LATE CONTRIBUTIONS 
TO 
AURAL SURGERY. 
BY 
CLARENCE J. BLAKE, M.I). 
BOSTON. 
READ (AT THE ANNUAL MEETING OF THE MASS. MED.SOC.) MAY -’4, 1870. 
BOSTON: 
PRINTED BY DAVID CLAPP & SON 334 WASHINGTON ST. 
1 8 7 0. LATE CONTRIBUTIONS 
TO 
ATJEAL STJRGEEY. 
BY 
CLARENCE J. BLAKE, M.D. 
BOSTON. 
READ (AT TIIE ANNUAL MEETING OF THE 31 ASS. MED. SOC.) MAY 24,1870. 
BOSTON 
PRINTED BY DAVID CLAPP & SON 334 WASHINGTON ST. 
18 7 0. PREFATORY NOTE. 
It has been the writer’s intention to give a short summary 
of improvements in instruments for the diagnosis and treat- 
ment of diseases of the ear during the last few years. So 
much has been done in this direction, that more space might 
have been advantageously occupied in its consideration, while 
to record the advances in the knowledge of the Anatomy, 
Physiology and Pathology of the ear for the same period of 
time, would require the compilation of a voluminous work’ 
far exceeding the limits of the following article. 
20 Beacon Street, 
Sept. 1, 1870'. LATE CONTRIBUTIONS TO AURAL SURGERY. 
The principal subject of this paper is one which has, as 
yet, received comparatively little general attention in this 
country. 
The treatment of diseases of the ear, aside from general 
practice, has had few advocates, while the study of the sub- 
ject has hardly kept pace with that of other branches of 
surgery, and it is only very lately that opportunities for 
instruction in otology, and for clinical study, have been 
afforded by our medical schools, and that we have had suit- 
able text books for the use of students. The appointments 
of qualified lecturers in the New-York and Philadelphia 
Hospitals, and in the Harvard Medical School, have sup- 
plied the former, and the revised edition of Toynbee, and 
Dr. lioosa’s translation of v. Troltsch, the latter want. 
Aural surgery, or the surgical treatment of affections of 
the ear, considered as a separate branch of the general 
science, is of very recent growth. Thirty years ago, the 
knowledge of the pathology and treatment of diseases of 
the car was very limited, and to-day it is far behind those 
other departments of medicine which have received especial 
attention. 
This is the more surprising, as the organ implicated plays 
so important a part in our daily life, and is the channel 
through which we receive many of the impressions which 
form and mould the character. As a special sense, hearing 6 
LATE CONTRIBUTIONS TO AURAL SURGERY. 
ranks only second to sight in importance, and a loss of it 
entails to a great degree the loss of everything that serves 
to make life useful and enjoyable. 
The rarity of affections of the ear cannot have been the 
ground for the neglect of surgical interference in their treat- 
ment ; this is to be traced rather to the situation of the more 
important parts of the organ, at the termination of a long 
narrow canal and in close relation to so vital a structure as 
the brain; to the delicacy of the functional apparatus of 
hearing, and to the fact that diseases of the ear are by no 
means so patent as those of the eye for instance, where a 
slight functional disturbance excites immediate attention and 
calls for speedy relief. 
Until Toynbee opened the way for a more thorough study 
by numerous and careful observations upon the pathology of 
diseases of the ear, the general treatment of this class of af- 
fections was for the most part empirical, and the surgery was 
almost entirely confined to the removal of foreign bodies 
from the meatus, and operations upon the auricle.* 
Contemporaneously with Toynbee, Wilde of Dublin con- 
tributed largely towards increasing the knowledge of this 
subject, by founding an aural clinic and instituting careful 
examinations of his cases, and so aided in laying the founda- 
tions of the future science of otology. The labors of Toyn- 
bee and Wilde gave an impetus to scientific investigation 
on the continent, and in the large universities numerous 
observers turned their attention to a field which had long 
been culpably neglected, and which, as they advanced, they 
found to promise a rich harvest. Nor has this promise been 
otherwise than fulfilled, for now almost every day brings 
the news of some further discovery in the anatomy or physi- 
ology of the organ of hearing, some further contribution to 
* The illustrations in most of the older works upon aural practice are con- 
fined principally to different forms of the car trumpet. LATE CONTRIBUTIONS TO AURAL SURGERY. 
7 
our knowledge of the pathology of its diseases, or the gratify- 
ing assurance that the list of so-called incurable affections 
has been still further diminished. Up to within a few years, 
the only methods of examining the ear were by means of a 
probe, or by placing the patient in such a position that sun- 
light or the light of a lamp should shine into the .meatus. 
The use of the probe was obviously objectionable, and that 
the simple illumination employed gave but an imperfect idea 
of the condition of the membrana tympani is shown in the 
illustrations of some of the earlier authors.* 
Kramer and Itard employed a bi-valve speculum for the 
purpose of dilating the meatus and concentrating the light 
upon the membrana tympani; this instrument is still in gen- 
eral use, but is by no means so efficient as the specula of 
Toynbee, Gruber, v. Trbltsch and Politzer, which are rap- 
idly taking its place. In using Kramer’s bi-valve speculum, 
the vision is obstructed by the hairs which project through 
the openings between the valves, and, moreofer, in the 
anxiety to obtain a clear view, the observer may forget the 
delicacy of the integument lining the meatus, and exert a 
presure liable to excite inflammation. 
