma of the, 206 hemorrhage in the, 205 hyperaemia of the, 196 hypertrophy of the, 202 inflammation of the, 197 injuries of the, 188 interlamellar abscess of the, 199 nerves of the, 24 operations upon the, 437 perforation of the, 193 physiology of the, 69 rupture of the, 193 secundaria, 27, 54 the artificial, 275 tubercle of the, 206 vessels of the, 23 vestibuli, 52 Membrane of Reissner, 52 of the foramen ovale, 27 rotundum, 27 Shrapnell's, 22 the tympanic, 20 Membranous labyrinth, 47 epithelium of the, 48 34 EX. 522 Membranous semicircular canals, 47 spiral lamina, 52 Me"nitire's disease, 487 Meningitis, 297 Methods of applying electricity, 466 Metric and English measures com- pared, 30 Microtia, 123 Middle ear mirror, Blake's, 88 or tympanum, 19 Millimeters and lines compared, 30 Mirror, Blake's middle ear, 88 Mirrors, rhinoscopic, 107 Modiolus, 50 Molluscs with sense capsules, 11 Motor nerves in the tympanum, 71 Mouth of the Eustachian tube, 37 Movement of lymph currents, 74, 75 of the round membrane, 70 stapes, 70 Mucous membrane of the tympanum, 33 physiology of the, 71 polypi in the tympanum, 282 Muscle, fixator basis stapedis, 33 laxator tympani (?), 32 stapedius, 32 tensor tympani, 26, 32 Muscles of the auricle, 14 Eustachian tube, 38 tympanum, 32 Music, 68 Myringitis, 197 treatment of, 199 Myxomas in the tympanum, 282 N. Nares, the posterior, 382 Nasal catarrh, chronic, 321 treatment of, 379 Nasal polypus canula, 403 Naso-pharynx, adenoid tumors in, 324 examination of the, 107 Nerve, auricularus magnus, 19 auriculo-temporal, 18 cochlear, 63 chorda tympani, 35, 71 facial, 61 filaments in the tympanum, 35 internal auditory, 62 physiology of the, 75 occipitalis minor, 19 posterior auricular, 18 tympanic branch of the glosso- pharyngeal, 34, 43 vestibular, 63 Nerves of the Eustachian tube, 42 external ear, 18 Nerves of the internal auditory mea- tus, 61 membrana tympani, 24 tympanum, 34 Nervous system decentralized, 9 first in radiates, 10 not demonstrable in amoeba, 9 Newman's atomizer, 370 Noise, 68 Nose, polypus in the, 323 Noyes's polypus forceps, 406 O. Objective sounds, 76 Ocelli in echinoderm radiates, 10 homologous with internal ear of vertebrates, 11 Occipitalis minor nerve, 19 Openings of semicircular canals into the vestibule, 44 Operations upon the membrana tym- pani, 437 Organ of Corti, 55 physiology of the, 73 hearing, general definition of an,11 in batrachians, 12 birds, 12 fishes, 11 invertebrates, 11 mammals, 12 reptiles, 12 vertebrates, 11 Osseous semicircular canals, 45 spiral lamina, 51 Ossicles of the ear, 28 physiology of the, 69 Osteo-periostitis and exostosis of ex- ternal auditory canal, 181 treatment of, 183 Otalgia, 207 treatment of, 208 Other tumors of the auricle, 143 Othaematomata of the auricle, 142 treatment of, 142 Otic capsule, 11 position of , i n in vertebrates, 11 vertebrates, 12 Otic ganglion, 34, 42 Otoconia, 49 Otoliths, 11, 49 physiology of the, 74 Otoscopes, 81 Otoscope, or hand mirror, 81 forehead, 82 Brunton's, 83 Hassenstine's, 83 Oval window, or foramen ovale, 27 INDEX. 523 Oval window .membrane, 27 physiology of the, 70 Overtones and harmonics, 73 Palato-pharyngeus muscle, 39 Paralysis of the facial nerve, 291 treatment of, 293 Perforations of the membrana tympani, 193 ^ * ' Perfume atomizer, 369 Perilymph, 47, 55 physiology of the, 74 Pharyngeal constrictor muscles, 39 tonsil, 40 plexus of nerves, 43 Pharyngitis, acute, 319 treatment of, 369 atrophic, 32 * treatment of, 416 chronic, 327 treatment of, 413 granular, 332 treatment of, 418 hypertrophic, 328 treatment of, 414 Pharvnx, glands of the, 40 Phlebitis, 296 Phlegmonous inflammation of the ex- ternal auditory canal, 176 treatment of, 177 Physiology of the auricle, 66 cochlear nerve, 73 endolymph, 74 ear, 66 Eustachian tube, 72 external auditory canal, 68 fixator basis stapedis muscle, 70 hairs of the external auditory meatus, 68 laxator tympani, 70 mastoid cells, 71 membranous semicircular ca- nals and vestibule, 73 organ of Corti, 73 ossicles, 69 otoliths, 74 oval window membrane, 70 perilymph, 74 round window membrane, 70 stapedius muscle, 70 tensor tympani muscle, 69 tympanic membrane, 69 mucous membrane, 71 vestibular nerve, 74 Pillars of the organ of Corti, 57 Pitch, or tone of sound, 68 Planum semilunare, 48 Politzer's air-bag, 101 eyelet and forceps, 441 Polypus in the nose, 323 treatment of, 401 Polypus in the tympanum, 280 treatment of, 283 Pomeroy's ear forceps, 96 Posterior nares, 382 auricular nerve, 18 Post-nasal syringe, 382 Post-pharyngeal abscess,.332 Pouches of the tympanum, 22 Powder-blower, Niemann's, 393 Sexton's, 393 Promontory, the, 26 Processus cochleariformis, 36 Protozoa, 9 with special sense organs, 10 Pyaemia, 297 Pyramid, or eminentia stapedii, 28 Q- Qualities of the electric currents, 464 Quality of sound, 68 R. Recessus cochlear is, 45 ellipticus, 45 sphoericus, 45 Reptiles, organ of hearing in, 12 Resonator of sound, the auricle a, 67 Reversible atomizer, 370 Rhinoscopic mirror, 107 Richardson's atomizer, 370 Rings and phalanges of Corti's organ, 57 Round membrane, movements of the, 70 Round window, or foramen rotundum, 27 membrane, physiology of the, 70 Rudimentary auricles, 123 S. Saccules of the vestibule, 48 Sacculus rotundus, 48 Sarcoma in the tympanum, 288 Sarcomata of the external ear, 145 treatment of, 146 Scala tympani, 54 vestibuli, 54 Scissors. Simrock's aural, 440 uvula, 414 Sebaceous cysts, 143 524 INDEX. Sebaceous cysts, treatment of, 143 Semicircular canals, the, 45 ampullae of, 47 membranous, 47 physiology of the, 73 openings of the, 44 osseous, 45 Sense capsules in lower forms of ani- mals, 10 pigmented in molluscs and articulates, 11 of equilibrium, 74 Sensitive nerves in the tympanum, 71 Sexton's powder-blower, 393 Shrapnell's membrane, 22 Siegle's pneumatic speculum, 87 Sight and hearing not differentiated in lower forms, 10 Simrock's aural scissors, 440 forceps, 405 Siphon douche, 385 Skin diseases of the external ear, 133 treatment of, 133 of the external ear, 16 Sound, definition of, 68 direction of, 75 intensity, or loudness of, 68 pitch, or tone of, 68 quality of, 68 vibrations of, 68 Sounds in auscultation, 105* objective, 76 subjective, 76 Special sense organs first in protozoa, 10 numerous in radiates, 10 Specula, Knapp's, 86 Wilde's, 85 Speculum, Frankel's nasal, 110 Kramer's bivalve, 87 Siegle's pneumatic, 87 Spier's self-retaining, 86 Thudichum's nasal, 110 Zaufal's tubular, 111 Spheno-palatine ganglion, 42 Spier's self-retaining speculum, 86 Spiral lamina, membranous, 53 osseous, 51 or cochlear canal, 50 Sponge-holder, Granger's, 392 Spray apparatus and tongue spatula, Cleborne's, 371 Stapedius muscle, 32 physiology of the, 70 Stapes, 31 ligaments of the, 31 movements of the, 70 Steam atomizer, 372 Steaming apparatus, 432 Stylo-pharyngeus muscle, 39 Subjective- sounds,, 76- Sulcus spiralis externus,.55 internus, 55 Support cells of Corti's organ, 57 Sympathetic nerves of the external ear, 19 Symptoms of aural electrization, 467 ear disease, 119 Syringe, Blake's middle ear, 443 fountain, 96 hard-rubber ear, 97 Kramer's, 97 post-nasal, 382 universal, 98 Upson's tumor, 402 Syringes, ear, 96 Syringing the ear, 98 T. Temporal bone, caries of the, 305 cerebral surface of the, 64 Tenotome, Green's, 447 Gruber's, 447 Weber-Liel's, 445 Tensor palati muscle, 38 tympani muscle, 26, 32 physiology of the, 69 Testing the hearing by the acumeter, 94 tuning-fork, 91 voice, 89 watch, 89 Theory of vibrations, 71 Throat, examination of the, 106 Thudichum's nasal speculum, 110 Tiemann's flexible throat forceps, 405 powder-blower, 393 Tinnitus, 210 treatment of, 213 Tobold's apparatus for examining the throat, 109 Tobold's laryngeal lancet, 428 Tone, or pitch of sound, 68 Tongue depressors, 108 spatula and spray apparatus, Cle- borne's, 371 Tonsilla pharyngea, 40 Tonsil, the, 40 incision of the, 379 Tonsillotome, Billings's, 411 Fahnestock's, 411 Tophi of the auricle, 143 treatment of, 144 Toynbee's artificial membrana tym- pani, 275, 505 application of, 277 explorer, 117 Tragus, the, 13 Treatment, general, of chronic inflam- mation of the tube and tympa- num, 364 INDEX. 