CLINICAL CONTRIBUTIONS TO OTOLOGY 
BY* 
C. R. AGNEW, M.D., and DAVID WEBSTER, M.D. 
NEW YORK 
[Reprinted from the Archives of Otology, Vol. x, No. 4, December, 1881] CLINICAL CONTRIBUTIONS TO OTOLOGY. 
C. R. AGNEW, M.D., and DAVID WEBSTER, M.D., 
New York. 
Case i.—Bi7iaural deafness, probably due to simultaneous exuda- 
tions into both labyrinths. 
Joseph R., ast. 40, came under observation December 14, 1874. 
The following letter which he brought with him from his family- 
physician, Dr. John Messenger, contains important facts in the 
history of his case. 
“ The patient, Mr. J. R., came to consult me July 6, 1874. He 
was then, and had been, living on Eightieth Street, a little west of 
Broadway, in a frame house, rather old, and surrounded with a 
growth of shrubbery, fruit-trees, vegetable garden, etc. He and 
his family had resided there for several years, and all had had good 
health up to the time when Mr. R. was attacked (July, 1874) with 
a severe ringing sound in the ears, which came on suddenly with- 
out pain or severe general or local distress. There was quite a 
severe nervous derangement, if I may so terra it. He was very 
weak and depressed. Deafness, almost total, was a symptom 
from the first. A loud and rather base sound was not heard as 
well as a sound of high or acute pitch. The shutting of a door, 
or something falling on the floor and making a shrill noise would 
startle him, and make him start up in a fright. A very careful 
survey of his person, ocular inspection, palpation, auscultation, 
analysis of the urine, chemical and microscopical, the constant 
and interrupted currents of the faradic and galvanic batteries, 
all failed to indicate the locality of any diseased structure. Mal- 
aria came in for a share in the cause of the trouble, but there, too, 
I failed in my efforts to convict the offender. He is a man of 
good, temperate, regular habits, and always has been so.” 
Reprinted from the Archives of Otology, Vol. x, No. 4, Dec., iBBx. 336 
Agnew and Webster. 
Mr. R. gave me the following account of the way in which his 
trouble was ushered in. About the first of July, while riding 
down Broadway in a horse-car, he thought he heard a fire-bell 
ringing, and said so to his wife. She replied that she heard noth- 
ing of the kind. Presently he heard the bells ringing again, but 
as his wife did not hear them he was forced to the conclusion that 
the sounds originated in his own ears. 
These sounds, with many variations, have persisted in the most 
distressing and annoying manner ever since. During the summer, 
while sitting in his garden, noises of bats, owls, and frogs were re- 
peated in his ears. Again the most furious steam-pumping sounds 
would be heard. 
The hearing of both ears was impaired from the first, but he 
was able to hear conversation for several months. The hearing of 
the right ear was very gradually lost first, and that of the left went 
in the same way a few weeks later. He had been unable to un- 
derstand spoken words for three or four weeks when he first came 
under our observation. He never lost the power of hearing cer- 
tain external sounds, such as his parrot saying “ cuckoo.” He is 
very nervous, certain noises going through him like an electric 
shock. His voice is somewhat raised in pitch, and not under 
good control. The tuning-fork is heard very faintly when placed 
in contact with his teeth. So far as could be determined by in- 
spection his external and middle ears were normal. His Eu- 
stachian tubes were easily opened. 
It was believed that the symptoms pointed to disease of both 
labyrinths, the result, perhaps, of some obscure intracranial dis- 
ease. An unfavorable prognosis was given, and the patient was 
placed upon a mixture containing iodide of potassium, bromide of 
potassium, bromide of ammonium, and sesquicarbonate of ammo- 
nia. Mercurial inunction was also used, and was carried to the 
point of slightly touching his gums. He was afterward treated 
with increasing doses of nitrate of strychnia, administered hypo- 
dermically, and by large doses of quinine. Electricity was applied 
to his Eustachian tubes and external auditory canals, both con- 
stant and interrupted currents, but all without appreciable effects. 