Gruber the elder, of Vienna, first employed a simple con- 
ical tube of metal in place of Kramer’s instrument, and the 
specula since constructed are merely modifications of this. 
Politzer has retained the form of the original almost exact- 
ly, but has substituted hard rubber for metal, on the grounds 
of cheapness and lightness ; the dark ground throws out the 
coloring of the membrana tympani more distinctly, and it is 
not necessary to warm the instrument before introducing it, 
as is often required in the case of the metal tubes. 
It was not till specula had been some time in use that any 
change was made in the method of illumination. 
* Compare Frank’s Ohrenhcilkunde, p. 297. LATE CONTRIBUTIONS TO AURAL SURGERY. 
In 1855, v. Troltsch devised a concave mirror, for the 
purpose of reflecting natural or artificial light, and concen- 
trating it within the speculum. The orifice in the centre 
of the mirror is for the convenience of the surgeon, the eye 
being brought in a direct line with the focal point. This 
mirror, though original with v. Troltsch, had been suggest- 
ed by a Westphalian surgeon—Dr. Hoffman—some fourteen 
years previously, but had not received the attention which it 
merited. 
Still earlier, in 1834 namely, Bonnafont had construct- 
ed a tubular reflector to be used with Kramers speculum. 
It consisted of a copper tube 20 c.m. long, and 15 m.m. in 
diameter, containing three lenses. Towards the lower end, 
and placed diagonally across the tube, was a centrally per- 
forated mirror to receive the light concentrated upon it from 
a funnel-shaped cylinder, placed at right angles to the tube, 
and reflect it into the meatus. This instrument of Bonna- 
font’s has served as the model for all of that class of reflec- 
tors receiving the light from a direction at a right angle to 
the long axis of the instrument. 
Of the modifications of Bonnafont’s reflector, Leiter’s and 
Hinton’s are perhaps the best. The one made by Leiter, 
of Vienna, is very simple in its construction; it is of hard 
rubber, dispenses with the funnel-shaped reflector, and can 
be fitted at its lower end with specula of different sizes. 
The other, designed by Mr. Hinton, of London, is a very 
elegant instrument; with it two persons are enabled to make 
an examination at the same time, and it is therefore valuable 
for purposes of demonstration. 
Since the first attempts at obtaining a clear illumination 
of the membrana tympani, the idea of facilitating the exami- 
nation of that structure by magnifying has been a favorite 
one with otologists. The instrument of Mr. Hinton does 
this to a slight degree, and Weber, of Berlin, has construct- LATE CONTRIBUTIONS TO AURAL SURGERY. 
9 
cd a lens speculum with this object in view. The speculum 
is fastened at one end of a metal frame, and the reflector at 
the other, the lens being placed just in front of the mouth 
of the speculum. Aside from the difficulty of adjusting the 
lens, the instrument, taken as a whole, is clumsy in con- 
struction, and requires considerable experience in its use. 
All of*the tubular reflectors and lens specula serve only 
for examination, and are of no immediate use when we come 
to operate upon the membrana tympani or within the middle 
ear. In this case we may employ either the direct rays of 
the sun, or artificial light, or the concave mirror attached to 
a spectacle frame or to a band passing around the head, or 
the instrument of Mr. Ritchie, to which I wish to draw 
especial attention. 
In all operations within the ear, a clear and steady illumi- 
nation is of the first importance. Where direct light of any 
kind is employed, a difficulty presents itself in that the ear 
to be operated upon, being towards the source from whence 
the light comes, the operator must so place himself that he 
may obtain an unobstructed view, and still not cast a shadow 
upon the field of operation ; and this is by no means an easy 
matter. The concave reflector obviates this difficulty to a 
certain extent, but not entirely. The light must be reflected 
from the mirror held in the hand or fixed upon the head in 
the manner described, and the hand of the operator coming 
between the mirror and the mouth of the speculum, neces- 
sarily casts a shadow. In addition to following the point of 
his instrument, the surgeon must give a due consideration to 
the illumination, and keep his head and the mirror steadily in 
proper position ; and, moreover, in order to get the clearest 
view, it is necessary to look through the orifice in the centre 
of the mirror, so that only one eye can be used : the natural 
residt is that the stereoscopic effect is lost, and it is very dif- 
ficult to estimate the distance between the point of the instru- LATE CONTRIBUTIONS TO AURAL SURGERY. 
ment and the eye.* Dr. Edward II. Clarke employs a 
mirror attached to a stand by a universal joint, for reflect- 
ing sunlight from a window into the room, and then by 
means of a lens of about two inches focus throws the li<dit 
© 
through a silver speculum into the meatus. By this means 
the degree of illumination can be very easily regulated, and 
a strong light can be thrown at will upon any piyt of the 
membrana tympani which it is desired to examine. 