525 Tnatment rf abscess of the external ear, 139 acute dermatitis of the external auditory canal, 166 inflammation of the tym- panum, 220 pharyngitis, 369 adenoid tumors, 406 anaemia of the internal ear, 475 angiomata of the external ear, 141 anthrax, 137 atrophic pharyngitis, 416 atrophy of the membrana tym- pani, 201 carcinoma, 288 caries of the temporal bone, 309 ceruminosis, 161 cholesteatoma in the tympa- num, 288 chronic adenoid dermatitis of the external auditory canal, 173 dermatitis of the external auditory canal, 170 inflammation of the Eusta- chian tube, 419 inflammation of the tympa- num, 434 nasal catarrh, 379 pharyngitis, 413 purulent inflammation of the tympanum, 245 comedones of the auricle, 143 coryza, 366 deaf-mutism, 501 ear disease, 122 eczema of the external ear, 132 enlarged tonsils, 409 enchondromata of the external ear, 144 epithelioma in the tympanum, 288 of the external ear, 147 erysipelas of the auricle, 128 erythema of the auricle, 128 exostoses in the tympanum, 291 foreign bodies in the external auditory canal, 155 fibromataof the external ear, 145 fracture of the auditory process, 150 frostbitten auricles, 130 furuncles of the external ear, 134 granular pharyngitis, 418 hemorrhages in the membrana tvmpani, 206 hyperaemia of the membrana "tympani, 197 Treatment of hyperaemia of the inter- nal ear, 480 hypertrophic pharyngitis, 414 hypertrophy of the membrana tympani, 204 inflammation of the labvrinth, 493 injuries of the external ear, 148 membrana tympani, 195 mastoid disease, 299 myringitis, 199 nasal polypi, 401 osteo-periostitis and exostosis of the external auditory canal, 183 otalgia, 208 othaematomata of the auricle, 142 paralysis of the facial nerve, 293 phlegmonous inflammation of the external auditory canal, 177 polypi in the tympanum, 283 sarcomata in the tympanum, 288 sebaceous cysts of the external ear, 143 skin diseases of the external ear, 133 tinnitus, 213 tophi of the auricle, 144 Triangle, or cone of light, 23 Trumpets, ear, 507 Tube, auscultation, 102 Tubercle of the membrana tvmpani, 206 Tumors, other, in the tympanum, 2;7 vascular, of the external ear, 140 Tuning-fork, testing the hearing bv the, 91 Tympanic artery, 23 branch of the glosso-pharyngeal nerve, 34 membrane, 20 physiology of the, 69 plexus of nerves, 35 scala, 54 Tympanum, acute inflammation of the, 215 carcinoma and sarcoma in the, 288 catarrhal inflammation of the, 316 cholesteatoma in the, 2S7 chronic inflammation of the, 339 purulent inflammation of the, 229 epithelioma in the, 288 exostoses in the, 288 facial nerve filaments in the, 35 fibromas in the, 282 lining of the, 33 526 INDEX. Tympanum, mucous membrane of the, 33 polypi in the, 282 muscles of the, 32 myxoma in the, 282 nerves of the, 34, 42 or middle ear, 19 other tumors in the, 287 polypi in the, 280 pouches in the, 22 sensitive nerves in the, 71 vessels of the, 33 walls of the, 19,24,26 U. V. Valsalva's method of inflation, 104 Vascular tumors of the external ear, 140 Veins of the cochlea, 60 of the labyrinth, 60 Vertebrates, organ of hearing in, 11 position of the otic capsule in, 12 Vertical section of the face and neck, 384 Vertigo after inflation, 106 Vessels of the Eustachian tube, 40 of the external ear, 16 of the internal ear, 60 of the membrana tympani, 23 of the tympanum, 33 Vestibular aqueduct, 45 nerve, 63 physiology of the, 74 saccules, 48 scala, 54 vessels, 60 Vestibule, membranous, physiology of the, 73 Vestibule of the internal ear, 44 Vibrations of sound, 68 theory of, 71 Voice, testing the hearing by the, 89 W. Wagner's handle and brushes, 391 Walls of the cochlea, 73 of the tympanum, 19, 24, 26 Watch, testing the hearing by the, 89 Weber-Liel's tenotome, 445 Wilde's ear specula. 85 Z. Zaufal's tubular speculum, 111 Zona arcuata, 55 denticulata, 55 pectinata, 55 Ultimate filaments of the cochlear nerve, 63 of the vestibular nerve, 63 Universal syringe, 98 Upson's tumor syringe, 402 Utriculus, 48 Uvula scissors, 414 BOERICKE & TAFEL'S ^HonicBopathic Publications.* A^ ALLEN, DR. T. F. The Encyclopedia of Pure Materia Medica; a Record of the Positive Effects of Drugs upon the Healthy Human Organism. With contributions from Dr. Richard Hughes, of England; Dr. C. Hering, of Philadelphia; Dr. Carroll Dunham, of New York; Dr. Adolph Lippe, of Philadelphia, and others. Ten vol- umes. Price, bound in cloth, $60.00 ; in half morocco or sheep, $70 00 This is the most complete and extensive work on Materia Medica ever attempted in the history of medicine—a work to which the homoeopathic practitioner may turn with the certainty of finding the whole pathogenetic record of any remedy ever used in homoeopathy, the record of which being published either in book form or in journals. The volumes average about 640 pages each. ALLEN, DR. T\ F. A General Symptom Register of the Homoe- opathic Materia Medica. By Timothy F. Allen, M.D., Author of the Encyclopedia of Pure Materia Medica. 1340 pages in one large volume. Price, in cloth, $12.00; in sheep or half morocco, $14 00 This Index to the Encyclopedia of Materia Medica is at the same time the best arranged and most complete Repertory ever attempted. Its inge- nious selection and arrangement of different kinds of type greatly facilitate its use. ANGELL, DR. H. C. 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It is this which renders his work I I le and which at the same time accounts for his occasional imperfections. We know 2 BOERICKE & TAFEL'S of no work of the kind in homoeopathic literature where the suggestions for the choice of medicines are given in a fresher or clearer manner, or in one better calculated to interest and inform the practitioner. We have only to add that the two volumes are highly credit- able to the publishers. The type is good, the paper good, and the binding excellent."— Monthly Homceopathic Review. • BELL, DR. JAMES B. The Homceopathic Therapeutics of Diarrhoea, Dysentery, Cholera, Cholera Morbus, Cholera Infantum, and all other loose evacuations of the bowels. Second edition by Drs. Bell and Laird. 275 pages. i2mo. Cloth, . . . . . . . . . . $1 50 This little book had a very large sale, and but few physicians' offices will be found with- out it The work was, without exception, very highly commended by the homceopathic press. BERJEAU, J. PH. The Homceopathic Treatment cf Syphilis, Gonorrhoea, Spermatorrhoea, and Urinary Diseases. Revised, with numerous additions, by J. H. P. Frost, M.D. 256 pages, nrao. Cloth,..........$1 50 " This work is unmistakably the production of a practical man. It is short, pithy, and contains a vast deal of sound, practical instruction. The diseases are briefly described; the directions for treatment are succinct and summary. It is a book which might with profit be consulted by all practitioners of homoeopathy."—North American Journal. BREYFOGLE, DR. W. L. Epitome of Homceopathic Medi- cines. 383 pages,........$1 25 Interleaved with writing paper. Half morocco, . . $2 25 We quote from the author's preface : "It has been my aim, throughout, to arrange in as concise form as possible, the leading symptoms of all well-established provings. To accomplish this, I have compared Lippe's Mat. Med.; the Symptomen-Codex; Jahr's Epitome; Boenninghausen's Therapeutic Pocket- Book, and Hale's New Remedies." BRYANT, DR. J. A Pocket Manual, or Repertory of Homoeo- pathic Medicine, Alphabetically and Nosologically arranged, which may be used as the Physicians' Vade-mecum, the Travellers' Medical Companion, or the Family Physician. Third edition. 352 pages. i8mo. Cloth,....... . . #1 50 BUTLER, DR. JOHN. Electricity in Surgery. Pp.112. Cloth, $1.00. These few pages are intended as a practical guide for the use of the specialist and general practitioner, and aim at showing the necessity of attaining accuracy of detail in all electro- surgical operations. The scope of the work precludes the possibility of more than cursory allusion to clinical cases, but is based almost entirely upon the author's own personal experience, and is for the most part composed of articles written from time to time for different periodicals, revised and condensed. BUTLER, Dr. JOHN. A Text-Book of Electro-Therapeutics and Electro-Surgery, for the Use of Students and General Practitioners. By John Butler, M.D., L.R.C.P.E., L.R.C.S.I., etc. Second edition, revised and enlarged. 350 pages. 