For the sake of dispensing with the reflector, any attempt 
to bring the light between the operator and the patient would 
be useless ; but to bring the light from one side and reflect it 
over the rim of the speculum, leaving the operator a clear 
field, and relieving him of the care of managing the illumi- 
nation, would greatly facilitate the performance of the more 
delicate operations upon and within the membrana tympani, 
especially those requiring time as well as care. On stating 
the requirements of the case to Mr. Edward S. Ritchie of 
this city, one of the ablest mechanicians in the country, he 
devised the instrument to which I have given his name, and 
which, while exceedingly simple in its construction, perfect- 
ly fulfils the purpose for which it was intended. 
It consists of a hand rubber specu- 
lum (Politzer’s) of the largest size, 
fitted with a metallic rim, to which 
is attached a revolving prism and 
an arm, bearing at its outer end a 
lens of about an inch focus ; this arm 
is moveable, but sufficiently firm to 
remain fixed at any angle at which 
it is placed. The prism is just 
within the focal distance of the lens, 
* In the Monatsfthrift fur Ohrcnheilkunde, December, 1869, Dr. DeRossi, of 
Genoa, under the title “L’Otoscope binoculaire,” describes a concave reflector 
constructed on the principle of the binocular ophthalmoscope. LATE CONTRIBUTIONS TO AURAL SURGERY. 
and its incident face is armed with a small metal shield, hav- 
ing an opening in the centre corresponding in its short di- 
ameter to the diameter of the pencil of light falling upon it 
from the lens. 
The advantage of the 
prism over a mirror or 
other reflecting surface 
is, that we have almost 
total reflection, and but 
little of the light concen- 
trated upon the prism by 
the lens is lost. 
In operating, an assis- 
tant is required to draw the auricle upward and backward, 
and keep the speculum in position, with the pencil of light 
upon the opening in the shield of the prism. It is not 
claimed for this instrument that it at all supersedes the head 
mirror of v. Trbltsch, but it is certainly of great advantage 
in the more complicated operations, where a steady and uni- 
form illumination is indispensable. The instrument, as a 
whole, weighs only about one hundred and fifty grains, and 
can be made much lighter; so that when once firmly insert- 
ed in the meatus, it remains in position, and there is no 
necessity for holding it nor fear of its slipping out of place 
during the operation. I have had ample opportunity for 
testing it, and find, as before intimated, that it greatly facil- 
itates the performance of delicate operations. 
As a result of inflammation of the middle ear, especially 
where it has occurred in childhood, we sometimes find ad- 
hesion of the lower end of the malleus to the promontory, 
and also synechias extending from the membrana tympani 
to various points on the wall of the tympanum and to the 
ossicula, sometimes forming quite a network. These adhe- 12 
LATE CONTRIBUTIONS TO AURAL SURGERY. 
sions greatly impair the functional activity of the sound-trans- 
mitting apparatus, by tying down the membrana tympani 
and destroying its vibratory power, and preventing move- 
ment of the ossicula. In 1864, Dr. Sigle, of Stuttgart, des- 
cribed an instrument of his own invention, the purpose of 
which was to facilitate the diagnosis of the presence of syne- 
chias, implicating the membrana tympani. It consists of a 
hard rubber speculum, the mouth of which forms a circular 
chamber, closed at its outer end by a thin plate of glass set 
ai an angle of about 50° to the long axis of the speculum. 
The chamber has an opening in its floor communicating with 
a flexible tube having a mouth-piece. The speculum being 
pressed tightly into the meatus, the air is exhausted by suc- 
tion through the tube, the air in the middle ear presses the 
membrana tympani outward, and those points at which there 
are adhesions are represented by slight depressions upon the 
general surface. By this means we are enabled not only to 
make an accurate diagnosis, but also to determine at what 
point to apply the knife for the purpose of liberating the 
membrane. 
• * 
Among the cases of disease of the ear which most frequent- 
ly apply to the general practitioner for relief, are those forms 
of inflammation of the middle ear and the meatus, accom- 
panied by a more or less offensive discharge and liable to 
the complication of aural polypi. Whatever may be the 
origin of these growths, their extirpation is indispensable to 
the successful treatment of the affection which they either 
originate or accompany. Of the means for effecting this 
purpose, the forceps, wire snare, and caustic applications, 
are most frequently employed. The forceps should never 
be used unless we are satisfied as to the point of origin of 
the polyp, and that none of the important structures of the 
ear are implicated in the growth. The satisfaction incident 
to the clean extraction of a large polyp, would be very much LATE CONTRIBUTIONS TO AURAL SURGERY. 
13 
diminished by finding a portion of the membrana tympani or 
one of the ossicula attached to it. Of wire snares, Sir 
William Wilde’s is the one described in all the later text- 
books, and most generally employed. In adding one more 
to the modifications of this instrument, I have endeavored to 
obviate a difficulty which I had found use, and also by 
a slight change to adapt it to another purpose. In Mr. Wilde’s 
snare, the bar which carries the slide and the arm which sup- 
ports the wire are in one piece. To slip the wire loop over 
a small polyp in the meatus when it grows from one of the 
side walls, it is necessary either to turn the whole instru- 
ment or else to twist the wire loop upon itself. The former 
is inconvenient; in the latter case, where the loop is drawn 
taut, it tends to return to its original position, and may 
either slip over the polyp or cut it oft’ obliquely, leaving a 
larger portion than is desirable for extirpation by the caustic. 
The wires running upon the outside of the arm are apt to 
*be in the way if slackened, and in a narrow meatus may cut 
into the integument if drawn upon. 
For the fixed arm a moveable tube of German silver (cZ) 
is substituted. This tube expands at the outer end into a 
flattened head (/*), having two openings for the passage of 
the wire ; the inner end of the tube fits into a broad band on 
the slide bar (Z>). The ends of the wire passing down the 
tube are fastened to a pin on the upper part of the slide (c) LATE CONTRIBUTIONS TO AURAL SURGERY. 
below which is a ring by which traction can be made. The 
slide is substantially the same as in the snare of Dr. E. II. 
Clarke A When ready for use, the metal tube, and with it 
the loop, can be turned in any desired direction, and firmly 
fixed in place by means of the small set screw (e). By un- 
screwing the thumb-ring (a), removing the slide and the tube 
and inserting in the place of the latter the lance-headed 
needle (g) employed for performing paracentesis, we have a 
myringotome possessing the advantage of enabling us to 
adjust the cutting edges according to the direction in which 
it is desired to make the incision. 
In no one section of aural surgery have svfch rapid ad- 
vances been made as in the diagnosis and treatment of affec- 
tions of the middle ear, and much still remains to be done. 
A glance at the anatomy of this portion of the organ of hearing 
shows us the important part which it plays in transmitting 
the vibrations received through the meatus to the internal 
ear, and an examination into the delicacy of structure and 
accurate adaptation of the several parts to the office which 
they have to perform, shows in what manner a slight lesion 
may result in extensive impairment of hearing. 
Aside from the effects of primary affections of the meni- 
brana tympani, the sequel® of acute and chronic inflamma- 
tion of the middle ear are manifold, and in a large propor- 
tion of the adult cases seeking relief from impairment of 
hearing and the accompanying subjective symptoms, the 
existing cause is traceable to structural lesions, the result of 
an inflammatory process occurring perhaps years previously. 
It is in this class of cases in addition to treatment institut- 
ed by means of catheterization by the Eustachian tube, that 
we most often are obliged to have recourse to direct surgical 
* Observations on tlie Nature and Treatment of Polypus of the Ear. Boston: 
1867. P.58. 15 
LATE CONTRIBUTIONS TO AURAL SURGERY 
interference through the meatus, with the hope of anything 
like permanent relief to the patient, and in tlqs direction it 
would seem that the most important improvements in aural 
surgery during the next few years arc to be made. 
The operation of paracentesis of the membrana tympani is 
by no means of modern origin ; its application, however, has 
of late been very much extended and the limit of cases with- 
in which it may be employed to advantage has been more 
accurately determined. In 1(549, Riolan propounded the 
question as to the advisability of destroying a portion of the 
membrana tympani in cases of deafness ; this proposition wras 
founded upoi> his observations of a case where the hearing 
was restored by an ear-spoon having been forced into the ear, 
tearing the membrane and fracturing the ossicida. The value 
of Riolan’s observations and suggestion was overlooked, 
however, and intentional laceration of the membrana tympani 
considered reprehensible. So strong was the feeling on this 
subject that, in 1750, Cheselden, who had been following 
out the experiments of Willis and Valsalva upon dogs, was 
prevented by popular outcry from operating upon a criminal 
condemned to death.* The credit of the first successful 
operation has been given to several surgeons, among whom 
the name of Sir Astley Cooper ranked first, but it is now 
pretty clearly established that a travelling charlatan named 
Eli employed it empirically for the cure of deafness in Paris, 
in 17(50, but met with but a moderate degree of success. 
In 1801, Cooper followed the publication of his observa- 
tions upon the effects of perforations of the membrana tym- 
pani upon the hearing, by reports of successful cases in 
which he had operated, propounding closure of the Eusta- 
chian tube as the single indication for the operation. Sub- 
sequent cases did not confirm the hopes raised by the first 
* Schwartzc: Archiv fur Obrenheilkunde, Bd. II., lift. I. LATE CONTRIBUTIONS TO AURAL SURGERY. 
results, and, dreading the effect upon his reputation and dis- 
couraged by U1 success in a large proportion of the patients 
who flocked to him from all parts of Europe, he finally aban- 
doned it. Ilis first publication, however, had attracted uni- 
versal attention upon the continent, innumerable instruments 
for attaining the desired end were invented, and there was a 
general and indiscriminate cutting, tearing and trephining of 
tympanic membranes from one end of Germany to the other. 