8vo. Cloth, $3 °° •' Butler's work gives with exceptional thoroughness all details of the latest researches on Electricity, which powerful agent has a great future, and rightly demands our most earnest consideration. But Homoeopathia especially must hail with delight the advent from out the ranks of her apostles of a writer of John Butler's ability. His book will also find a large circle of non-homoeopathic readers, since it does not conflict with the tenets of any thera- peutic sect, and particular care has been bestowed on the technical part of electro-therapeia." —HOMQZOPATISCHE RUNDSCHAU. HOMCEOPATHIC PUBLICATIONS. 3 DAKE, DR. WM. C. Pathology and Treatment of Diphtheria. By Wm. C. Dake, M.D., of Nashville, Tenn. 55 pages. 8vo. Pa- per, ......... . 50 cts. This interesting monograph was enlarged from a paper read at the Third Annual Meeting of the Homceopathic Society of Tennessee, held at Mem- phis, September 19, 1877. It gives a report of one hundred and seventy-six cases treated during a period of eleven months. It well repays a careful perusal. DUNHAM, CARROLL, A.M., M.D. Homoeopathy the Science of Therapeutics. A collection of papers elucidating and illustrating the principles of homoeopathy. 529 pages. 8vo. Cloth, . $3 00 Half morocco, . . . . . . . . . #4 00 " After reading this work no one will attempt to justify the practice of alternation of remedies. It is simply the lazy man's expedient to escape close thinking or to cover his ignorance. The one remedy alone can be accurate and scientific; a second or third only complicates and spoils the case, and wdl inevitably ruin a good reputation. But to come to more practical matters, more than one-half of this volume is devoted to a careful analysis of various drug-provings. It teaches us Materia Medica after a new fashion, so that a fool can understand, not only the full measure of usefulness, but also the limitations which surround the drug. . . . We ought to give an illustration of his method of analysis, but space forbids. We can only urge the thoughtful and studious to obtain the book, which they will esteem as second only to the Organon in its philosophy and learning."—The American H(J.M(EOPATHIST. DUNHAM, CARROLL, A.M., M.D. Lectures on Materia Med- ica. 858 pages. 8vo. Cloth,......#5 00 Half morocco, . . . . . . . . . $6 00 . . . " Vol. I is adorned with a most perfect likeness of Dr. Dunham, upon which stranger and friend will gaze with pleasure. To one skilled in the science of physiognomy there will be seen the unmistakable impress of the great soul that looked so long and stead- fastly out of its fair windows. But our readers will be chiefly concerned with the contents of these two books. They are even better than their embellishments. They are chiefly such lectures on Materia Medica as Dr. Dunham alone knew how to write. They are pre- ceded quite naturally by introductory lectures, which he was accustomed to deliver to his classes on general therapeutics, on rules which should guide us in studying drugs, and on the therapeutic law. At the close of Vol. II we have several papers of great interest, but the most important fact of all is that we have here over fifty of our leading remedies pre- sented in a method which belonged peculiarly to the author, as one of the most successful teachers our school has yet produced. . . . Blessed will be the library they adorn, and wise the man or woman into whose mind their light shall shine."—Cincinnati Medical Advance. EATON, DR. MORTON M., on the Medical and Surgical Dis- eases of Women, with their Homceopathic Treatment. Fully illus- trated. Pp. 781. 8vo. Sheep,......#6 50 This work is received with great favor by the profession, and is com- mended by the homceopathic press as being the best and most complete work on the subject hitherto issued. "This is a large, handsome volume of 782 pages, beautifully printed on good paper, and strongly bound in leather. The illustrations are numerous and good and well bring out the anatomical relationship of the parts, and put the various dislocations before the mind very clearly indeed; in fact, almost too clearly, for he who learns thus, and then tries to carry his knowledge into practice, will feel rather disappointed at the less obliging disposi- tion of nature herself. Drawings of almost all the principal instruments are given, and the whole subject brought down to date. There is an air about this work that commends it very much to our judgment for the use of the student, and of the general practitioner, and 4 BOERICKE & TAFEL'S hence, we believe, it is destined to become the class-book in homceopathic colleges for many years to come. There is a healthy absence of the scissors and paste business. The author holds the candle of his own experience, and thus affords a reliable aid to the gynaecological path-finder in all his freshness and inexperience."—From the Homceopathic World for January, 1881. EGGERT, DR. W. The Homceopathic Therapeutics of Uterine and Vaginal Discharges. 543 pages. 8vo. Half morocco, $3 50 The author brought here together in an admirable and comprehensive arrangement everything published to date on the subject in the whole homce- opathic literature, besides embodying his own abundant personal experience. The contents, divided into eight parts, are arranged as follows: Part I. Treats on Menstruation ana Dysmenorrhcea; Part II. Menor- rhagia ; Part III. Amenorrhcea; Part IV. Abortion and Miscarriage; Part V. Metrorrhagia; Part VI. Fluor albus; Part VII. Lochia; and Part VIII. General Concomitants. No work as complete as this, on the subject, was ever before attempted, and we feel assured that it will meet with great favor by the profession. " The book is a counterpart of Bell on Diarrhoea, and Dunham on Whooping cough. Synthetics, Diagnosis and Pathology are left out as not coming within the scope of the work. The author in his preface says: Remedies and their symptoms are left out, and the symp- toms and their remedies have received sole attention—that is what the busy practitioner wants. The work is one of the essentials in a library."—American Observer. "A most exhaustive treatise, admirably arranged, covering all that is known of thera- peutics in this important department."—Homoeopathic Times. GUERNSEY, DR. H. N. The Application of the Principles and Practice of Homoeopathy to Obstetrics and the Dis- orders Peculiar to Women and Young Children. By Henry N. Guernsey, M D., Professor of Obstetrics and Diseases of Women and Children in the Homceopathic Medical College of Pennsylvania, etc., etc. With numerous Illustrations. Third edition, revised, en- larged, and greatly improved. 1004 pages. 8vo. Half morocco, $800 This standard work, with the numerous improvements and additions, is the most com- plete and comprehensive work on the subject in the English language. Of the previous editions, almost four thousand copies are in the hands of the profession, and of this third edition a goodly number have already been taken up. There are few other professional works that can boast of a like popularity, and with all new improvements and experiences diligently collected and faithfully incorporated into each successive edition, this favorite work will retain its hold on the high esteem it is held in by the profession, for years to come. It is superfluous to add that it was and is used from its first appearance as a text-book at the homoeopathic colleges. GUERNSEY, DR. E. Homceopathic Domestic Practice. With Full Descriptions of the Dose to each single Case. Containing also Chapters on Anatomy, Physiology, Hygiene, and an abridged Materia Medica. Tenth enlarged, revised, and improved edition. 653 pages. Half leather, . . .......#2 50 GUERNSEY, DR. W. E. The Traveller's Medical Repertory and Family Adviser for the Homceopathic Treatment of Acute Diseases. 36 pages. Cloth, . . . .30 cts. This little work has been arranged with a view to represent in as compact a manner as possible all the diseases—or rather disorders—which the non professional would attempt to HOMCEOPATHIC PUBLICATIONS. 5 prescribe for. it being intended only for the treatment of simple or acute diseases, or to allay the suffering in maladies of a more serious nature until a homceopathic practitioner can be summoned. HAHNEMANN, DR. S. The Lesser Writings of. Collected and Translated by R. E. Dudgeon, M.D. With a Preface and Notes by E. Marcy, M.D. With a Steel Engraving ot Hahnemann from the statue of Steinhauser. 