Himly, of Gottingen, put an end to this reckless experi- 
menting by proving that the operation was by no means 
either harmless or a universal remedy for deafness, and could 
only be of service in certain cases, very few in-number ; and 
it shortly fell into more disrepute than it deserved. But 
science was by no means a loser; the haphazard operators 
became careful observers ; the numerous cases operated upon 
supplied ample material, and the first step was taken towards 
a knowledge of the functions of the membrana tympani and 
ossicula, and an appreciation of the importance of the study 
of their pathology. As a result, the indications for this 
operation were more clearly determined, and later observers 
have greatly enlarged the list of cases in which paracentesis 
may be resorted to as the readiest means of relief. Obstruc- 
tions of the Eustachian tube, thickening of the membrana 
tympani, and the accumulation of blood, pus and mucus in 
the tympanum, were considered the sole indications for the 
operation by the majority of authors, up to within ten years. 
Frank, however, in his Lehrbuch dcr Ohrenheilkunde, 1845, 
lays particular stress upon its diagnostic value in cases of 
thickening of the membrane and occlusion of the Eustachian 
tube as a means of determining the character of the contents 
of the tympanum.* The employment of bougies for the 
* Frank: Praktische Anleitung zur Erkcntniss u. Behandlung der Oliren- 
krankhciten. Erlangen: 1845. Pp. 74, 75. LATE CONTRIBUTIONS TO AURAL SURGERY. 
17 
relief of obstruction of the Eustachian tube* obviated the 
necessity for the more serious procedure, and limited it to 
cases of atresia of that passage ; and Gruber, of Vienna, in 
an article on Myringodectomy, 1803,f contributed greatly 
to extending its applicability, by giving four indications in 
addition to those already enumerated, namely—partial ossi- 
fication (calcareous deposits) of the membrana tympani when 
accompanied by loss of hearing and subjective noises ; cica- 
trices which interfere with the function of this structure ; at- 
tenuation of the membrana tympani when in consequence of 
the loss of its resiliency it is pressed inwards and excites 
subjective symptoms ; abnormal adhesions of the structures 
within the tympanum, when their character and extent can 
be accurately determined, and the operation will open the 
way for their removal. 
In the purulent inflammation of the middle ear frequently 
accompanying scarlet-fever or measles, the operation, if re- 
sorted to in time, may be the means of warding off the disas- 
trous results which entail a greater or less degree of per- 
manent deafness, and contribute a goodly percentage to the 
inmates of our deaf-mute institutions. In the natural course 
of the disease, that is in the severer cases, as a general rule 
the pressure of the confined discharge upon the inflamed 
membrana tympani gradually causes thinning and rupture, 
leaving an opening which enlarges as tha inflammation and 
discharge continue, until the greater portion of the mem- 
brane may be destroyed and such changes take place within 
the tympanum as to result finally in a condition of things 
which it is beyond the present degree of surgical skill to 
remedy. A timely use of the knife would relieve the pres- 
* Schwartze, 1. c. 
t Allg. AVicncr Med. Zeitung, 1863. LATE CONTRIBUTIONS TO AURAL SURGERY. 
sure upon the membrane and within the tympanum and by 
permitting an early escape of the discharge would favor 
resolution. 
Quite recently considerable attention has been drawn to 
the value of paracentesis in cases of accumulation of exces- 
sive mucous secretion within the tympanum by Dr. Adam 
Politzer,* Prof. Moos,f Mr. and others, and their 
observations show a much greater frequency of such cases 
than was generally supposed. 
The accumulation of the secretion in the tympanum is the 
result of an inflammation in that cavity accompanied or fol- 
lowed by diminished permeability of the Eustachian tube, 
the fluid is often very thick and tenacious, and does not 
easily make its escape by the natural channel down into the 
throat; by its pressure upon the membrana tympani it inter- 
feres with the functions of the sound-transmitting apparatus 
and greatly diminishes the hearing power, while a corres- 
ponding pressure upon the base of the stapes and the mem- 
brane of the fenestra rotunda, gives rise to ringing, singing 
or rushing sounds, and reflexly causes vertigo, nausea and 
even vomiting. Catheterization of the Eustachian tube or 
the use of Politzer’s air douche, give but partial relief, the 
inflammatory process having generally decreased the patency 
of that passage in a greater or less degree, so that exit is per- 
mitted to but a small portion of the fluid, and that which re- 
mains serves to keep up the irritation and favor a still further 
secretion. A free incision through the membrana tympani 
enables us to force the secretion outwards into the meatus by 
injecting air through the Eustachian tube, and this procedure 
* Wiener Med. Wochensehrift, 1867. 
f Archiv. of Ophthalmology and Otology, 1870. 
J Guy’s Hospital Reports, 1869. LATE CONTRIBUTIONS TO AURAL SURGERY. 
19 
is generally followed by an immediate increase in hearing 
and freedom from the distressing subjective symptoms.* 
The opening in the membrane closes readily within three 
or four days, and it is sometimes necessary to repeat the in- 
cision four, five or even six times. Catheterization or the 
simple air douche should always accompany the operation, 
and it is well to continue it for some time after the tendency 
to excesive secretion is diminished, in order to restore the 
membrane lining the tympanum to a healthy condition, and 
secure a sufficient permeability of the Eustachian tube to 
guard against the liability of a recurrence of the trouble. 
The fact above mentioned concerning the readiness with 
which incisions through the membrana tympani become 
closed brings us to the consideration of a question which has 
long occupied the attention of aural surgeons, namely—the 
possibility of establishing a permanent opening into the 
tympanic cavity. 
Where the sound-transmitting apparatus no longer fulfils 
its office, and the membrana tympani remains intact, it pre- 
sents an obstacle to the passage of sonorous vibrations. In 
such case, if there is no contra-indication, such as an affec- 
tion of the labyrinth or of the vestibular attachment of the 
stapes, an opening through the membrana tympani would 
allow the sound waves to pass into the tympanum, and, falling 
upon the base of the stapes, to be transmitted to the auditory 
nerve. The instruments first employed for paracentesis were 
either fine trochars, needles, stilets or knives of various 
shapes ; it was soon found that the openings closed completely, 
and that the relief gained by the operation was only tempor- 
ary. Trephines were then resorted to, but with no better 
success, and the excision of even a large portion of the mem- 
* Mr. Toynbee proposed the removal of fluid from the tympanum by means 
of a small syringe introduced through the membrana tympani. Trans. Am. 
Otological Society, 1869. LATE CONTRIBUTIONS TO AURAL SURGERY. 
brane did not prevent subsequent closure of the opening. 
Bonnafont followed trephining by cauterization of the edges 
of the wound and by the introduction of bougies and metal- 
lic canuke, in one case allowing a canula to remain forty- 
five days; within six days after its removal, however, the 
size of the opening had so far diminished that it was impos- 
sible to reinsert the tube.* Perforations were also made 
with caustics, but closed with equal rapidity, and this method 
was found objectionable on account of the danger of exciting 
severe inflammation. 
In 1859, Erhard proposed the substitution of a wire heated 
by an electric current, for caustic, and the white-hot trochar. 
Voltolini, who had occupied himself with the application of 
galvano-caustic in the treatment of diseases of the throat and 
for the cauterization of aural polypi, developed the idea, and 
in December, 1867, published an account of his first opera- 
tion and the instrument employed, f 
About a year later I had the opportunity of witnessing in 
Vienna the experiments of Drs. Politzer and Chimani and 
Prof. Moos, with galvano-caustic. The instrument was the 
simple point of fine platinum wire used in the cauterization 
of granulations and polypi. The object to be attained, a 
perforation made quickly and painlessly, which should re- 
main open without further interference. Three cases were 
selected from patients in the aural clinic of the Garrison 
Hospital No. 1, and submitted to the experiment. The 
platinum point, being pressed against the membrane in the 
anterior inferior segment, was quickly brought to a white 
heat by a battery consisting of two Grove’s cells. Instead 
of passing painlessly through, however, in each case the pain 
caused was so severe that further attempts were abandoned. 
* Bonnafont: Traite tlieorique et pratique des Maladies de l’Oreille. Paris: 
1860. P. 375. 
t Monatschrift fur Ohrenheilkunde, 1867, No. 3. LATE CONTRIBUTION8 TO AURAL SURGERY. 
Four days later I examined one of the patients and found 
an acute myringitis on both sides, and it is not improbable 
that the result was the same in the two other cases, judging 
from the fact that the pain and congestion following the ap- 
plication of the heated wire was the same in all. 
Dr. AVreden, of St. Petersburg, proposed, in addition to 
cutting out a large piece of the membrane, the removal of a 
portion of the lower end of th6 malleus, and constructed two 
very ingenious instruments for effecting his purpose. The 
one for cutting away the membrane consists of a handle sup- 
porting at an angle of about 70° a knife, the blade of which 
is made to describe a perfect circle by pressure upon a slide 
moving in the handle. The other, for excision of the bone, 
is a pair of stout shears for cutting, and below them a 1 ight 
pair of forceps for seizing and extracting the excised portion : 
botli slide in a tube after the manner of the branches of the 
lever-ring forceps used for the extraction of polypi. 
In the comprehensive and valuable work upon aural sur- 
gery by Dr. Jos. Gruber, of Vienna, just published, the 
author describes an instrument of his own, to which he gives 
the name Myringectome, and which serves not only for cut- 
ting away a portion of the membrane, but also for Wreden’s 
operation of Sphyrotomy. It is modelled upon the principle 
of the lithotrite, the end of the stationary blade being circular 
and fenestrated; into the opening the end of the moveable 
blade fits like a punch. In operating, a slit is first cut 
through the membrana tympani with a knife or paracentesis 
needle, the lower blade of the myringectome introduced 
through the opening and brought in contact with the inner 
surface of the membrane ; the upper blade, being forced down- 
ward by means of a small screw, punches out a circular piece 
which may be extracted between the blades of the instru- 
ment. This procedure may be repeated until an opening of' the 
desired size is obtained. LATE CONTRIBUTIONS TO AURAL SURGERY. 
A short time before his experiments with galvano-caustic, 
Dr. Politzer had succeeded in establishing a permanent 
opening in the case of a woman who had suffered from acute 
purulent inflammation of the middle ear, accompanied by per- 
foration of the membrane. The inflammation subsided, the 
discharge ceased, and the opening into the tympanum 
remaining, she was able to hear distinctly. Subsequently, 
however, the opening became "'closed by cicatricial tissue and 
the hearing greatly diminished. While in this condition she 
applied to Dr. Politzer, who made an incision through the 
cicatrix, dilated it by means of a sea-tangle tent, and then in- 
serted a small hard rubber tube, having a groove cut in it 
for the reception of the edges of the wound. 