784 pages. Half bound, . . . . $3 00 This valuable work contains a large number of Essays, of great interest to laymen as well as medical men, upon Diet, the Prevention of Diseases, Ventilation of Dwellings, etc. As many of these papers were written before the discovery of the homoeopathic theory of cure, the reader will be enabled to peruse in this volume the ideas of a gigantic intellect when directed to subjects of general and practical interest. HAHNEMANN, DR. S. Organon of the Art of Healing. By Samuel Hahnemann. "Aude Sapere." Fifth American edition, trans- • lated from the Fifth German edition, by C. Wesselhceft, M.D. 244 pages. 8vo. Cloth,........#1 75 This fifth edition of "Hahnemann Organon" has a history. So many complaints were made again and again of the incorrectness and cumbersome style of former and existing editions to the publishers, that, yielding to the pressure, they promised to destroy the plates of the fourth edition, and to bring out an entire re-translation in 1876, the* Centennial year. After due consideration, and on the warm recommendation of Dr. Constantine Hering and others, the task of making this re-translation was confided to Dr. C. Wesselhceft, and the result of years of labor is now before the profession, who will be best able themselves to judge how well he succeeded in acquit- ting himself of the difficult task. " To insure a correct rendition of the text of the author, they (the publishers) selected as his translator Dr. Conrad Wesselhceft of Boston, an educated physician in every respect, and from his youth up perfectly familiar with the English and German languages, than whom no better selection could have been made." "That he has made, as he himself de- clares, ' an entirely new and independent translation of the whole work,' a careful compari- son of the various paragraphs, notes, etc., with those contained in previous editions, gives abundant evidence; and while he has, so far as was possible, adhered strictly to the letter of Hahnemann's text, he has at the same time given a pleasantly flowing rendition that avoids the harshness of a strictly literal translation."—Hahnemannian Monthly. HALE, DR. E. M. Lectures on Diseases of the Heart. In Three Parts. Part I. Functional Disorders of the Heart. Part II. Inflamma- tory Affections of the Heart. Part III. Organic Diseases of the Heart. Second enlarged edition. 248 pages. Cloth, . . . $1 75 HALE, DR. E. M. Materia Medica and Special Therapeutics of the New Remedies. Fifth edition, revised and enlarged. In two Volumes. Vol. I. Special Symptomatology. With new Botanical and Pharmaco- logical Notes and Appendix. 1882. 746 pages. Cloth, . . $5 00 Half morocco,.........6 °° Vol. II. Special Therapeutics. With Illustrative Clinical Cases. 900 pages. Cloth,.........$5 00 Half morocco,.........$6 00 6 boericke & tafel's " Dr. Hale's work on 'New Remedies' is one both well known and much appreciated on this side of the Atlantic. For many medicines of considerable value we are indebted to his researches. In the present edition the symptoms produced by the drug investigated and those which they have been observed to cure, are separated from the clinical observations, by which the former have been confirmed. That this volume contains a very large amount of invaluable information is incontestable, and that every effort has been made to secure both fulness of detail and accuracy of statement, is apparent throughout. For these reasons we can confidently commend Dr. Hale's fourth edition of his well-known work on the ' New Remedies' to our homceopathic colleagues."—Monthly Homceopathic Review. "We do not hesitate to say that by these publications Dr. Hale rendered an inestimable service to homoeopathy, and thereby to the art of medicine. ' The school of Hahnemann in every country owes him hearty thanks for all this; and allopathy is beginning to share our gain.' The author is given credit for having in this fourth edition corrected the mistake for which the third one had been taxed rather severely, by restoring in Vol. II the ' special therapeutics,' instead of the ' characteristics ' of the third edition."—British Journal of Homceopathy. HALE, DR. E. M. The Medical, Surgical, and Hygienic Treat- ment of Diseases of Women, especially those causing Ster- ility, the Disorders and Accidents of Pregnancy, and Pain- ful and Difficult Labor. By Edwin M. Hale, M.D., Professor of Materia Medica and Therapeutics in the Chicago Homceopathic College, etc., etc. Second enlarged edition. 378 pages. 8vo. Cloth, $2 50 ' This new work embodies the observations and experience of the author during twenty- five years of active and extensive practice and is designed to supplement rather than super- cede kindred works. The arrangtjnent of the subjects treated is methodical and convenient; the introduction containing an article inserted by permission of Dr. Jackson, of Chicago, the author upon the ovular and ovulation theory of menstruation, which contains all the obser- vations of practical importance known on this subject to date. The diseases causing sterility are fully described, and the medical, surgical and hygienic treatment pointed out. The more generally 'employed medicines are enumerated, but their special or specific indications are unfortunately omitted. The general practitioner will find a great many valuable things for his daily rounds, and cannot afford to do without the book. The great reputation and ability of the author are sufficient to recommend the work, and to guarantee an appreciative reception and large sale."—Hahnemannian Monthly. HART, DR. C. P. Diseases of the Nervous System. Being a Treatise on Spasmodic, Paralytic, Neuralgic and Mental Affections. For the use of Students and Practitioners of Medicine. By Chas. Por- ter Hart, M.D , Honorary Member of the College of Physicians and Surgeons of Michigan, etc., etc., etc. Pp.409. 8vo. Cloth, $3 00 " This work supplies a need keenly felt in our school—a work which will be useful alike to the general practitioner and specialist; containing, as it does, not only a condensed compilation of the views of the best authorities on the subject treated, but also the author's own clinical experience; to which is appended the appropriate homoeopathic treatment of each disease. It is written in an easy, flowing style, at the same time there is no waste of words. ***** We consider the work a highly valuable one, bearing the evidence of hard work, considerable research and experience."—Medico-Chirurgical Quarterly. " We feel proud that in Hart's ' Diseases of the Nervous System' we have a work up to date, a work which we need not feel ashamed to put in the hands of the neurologist or alienist for critical examination, a work for which we predict a rapid sale."—North Amer- ican Journal of Homceopathy. HELMUTH, DR. W. T. A System of Surgery. Illustrated with 568 Engravings on Wood. By Wm. Tod Helmuth, M.D. Fourth edi- tion. 1000 pages. Sheep, . . . . . . . $8 50 This edition of Dr. Helmuth's great work is already in appearance a great improve- ment over the old edition, it being well printed on' fine paper, and well bound. By in- creasing the size of the page, decreasing the size of type, and setting up solid, fully one-half more printed matter is given than in the previous edition, albeit there are over 200 pages HOMOEOPATHIC PUBLICATIONS. 7 less; and while the old edition, bound in sheep, was sold at $11.50 by its publishers, this improved third edition is now furnished at £3 less, or for S8.50. The author brought the work fully up to date, and for an enumeration of some of the more important improvements, we cannot do better than to refer to Dr. Helmuth's own Preface. HEMPEL, DR. C. J., and DR. J. BEAKLEY. Homceopathic Theory and Practice. With the Homceopathic Treatment of Surgi- cal Diseases, designed for Students and Practitioners of Medicine, and as a Guide for an intelligent public generally. Fourth edition, uoo pages,...........J300 HERING, DR. C. Condensed Materia Medica. Second edition. More condensed, revised, enlarged, and improved, . . $7 00 In February, 1877, we were able to announce the completion of Hering's Condensed Materia Medica. The work, as was to be expected, was bought up with avidity by the pro- fession and already in the fall of 1878 the author set to work perfecting a second and im- proved edition. By still more condensing many of the remedies, a number of new ones could be added without much increasing the size and the price of the work. This new edition is now ready for the profession, and will be the standard work par excellence for the practitioner's daily reference. HEINIGKE, DR. CARL. Pathogenetic Outlines of Homoeo- pathic Drugs. Translated from the German by Emil Tietze, M.D., of Philadelphia. 