Forty-eight hours after the operation, the tube or 
eyelet was firmly in place, the edges of the opening 
having closed around it. Before the operation a 
test watch was heard only when brought in contact 
with the ear ; the same watch was now heard at a distance of 
nine inches. This improvement continued gradually to in- 
crease during the next six months, at the end of which time 
the hearing was very nearly normal.* The circumstances 
of Dr. Politzer’s case greatly favored success. The mem- 
brana tympani was at no point adherent to the opposite wall 
of the tympanum, nor was it particularly concave ; the eyelet 
was inserted in a thin elastic cicatrix formed by the outer and 
inner coats of the membrana tympani, and not in a mem- 
brane thickened by an old inflammatory process and rich in 
bloodvessels, and the meatus admitted a large sized specu- 
lum. We cannot expect to find equally favorable conditions 
in all the cases to which this operation is applicable. The 
* An account of the operation, together with the substance of Dr. Politzer’s 
article upon the subject of permanent artificial openings in the membrana tym- 
pani, was published in the Boston Medical and Surgical Journal of March 2-5th, 
1869, to which I would refer for a fuller explanation of the method of procedure. LATE CONTRIBUTIONS TO AURAL SURGERY. 
23 
eyelet must necessarily project into the tympanic cavity, and 
as the distance from the promontory to the membrana tym- 
pani is only about 3 m. m., a very slight concavity of the 
latter would oblige us to choose as the point for insertion a 
portion of the membrane corresponding to a recess in the 
opposite wall, either the anterior inferior segment near the 
opening of the Eustachian tube, or posteriorly below the in- 
cus and near the periphery, if we would not run the risk of 
having the inner end of the eyelet come in contact with the 
tympanic wall; in which case closure of the opening by 
secretion would be the least evil which we might expect. 
AYhere the malleus is in contact with the promontory, the 
difficulty is still greater, and it may be necessary to cut the 
manubrium free from the promontory to which it is adherent, 
as preliminary to the insertion of the eyelet. 
Subsequent observation of Dr. Politzer’s case developed a 
very interesting fact. Five months after the operation it 
was found that the eyelet which had been inserted near the 
malleus had moved in the direction of the radiating fibres of 
the lamina propria, and lay close to the periphery of the 
membrane, its outer end resting on the posterior wall of the 
mfeatus. This observation, in addition to its physiological 
interest, is of practical importance and adds another compli- 
cation to Politzer's operation; for, knowing that if inserted 
near the centre of the membrane it will certainly in course of 
time reach the periphery by the shortest course, the eyelet 
must be so placed that in its wandering the inner end may 
not come in contact with the descending process of the incus 
or any of the projecting parts of the tympanic wall. Not- 
withstanding the difficulties besetting this operation, and the 
fact that though performed with all judgment and delicacy 
a favorable result cannot be insured on account of the liability 
of subsequent inflammation and stoppage of the opening in 
the eyelet, we should not hesitate to resort to it when there LATE CONTRIBUTIONS TO AURAL SURGERY. 
is a prospect of success, because there are so many cases 
where the establishment of a permanent opening is the only 
means of which we have at present any knowledge whereby 
the hearing may be restored, or the patient freed from sub- 
jective symptoms, which are sometimes so severe as to entirely 
preclude mental labor and even induce insanity. 
The operations confined to the cavity of the tympanum 
are very few in number. Of these, the removal of polypi and 
of adhesions, as already mentioned, and tenotomy, are the 
most important. In consequence of long continued closure 
of the Eustachian tube, the air within the tympanum is grad- 
ually absorbed, and the pressure of the atmosphere externally 
forces the membrana tympani inwards and maintains it in 
that position ; the tensor tympani muscle is relaxed and final- 
ly becomes retracted so that even after the permeability of 
the Eustachian tube has been re-established, the membrane, 
held by the muscle, retains its abnormal position; it is in 
this condition that the operation of tenotomy is applicable. 
Weber’s tenotome* closely resembles the knife which 
Wreden employed for the first part of his operation, except 
that for the knife blade, a small hook with a cutting; edg;e 
is substituted. An opening is made through the membrane 
in front of the malleus, and the hook introduced and caught 
over the tendon of the mus- 
cle close to its insertion. 
By operating the slide in 
the handle of the instru- 
ment, the hook is made to 
describe a quarter of a 
circle, and cut through the 
tendon. From operations 
performed with Weber’s 
instrument upon the cad- 
* Monatschrift for Olirenheilkunde, December, 1868. LATE CONTRIBUTIONS* TO AURAL SURGERY. 
aver, I should question the advisability of employing it upon 
the living subject. Unless handled with the greatest care 
there is apt to he extensive laceration of the membrane, and 
the shape of the hook is such that considerable force is some- 
times required before the tendon can be divided. 
Politzer has proposed hermetically closing the meatus in 
cases of retraction of the tensor tympani, when there is pas- 
sage for air through the Eustachian tube. The meatus is 
tightly plugged with a wrad of cotton wool soaked in oil or 
smeared with simple cerate, which is allowed to remain 
twenty-four hours at a time ; the air between the plug and 
the membrana tympani is rapidly absorbed, and the air with- 
in the tympanum exerts a steady pressure outwards. In 
many cases this simple procedure is very effectual in reliev- 
ing the tension of the muscle and restoring the membrane to 
its proper position. 
Since the first use of the catheter, introduced through the 
nostril,* the method of treatment of diseases of the middle 
ear through the Eustachian tube, and the treatment of affec- 
tions of the Eustachian tube itself, has remained very much 
the same. 
Since Cleland’s time the catheter has passed through 
divers modifications, which it would be superfluous to notice 
here. The instrument, in its present form, serves not only 
for diagnostic but also for therapeutic purposes. By its use 
in connection with the otoscope, we are enabled to determine 
the condition of the Eustachian tube and middle ear, and 
diagnosticate the existence of small openings in the mem- 
brana tympani. Through it we may introduce medicated 
solutions and vapors, and where the condition of the passage 
demands it, bougies for purposes of dilatation—the small cat- 
gut, laminaria and the finer sizes of the French olivary bougie 
* By Cleland, 1741. LATE CONTRIBUTIONS TO AURAL SURGERY. 
being most commonly employed. Of these, the latter is 
preferable, as it is passed more readily than the cat-gut, 
while the degree to which the laminaria will dilate is very 
variable, and there are cases on record where laminaria 
bougies have broken in the Eustachian tube, an accident the 
possible results of which we cannot contemplate without 
dread. In injecting medicated solutions through the catheter, 
it is a question as to how much of the fluid reaches the mid- 
dle ear, though the quantity injected through the catheter at 
different times may be the same : a varying proportion runs 
down into the throat, according to the position of the beak of 
the instrument and the degree of permeability of the Eusta- 
chian tube. 
With medicated vapors the same question holds good, and 
it is with the view of furnishing a reliable means of medica- 
tion per tubam that Weber has devised the double catheter 
described in the fifth number of the Monatschrift fur Ohrcn- 
heilkunde, 18G8, and to which he gives the name " pharmaco- 
koniantron.” A silver catheter beino- introduced in the usual 
O 
manner, a small flexible catheter, having a lateral opening at 
the beak, is passed through it, up the Eustachian tube and 
into the tympanum. At the outer end of the flexible catheter 
is a mark corresponding to the lateral opening in the beak. 
With this for a guide the opening can be turned in any desired 
direction, and the fluid introduced into the catheter be ejected 
in the form of a fine spray by means of air forced in with a 
balloon. As a substitute for catheterization, which is some- 
times impossible, and always disagreeable to the patient, 
Dr. Politzer introduced the use of a rubber balloon, having a 
short curved beak attached to it by a flexible tube ; this being 
passed into the nostril and the alae closed upon it by the 
thumb and forefinger of the left hand, the patient is made to 
swallow ; at the moment of contraction of the muscles of the 
pharynx the balloon is compressed. The air which is forced LATE CONTRIBUTIONS TO AURAL SURGERY. 
in at the nostrils cannot make its exit by the same passage, 
and cannot escape down the throat; it must, therefore, pass 
up the Eustachian tube and into the tympanum. This con- 
stitutes one of our most valued means of treatment at the 
present time. 
In addition to local treatment in affections of the middle 
ear, a due attention to the condition of the throat and nasal 
passages is often of erpial importance. For the purpose of 
making applications to the naso-pharyngeal space, and as a 
substitute for the nasal douche, which sometimes cannot 
easily be borne, and does more harm than good in such 
cases, Leiter, of Vienna, has constructed the atomizer, 
represented in the accompanying woodcut. The instru- 
rnient is of hard rubber and con- 
sists of a tube b, enclosing a 
smaller tube which communi- 
cates with the dip-pipe c. At 
d, a flexible tube with double 
bulbs is connected, by which air 
is forced into the atomizer. 
At e, mouthpieces of different 
shapes can be attached by screw- 
ing them on to the tube, and by 
varying the position of the open- 
ings in the mouthpieces the jet 
of spray can be turned in any direction. By removing the 
mouthpiece a stream of water can be substituted for the spray. 
The whole apparatus fits like a stopper into the bottle a, con- 
taining the medicated solution. With the mouth-piece repre- 
sented at g, applications may be made not only to the upper 
part of the pharynx, through the mouth, but also to the larynx 
and vocal cords. LATE CONTRIBUTIONS TO AURAL SURGERY. 
The consideration of diseases of the labyrinth, and in this 
connection of the experiments of Brenner and others in the 
application of the electric current to diagnosis and treatment 
of labyrinth affections, though exceedingly interesting, 
would of necessity be lengthy, and moreover would scarcely 
come within the scope of this communication. The same 
may be said of the different forms of parasitic growth in the 
external meatus, and either subject alone would afford material 
for a separate paper.