576 pages. 8vo. Cloth, . . . . $3 50 This work, but shortly issued, is already meeting with a large sale and an appreciative reception. It differs from most works of its class in these respects : 1. That the symptomatic outlines of the various drugs are based exclusively upon the ' pathogenetic" results of provings. 2. That the anatomico-physiological arrangement of the symptoms renders easier the understanding and survey of the provings. 3. That the pathogenetic pictures drawn of most of the drugs, gives the reader a clearer idea and a more exact impression of the action of the various remedies. Each remedy is introduced with a brief account of its preparation, duration of action and antidotes. HOLCOMBE, DR. W. H. Yellow Fever and its Homceopathic Treatment,.........10 cts. HOLCOMBE, DR. W. H. What is Homceopathy? A new ex- position of a great truth. 28 pages. 8vo. Paper cover. Per dozen, $1.25,........• • 15 cts. " Prove all things, hold fast that which is good."—St. Paul. HOLCOMBE, DR. W. H. How I became a Homoeopath. 28 pages. 8vo. Paper cover. Per dozen, $1.25, . . . 15 cts. HOLCOMBE, DR. W. H. Special Report of the Homceopathic Yellow Fever Commission, ordered by the American Institute of Homoeopathy for presentation to Congress. 32 pages. 8vo. Paper. Per hundred, #4.00,........5 cts- This Report, written in Dr. Holcombe's masterly manner, is one of the best campaign documents for homceopathy. The statistics must convince the most skeptical, and every homoeopathic practitioner should feel in duty bound to aid in securing its widest possible circulation. HOMCEOPATHIC POULTRY PHYSICIAN (Poultry Veteri- narian) * or, Plain Directions for the Homceopathic Treatment of the 8 boericke & tafel's most Common Ailments of Fowls, Ducks, Geese, Turkeys and Pigeons, based on the author's large experience, and compiled from the most re- liable sources, by Dr. Fr. Schroter. Translated from the German. 84 pages. i2mo. Cloth, ....... 50 cts. We imported hundreds of copies of this work in the original German for our customers, and as it gave good satisfaction, we thought it advisable to give it an English dress, so as to make it available to the public generally. The little work sells very fast, and our readers will doubtless often have an opportunity to draw the attention of their patrons to it. HOMCEOPATHIC COOKERY, Second edition. With Additions by the Lady of an American Homceopathic Physician. Designed chiefly for the Use of such Persons as are under Homceopathic Treatment. 176 pages, .......... 50 cts. HULL'S JAHR. A New Manual of Homceopathic Practice. Edited, with Annotations and Additions, by F. G. Snelling, M.D. Sixth American edition. With an Appendix of the New Remedies, by C. J. Hempel, M.D. 2 volumes. 2076 pages, . . $9 00 The first volume, containing the symptomatology, gives the complete pathogenesis of two hundred and eighty-seven remedies, besides, a large number of new remedies are added by Dr. Hempel, in the appendix. The second volume contains an admirably arranged Re- pertory. Each chapter is accompanied by copious clinical remarks and the concomitant symptoms of the chief remedies for the malady treated of, thus imparting a mass of informa- tion, rendering the work indispensable to every student and practitioner of medicine. JAHR, DR. G. H. G. Therapeutic Guide ; the most Important Re- sults of more than Forty Years' Practice. With Personal Observations regarding the truly reliable and practically verified Curative Indications in actual cases of disease. Translated, with Notes and New Remedies, by C. J. Hempel, M.D. 546 pages,.....$3 00 " With this characteristically long title, the veteran and indefatigable Jahr gives us another volume of homoeopathies. Besides the explanation of its purport contained in the title itself, the author's preface still further sets forth its distinctive aim. It is intended, he says, as a ' guide to beginners, where I only indicate the most important and decisive points for the selection of a remedy, and where I do not offer anything but what my own individual experience, during a practice of forty years, has enabled me to verify as absolutely decisive in choosing the proper remedy. The reader will easily comprehend that, in carrying out this plan, I had rigidly to exclude all cases concerning which I had no experience of my own to offer......We are bound to say that the book itself is agreeable, chatty, and full of practical observation. It may be read straight through with interest, and referred to in the treatment of particular cases with advantage."—British Journal of Homceopathy. JAHR, DR. G. H. G. The Homoeopathic Treatment of Dis- eases of Females and Infants at the Breast. Translated from the French by C. J. Hempel, M.D. 422 pages. Half leather, $2 00 This work deserves the most careful attention on the part of homoeopathic practitioners. The diseases to which the female organism is subject are described with the most minute correctness, and the treatment is likewise indicated with a care that would seem to defy criticism. No one can fail to study this work but with profit and pleasure. INDEX to the first eighteen volumes of the North American Journal of Homceopathy. Paper,........$2 00 JONES, DR. SAMUEL A. The Grounds of Homoeopathic ' Faith. Three Lectures, delivered at the request of Matriculates of the Department of Medicine and Surgery (Old School) of the University of HOMCEOPATHIC PUBLICATIONS. 9 Michigan. By Samuel A. Jones, M.D., Professor of Materia Medica, Therapeutics, and Experimental Pathogenesy in the Homceopathic Medical College of the University of Michigan, etc., etc. 92 pages. i2mo. Cloth. Per dozen, $300; per hundred, $20.00, . 30 cts. Lecture first is on The Law of Similars; its Claim to be a Science in that it Enables Perversion. Lecture second, The Single Remedy a Necessity of Science. Lecture third, The Minimum Dose»a.n Inevitable Sequence. A fourth Lecture, on The Dynamization Theory, was to have finished the course, but was prevented by the approach of final examinations, the preparation for which left no time tor hearing evening lectures. The Lectures are issued in a convenient size for the coat-pocket; and as an earnest testi- mony to the truth, we believe they will find their way into many a homceopathic household. JOHNSON, DR. I. D. Therapeutic Key; or, Practical Guide for the Homceopathic Treatment of Acute Diseases. Tenth edition. 347 pages. Bound in linen,.......$1 75 Bound in flexible cover, . . . . . . . $2 25 This has been one of the best selling works on our shelves; more copies being in circu- lation of this than of any two other professional works put together. It is safe to say that there are but few homoeopathic practitioners in this country but have one or more copies of this little remembrancer in their possession. JOHNSON, DR. I. D. A Guide to Homceopathic Practice. De- signed for the use of Families and Private Individuals. 494 pages. Cloth, ...........$2 00 This is the latest work on Domestic Practice issued, and the well and favorably known author has surpassed himself. In his book fifty-six remedies are introduced for internal ap- plication, and four for external use. The work consists of two parts. Part I is subdivided into seventeen chapters, each being devoted to a special part of the body, or to a peculiar class of disease. Part II contains a short and concise Materia Medica, i. e., gives the symptoms peculiar to each remedy. The whole is carefully written with a view of avoiding technical terms as much as possible, thus insuring its comprehension by any person of ordi- nary intelligence. A complete set of remedies in vials holding over fifty doses each, is fur- nished for $7, or in vials holding over one hundred doses each for $10, or book and case complete for $9 or #12 respectively. Address orders to Boericke & Tafel's Pharmacies at New York, Philadelphia, Baltimore, Chicago, New Orleans, or San Francisco. JOSLIN, DR. B. F. Principles of Homceopathy. In a Series of Lectures. 185 pages. i2mo. Cloth, .... 60 cts. KREUSSLER, DR. E. The Homceopathic Treatment of Acute and Chronic Diseases. Translated from the German, with Im- portant Additions and Revisions, by C. J. Hempel, M.D. 190 pages, ....■••••• 00 cts. The author is a practitioner of great experience and acknowledged talent. This work is distinguished by concise brevity and lucid simplicity in the description of the various diseases that usually come under the observation of physicians, and the remedies for the various symptoms are carefully indicated. Dr. Hempel has interspersed it with a number of highly useful and interesting notes, which cannot fail to enhance die value of this work to American physicians. LAURIE and McCLATCHEY. The Homceopathic Domestic Medicine. By Joseph Laurie, M.D. Ninth American, from the Twenty-first English edition. Edited and Revised, with Numerous and Important Additions, and the Introduction of the New Remedies. By R. J. McClatchey, M.D. 1044 pages. 8vo. Half morocco, #500 " We do not hesitate to indorse the claims made by the publishers, that this is the most complete, clear, and comprehensive treatise on the domestic homoeopathic treatment of dis- 10 BOERICKE & TAFEL'S eases extant. This handsome volume of nearly eleven hundred pages is divided into six parts. Part one is introductory, and is almost faultless. It gives the most complete and exact directions for the maintenance of health and of the method of investigating the con- dition of the sick, and of discriminating between different diseases. It is written in the most lucid style and is above all things wonderfully free from technicalities. Part two treats of symptoms character, distinctions, and treatment of general ^'seases, together with a chapter on casualties. Part three takes up diseases peculiar to-women. Part four is devoted to the disorders of infancy and childhood. Part five gives the characteristic symptoms of the medicines referred to in the body of the work, while Part six introduces the repertory."—Hahnemannian Monthly. ' Of the usefulness of this work in cases where no educated homoeopathic physician is within reach, there can be no question. There is no doubt that domestic homceopathy has done much to make the science known; it has also saved lives in emergencies. The prac- tice has never been so well presented to the public as in this excellent volume."—New Eng. Med. Gazette. A complete set of remedies of one hundred and four vials, containing over fifty doses each, is furnished for $12, put up in an elegant mahogany case. A similar set in vials con- taining over one hundred doses each, is furnished for $18. or book and case complete for $17 or $23 respectively. Address orders to Boericke & Tafel's Pharmacies at New York, Philadelphia, Baltimore, Chicago, New Orleans, or San Francisco. LILIENTHAL, DR. S. Homceopathic Therapeutics. By S. Lilienthal, M.D., Editor of North American Journal of Homoeo- pathy, Professor of Clinical Medicine and Psychology in the New York Homceopathic Medical College, and Professor of Theory and Practice in the New York College Hospital for Women, etc. Second edition. 8vo,...........$5 00 Half morocco, . . . . . . . . . $6 00 " Certainly no one in our ranks is so well qualified for this work as he who has done it, and in considering the work done, we must have a true conception of the proper sphere of such a work. For the fresh graduate, this book will be invaluable, and to all such we un- hesitatingly and very earnestly commend it. To the older one, who says he has no use for this book, we have nothing to say. He is a good one to avoid when well; and to dread when ill. We also hope that he is severely an unicum."—Prof. Sam. A. Jones in Ameri- can Homozopathist. " . . . It is an extraordinary useful book, and those who add it to their library will never feel regret, for we are not saying too much in pronouncing it the best WORK ON therapeutics in homceopathic (or any other) literature. With this under one elbow, and Hering's or Allen's Materia Medica under the other, the careful homoeopathic practitioner can refute Niemayer's too confident assertion, ' I declare it idle to hope for a time when a medical prescription should be the simple resultant of known quantities.' Doctor, by all means buy Lilienthal's Homceopathic Therapeutics. It contains a mine of wealth."— Prof. Chas. Gatchel in Ibid. LUTZE, DR. A. Manual of Homceopathic Theory and Prac- tice. Designed for the use of Physicians and Families. Translated from the German, with additions by C. J. Hempel, M.D. From the sixtieth thousand of the German edition. 750 pages. 8vo. Half leather, . . . . . . . . . $2 50 This work, from the pen of the late Dr. Lutze, has the largest circulation of any homoeo- pathic work in Germany, no less than sixty thousand copies having been sold. The intro- duction, occupying over fifty pages, contains the question of dose, and rules for examining the patient, and diet; the next sixty pages contain a condensed pathogenesis of the remedies treated of in the work; the description and treatment of diseases occupy four hundred and eighteen pages, and the whole concludes with one hundred and seventy-three pages of reper- tory and a copious index, thus forming a concise and complete work on theory and practice. MALAN, H. Family Guide to the Administration of Homoeo- pathic Remedies. 112 pages. 321110. Cloth, . . 30 cts. homceopathic publications. 11 MANUAL OF HOMCEOPATHIC VETERINARY PRAC- TICE. Designed for all kinds of Domestic Animals and Fowls, pre- scribing their proper treatment when injured or diseased, and their par- ticular care and general management in health. Second and enlarged edition. 684 pages. 8vo. Half morocco, . . . $$ 00 " In order to rightly estimate the value and comprehensiveness of this great work, the reader should compare it, as we have done, with the best of those already before the public. In size, fulness and practical value it is head and shoulders above the very best of them, while in many most important disorders it is far superior to them altogether, containing, as it does, recent forms of disease of which they make no mention."—Hahnemannian Monthly. MARSDEN, DR. J. H. Handbook of Practical Midwifery, with full instructions for the Homoeopathic Treatment of the Diseases of Pregnancy, and the Accidents and Diseases in- cident to Labor and the Puerperal State. By J. H. Marsden, A.M., M.D. 315 pages. Cloth,.....$2 25 " It is seldom we have perused a text-book with such entire satisfaction as this. The author has certainly succeeded in his design >f furnishing the student and young practitioner, within as narrow limits as possible, all necessary instruction-in practical midwifery. The work shows on every page extended research and thorough practical knowledge. The style is clear, the array of facts unique, and the deductions judicious and practical. We are par- ticularly pleased with his discussion on the management of labor, and the management of mother and child immediately after the birth, but much is left open to the common-sense and practical judgment of the attendant in peculiar and individual cases."—Homeopathic Times. MOHR, DR. CHARLES. The Incompatible Remedies of the Homoeopathic Materia Medica. By Charles Mohr, M.D., Lec- turer on Homceopathic Pharmaceutics, Hahnemann Medical College, Philadelphia. (A paper read before the Homceopathic Medical Society of the County of Philadelphia.) Pamphlet, in cover, . . 10 cts. This is an interesting paper, which will well repay perusal and study. It gives a list of fifty-seven remedies and their incompatibles, diligently collated from the best-known sources. MORGAN, DR. W. The Text-book for Domestic Practice, being plain and concise directions for the Administration of Homoeo- pathic Medicines in Simple Ailments. 191 pages. 32mo. Cloth, 50 cts. This is a concise and short treatise on the most common ailments, printed in convenient size for the pocket; a veritable traveller's companion. A complete set of thirty remedies, in vials holding over fifty doses each, is furnished for $4.50, in stout mahogany case; or same set in vials holding over one hundred doses each, for S6.50; or book and case complete for $5 or $7 respectively. Address orders to Boericke & Tafel's Pharmacies, New York, Philadelphia, Baltimore, Chicago, New Orleans, or San Francisco. MURE, DR. B. Materia Medica; or, Provings of the Principal Ani- mal and Vegetable Poisons of the Brazilian Empire, and their Applica- tion in the Treatment of Diseases. Translated from the French, and arranged according to Hahnemann's Method, by C. J. Hempel, M.D. 220 pages. i2mo. Cloth,.......$1 00 This volume, from the pen of the celebrated Dr. Mure, of Rio Janeiro contains the pathogenesis of thirty-two remedies, a number of which have been used in general practice ever since the appearance of the work. A faithful wood-cut of the plant or animal treated of accompanies each pathogenesis. 12 boericke & tafel's NEIDHARD, DR. C. On the Universality of the Homceopathic Law of Cure,......' . . .30 cts. NEW PROVINGS of Cistus Canadensis, Cobaltum, Zingiber and Mer- curius Proto-Ipdatus. 96 pages. Paper, . . . • 75 cts. NORTH AMERICAN JOURNAL OF HOMCEOPATHY. Pub- lished quarterly on the first days of August, November, February and May. Edited by S. Lilienthal, M.D. Vol. X, New Series, com- menced in August, 1879. Subscription price per volume, in advance, $4 00 ■ Complete sets of the first twenty-seven volumes, in half morocco bind- ing, including Index to the first eighteen volumes, . . $90 00 Index to the first eighteen volumes, . . . . $2 00 OEHME, DR. F. G. Therapeutics of Diphtheritis. A Compila- tion and Critical Review of the German and American Homceopathic Literature. Second enlarged edition. 84 pages. Cloth, . 60 cts. " This pamphlet contains the best compilation of reliable testimony relative to diph- theria that has appeared from the pen of any member of our school."—Ohio Medical and Surgical Reporter. " Although he claims nothing more for his book than that it is a compilation, with ' critical reviews,' he has done his work so well and thoroughly as to merit all praise."— Hahnemannian Monthly. " Dr. Oehme's little book will be worth many times its price to any one who has to treat this terrible disease."—British Journal of Homoeopathy. "It is the best monograph we have yet seen on diphtheria."—Cincinnati Medical Advance. PETERS, DR. J. C. A Complete Treatise on Headaches and Diseases of the Head. I. The Nature and Treatment of Head- aches. II. The Nature and Treatment of Apoplexy. III. The Nature and Treatment of Mental Derangement. IV. The Nature and Treat- ment of Irritation, Congestion, and Inflammation of the Brain and its Membranes. Based on Th. J. Riickert's Clinical Experiences in Homceopathy. 586 pages. Half leather, . .x . . $2 50 PETERS, DR. J. C. A Treatise on Apoplexy. With an Appendix on Softening of the Brain and Paralysis. Based on Th. J. Riickert's Clinical Experiences in Homceopathy. 164 pages. 8vo. Cloth, $1 00 PETERS, DR. J. C. The Diseases of Females and Married Females. Second edition. Two parts in one volume. 356 pages. Cloth, . . . ........$1 50 PETERS, DR. J. C. A Treatise on the Principal Diseases of the Eyes. Based on Th. J. Riickert's Clinical Experiences in Ho- mceopathy. 291 pages. 8vo. Cloth, . . . . . |i go PETERS, DR. J. C. A Treatise on the Inflammatory and Or- ganic Diseases of the Brain. Based on Th. J. Riickert's Clinical Experiences in Homoeopathy. 156 pages. 8vo. Cloth, . |i 00 HOMCEOPATHIC PUBLICATIONS. 13 PETERS, DR. J. C. A Treatise on Nervous Derangement and Mental Disorders. Based on Th. J. Riickert's Clinical Experiences in Homceopathy. 104 pages. 8vo. Cloth, . . . $1 00 PHYSICIAN'S VISITING LIST AND POCKET REPER- TORY, THE HOMCEOPATHIC. By Robert Faulkner, M.D. Second edition, . . . . . . . . . $2 00 " Dr. Faulkner's Visiting List is well adapted to render the details of daily work more perfectly recorded than any book prepared for the same purpose with which we have hitherto met. It comjjnences with Almanacs for 1877 ar>d 1878; then follow an obstetric calendar; a list of Poisons and their Antidotes; an account of Marshall Hall's ready method in As- phyxia ; a Repertory of between sixty and seventy pages; pages marked for general memo- randa; Vaccination Records; Record of Deaths; Nurses; Friends and others; Obstetric Record, which is especially complete; and finally pages ruled to keep notes of daily visits, and also spaces marked for name of the medicine ordered on each day. The plan devised is so simple, so efficient, and so clear, that we illustrate it on a scale just half the size of the original (here follows illustration). The list is not divided into special months, but its use may be as easily commenced in the middle of the year as at the beginning. We heartily recommend Faulkner's List to our colleagues who may be now making preparations for the duties of 1878."—Monthly Homoeopathic Review, London. RAUE, DR. C. G. Special Pathology and Diagnosis, with Therapeutic Hints. 1072 pages. 8vo. Half morocco. Second edition, ,. . . . . . . . . . I7 00 This standard work is used as a textbook in all our colleges, and is found in almost every physician's library. An especially commendable feature is that it contains the application of nearly all the new remedies contained in Dr. Hale's work on Materia Medica. REIL, DR. A. ACONITE, Monograph on, its Therapeutic and Physiological Effects, together with its Uses and Accurate Statements, derived from the various Sources of Medical Literature. By A. Reil, M.D. Translated from the German by H. B. Millard, M.D. Prize essay. 168 pages, . . .68 cts. "This Monograph, probably the best which has ever been published upon the subject, has been translated and given to the public in English, by Dr. Millard, of New York. Apart from the intrinsic value of the work, which is well-known to all medical German scholars, the translation of it has been completed in the most thorough and painstaking way; and all the Latin and Greek quotations have been carefully rendered into English. The book itself is a work of great merit, thoroughly exhausting the whole range of the subject. To obtain a thorough view of the spirit of the action of the drug, we can recommend no better work."—North American Journal. RUDDOCK, DR. Principles, Practice, and Progress of Homoe- opathy. 5 cts.; per hundred, $3 ; per thousand, . . $25 00 RUSH, DR. JOHN. Veterinary Surgeon. The Handbook to Vet- erinary Homceopathy; or, the Homceopathic Treatment of Horses, Cattle, Sheep, Dogs, and Swine. From the London edition. With numerous additions from the Seventh German edition of Dr. F. E. Gunther's " Homoeopathic Veterinary." Translated by J. F. Sheer, M.D. 150 pages. i8mo. Cloth,.....50 cts. SCHAEFER, J. C. New Manual of Homceopathic Veterinary Medicine. An easy and comprehensive arrangement of Diseases, adapted to the use of every owner of Domestic Animals, and especially designed for the Farmer living out of the reach of medical advice, and showing him the way of treating his sick Horses, Cattle, Sheep, Swine* 14 boericke & tafel's and Dogs, in the most simple, expeditious, safe, and cheap manner. Translated from the German, with numerous Additions from other Veterinary Manuals, by C. J. Hempel, M.D. 321 pages. 8vo. Cloth, . . . ........ $2 00 SCHWABE, DR. WILLMAR. Pharmacopoefa Homoeopathica Polyglottica. Second edition. Cloth, . . . . I3 00 SHARP'S TRACTS ON HOMCEOPATHY, each, . . 5 cts. Per hundred, . . . . . . . . . $3 00 No. 1. What is Homceopathy? " No. 7. The Principles of Homoeopathy. No. 2. The Defence of Homoeopathy. No. 8. Controversy on " No. 3. The Truth of " No. 9. Remedies of " No. 4. The small Doses of " No. 10. Provings of " No. 5. The Difficulties of " No. 11. Single Medicines of " No. 6. Advantages of " No. 12. Common-sense of " SHARP'S TRACTS. Complete set of Twelve Numbers, . 50 cts. Bound,..........75 cts. SMALL, DR. A. E. Manual of Homoeopathic Practice, for the use of Families and Private Individuals. Fifteenth enlarged edition. 831 pages. 8vo. Half leather,......$2 50 SMALL, DR. A. E. Manual of Homoeopathic Practice. Trans- lated into German by C. J. Hempel, M.D. Eleventh edition. 643 pages. 8vo. Cloth,........$2 50 SMALL, DR. A. E. Diseases of the Nervous System, to which is added a Treatise on the Diseases of the Skin, by Dr. C. E. Tooth- aker. 216 pages. 8vo. Cloth,.....#1 00 This treatise is from the pen of the distinguished author of the well-known and highly popular work entitled, " Small's Domestic Practice." It contains an elaborate description of the diseases of the nervous system, together with a full statement of the remedies which have been used with beneficial effect in the treatment of these disorders. STAPF, DR. E. Additions to the Materia Medica Pura. Trans- lated by C. J. Hempel, M.D. 292 pages. 8vo. Cloth, . $1 50 This work is an indispensable appendix to Hahnemann's Materia Medica Pura. Every remedy is accompanied with extensive and most interesting clinical remarks, and a variety of cases illustrative of its therapeutical uses. VERDI, DR. T. S. Maternity; a Popular Treatise for Young Wives and Mothers. By Tullio Suzzara Verdi, A.M., M.D., of Washington, D. C. 450 pages. i2mo. Cloth, . . . ^00 " No one needs instruction more than a young mother, and the directions given by Dr Verdi in this work are such as I should take great pleasure in recommending to all the young mothers, and some of the old ones, in the range of my practice."—George E Shipman M.D., Chicago, 111. "Dr. Verdi's book is replete with useful suggestions for wives and mothers, and his medical instructions for home use accord with the maxims of my best experience in prac- tice."—John F. Gray, M.D., New York City. v VERDI, DR. T. S. Mothers and Daughters ; Practical Studies for the Conservation of the Health of Girls. By Tullio Suzzara Verdi, A.M,M.D. 287 pages, nmo. Cloth, . . . . $1 50 homceopathic publications. 15 "The people, and especially the women, need enlightening on many points connected with their physical life, and the time is fast approaching when it will no longer be thought singular or ' Yankeeish' that a woman should be instructed in regard to her sexuality, its or- gans and their functions. . . . Dr. Verdi is doing a good work in writing such books, and we trust he will continue in the course he has adopted of educating the mother and daughters. The book is handsomely presented. It is printed with good type on fine and is neatly and substantially bound."—Hahnemannian Monthly. U^^J I VON TAGEN. Biliary Calculi, Perineorrhaphy, Hospital Gan- grene, and its Kindred Diseases. 154 pages. 8vo. Cloth, $1 25 " VoriT||gen was an industrious worker, a close observer, an able writer. The essays before Is beatfthe marks of this. They are written in an easy, flowing, graceful style, and are full of jUiuable suggestions. While the essay on perineorrhaphy is mainly of interest to the surgeon, the other essays concern the general practitioner. They are exhaustive and abound in good things. The author is especially emphatic in recommending the use of bro- mine in the treatment of hospital gangrene, and furnishes striking clinical evidence in sup- port of his recommendation. "The book forms a neat volume of 150 pages, and is well worthy of careful study."— Medical Counselor. WILLIAMSON, DR. W. Diseases of Females and Childr^j^fc and their Homceopathic Treatment. Third enlarged edfffl^^ 256 pages. i2mo. Cloth, . . . . . • . $1 00 This work contains a short treatise on the homceopathic treatment of the diseases of fe- males and children, the conduct to be observed during pregnancy, labor, and confinement, and directions for the management of new-born infants. WINSLOW, DR. W. H. The Human Ear and Its Diseases. A Practical Treatise upon the Examination, Recognition, and Treat- ment of Affections of the Ear and Associate Parts, Prepared for the In- struction of Students and the Guidance of Physicians. By W. H. Win- slow, M.D., Ph.D., Oculist and Aurist to the Fittsburg Homceopathic Hospital, etc., etc., with one hundred and thirty-eight illustrations. Boericke & Tafel: New York and Philadelphia. Pp. 526. 8vo. Cloth,...........$4 5° "... We hail with pleasure the advent of this work. There is perhaps no branch in the science of medicine in which there has been so little advance as in that of otology. Our author has treated his subject very systematically, giving first the anatomy, then the physiology, as at present understood, methods of examination, morbid changes and injuries, and finally the therapeutics. This last is of especial value to us, as our provings are singu- larly deficient in reference to symptoms of the ear. . . . This book is a move in ihe right direction, and we earnestly hope it will prove a stimulus for other specialists of our school."—New England Medical Gazette. «... Moreover, he has literally crammed the work with thoughts and suggestions of a practical kind, such as could only be the outgrowth of a large personal experience and long-continued habits of close and careful observation. . . . The work is thoroughly practical throughout; theories are left iu the background, and the hard facts of the business of the otologist are portrayed with a distinctness and force which characterize all the writings of this author.—Hahnemannian Monthly. WORCESTER, DR. S. Repertory to the Modalities. In their Relations to Temperature, Air, Water, Winds, Weather an^ Seasons. Based mainly upon Hering's Condensed Materia Medica, with additions from Allen, Lippe, and Hale. Compiled and arranged by Samuel Worcester, M.D, Salem, Mass., Lecturer on Insanity and its Jurisprudence at Boston University School of Medicine, etc., etc. 1880. 160 pages. i2mo. Cloth, . . . <\» • ^ 2S 16 BOERICKE & TAFEL'S HOMCEOPATHIC publications. " This ' Repertory to the Modalities' is indeed a most useful undertaking, and will, without question, be a material aid to rapid and sound prescribing where there are promi- nent modalities. The first chapter treats of the sun and its effects, both beneficial and hurt- ful, and we see at a glance that Strontium carb., Anacardium, Conium mac, and Kali bich. are iikely to be useful to patients who like basking in the sun. No doubt many of these mo^^^ies are more or less fanciful; still a great many of them are real and of vast clinical ranjj^P " The book is nicely printed on good paper, and strongly bound. It contains only 160 pages. We predict that it will meet with a steady, long-continued sale, and in the course of time be found on the tables of most of those careful and conscientious prescribers who admit the philosophical value of (for instance) lunar aggravations, effects of thunder-storms, etc. And who, being without the priggishness of mere brute science, does not rjj^-lj' >M(EO- pathic World. WORCESTER, DR. S. Insanity and Its Treatment. Lectures on the Treatment of Insanity and Kindred Nervous Diseases. By Samuel Worcester, M.D., Salem, Mass. Lecturer on Insanity, Ner- vous Diseases and Dermatology, at Boston University School of Medi- cine, etc., etc.,.........$3 5° ^^^J)r. Worcester was for a number of years assistant physician of the Butler ^BSpitaf for the Insane, at Providence, R. I., and was appointed shortly after as Lecturer on Insanity and Nervous Diseases to the Boston University School of Medicine. The work, comprising nearly five hundred pages, will be welcomed by every homceopathic practitioner, for every physician is called upon sooner or later to undertake the treatment of cases of insanity among his patrons' families, inasmuch as very many are loth to deliver any afflicted member to a public institution without having first exhausted all means within their power to effect a cure, and the family physician naturally is the first to be put in charge of the case. It is, therefore, of paramount importance that every homoeopathic practitioner's library should contakt such an indispensa- ble work. " The basis of Dr. Worcester's work was a course of lectures delivered before the senior students of the Boston University School of Medicine. As now presented with some altera- tions and additions, it makes a very excellent text-book for sfudents and practitioners. Dr. Worcester has drawn very largely upon standard authorities and his own experience, which has not been small. In the direction of homceopathic treatment, he has received valuable assistance from Drs. Talcott and Butler, of the New York State Insane Asylum. It is not, nor does it pretend to be, an exhaustive work; but as a well-digested summary of our present knowledge of insanity, we feel sure that it will give satisfaction. We cordially recommend it."—New England Medical Gazette. JUST ISSUED! THE AMERICAN HOMCEOPATHIC PHARMACOPOEIA. Compiled and Published by Boericke & Tafel. Pp. 523, 8vo. Cloth, $3.50. No physician, busy or otherwise, can afford to neglect a correct knowledge of the forms and preparations of his armament against disease. This knowledge is as necessary in con- trolling legitimate operations on part of the pharmacist, as in preparing remedies individually. In point of general information and especially of minute and unmistakable directions, the work stands alone apiong the recent publications on this subject. 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