On January 4, 1875, I tested his hearing with my watch and 
was surprised to find that he could hear it with his right ear at a 
distance of six inches (-gV), and with his left at eight inches 
I repeated this test at different visits afterward, and found that his 
power of hearing the ticking of my watch varied, the farthest Clinical Contributions to Otology. 
337 
point at which he heard it any time being fifteen inches (-gif). 
The test of his power to hear the watch was repeated and con- 
firmed by Dr. Agnew. 
We saw Mr. R. again more than a year afterward (March 15, 
1576). He said that in about a month after the date of his last 
visit the subjective noises almost entirely disappeared, and that 
since that time he has been free from tinnitus, except during men- 
tal excitement, when he hears one, two, or three sounds like the 
blows of a hammer. The stronger the excitement the longer these 
sounds continue. He hears the watch pressed against the right 
ear, and at a distance of two inches from the left ear. He hears 
the sound of his own voice and controls it better than when I 
first saw him. He says he has had much domestic trouble since 
he stopped treatment, and has used tea, coffee, and beer freely, and 
to this he attributes his not hearing the watch so well as formerly. 
We placed him near a piano, with his eyes closed, and struck all 
the keys in succession. He heard a sound when a and din the 
highest octave, f in the lowest octave, and f in the next to the 
lowest octave were struck, but not every time. He counted cor- 
rectly every time the strokes on a tumbler with the back of a jack- 
knife blade, with his back turned, at a distance of twenty feet. 
Mr. R. states that he had a fall on his head during the fire at 
the Fifth Avenue Theatre, about a year before his ear trouble set 
in, but he does not think that was the cause of it. His residence 
was in a malarious district, but he thinks his deafness may be 
more directly due to his long and arduous labors in a new and 
damp painting-room, where he frequently spent fifty hours with- 
out intermission. 
This patient never had venereal disease of any kind. It 
will be noticed that he at no time suffered from vomiting 
or from vertigo. It seems extremely improbable that the 
disease began in his ear drums. An attack of otitis media 
so sudden as this, and severe enough to produce such 
damaging results, could scarcely occur without pain, more 
or less severe, and this patient never had an earache, and 
not even well-marked headache, his main symptom, aside 
from deafness and tinnitus, being intense nervous irritabil- 
ity. Moreover, his drum-heads were normal, on inspection, 
when we first saw him, nearly six months after the disease 
was ushered in. There can be little, if any, doubt, then, 338 
Agnew and Webster. 
that it was an affection of both internal ears. Perhaps we 
may be permitted to go a step further, and venture to ex- 
press an opinion as to the character of this affection. All 
the symptoms in the case would be accounted for by the 
hypothesis of a simultaneous hemorrhage, or a simultaneous 
exudation, occurring in both labyrinths. Reported cases of 
hemorrhage into both labyrinths have usually, if not always, 
been the results of traumatism, as falls or blows upon the 
head. But we see no reason why apoplexies may not occur 
in both labyrinths as well as in both retinae simultaneously, 
and we do occasionally meet with cases of the latter 
without any assignable cause save changes in the walls of 
the blood-vessels. But in the case reported above, the 
theory of a labyrinthine exudation seems to me the more 
probable one. Mr. R. seems to have been surrounded by 
the most favorable circumstances for “ taking cold.” May 
he not have “ caught cold ” in that “ new and damp paint- 
ing-room where he frequently spent fifty hours without 
intermission”; and may not that “cold,” which in one 
man would have produced a pneumonia, and in another 
an otitis media, have produced in Mr. R. an inflammation 
of his auditory nerves, or an “ otitis labyrinthica ” of both 
sides ? 
The fact that the patient could hear the watch readily at 
a distance of several inches while totally deaf to conversa- 
tion is very remarkable, and we can only explain it by sup- 
posing that the exudations which occurred in both laby- 
rinths were plastic father than serous, and produced pressure 
upon certain areas of the terminal fibres of the auditory 
nerve, while other portions were left comparatively free 
from pressure. 
Case 2.— Wound of the membrana tympani by an oak stub. 
Deo. 21, 1875. C., set 36, stated that four days ago, while out 
hunting, in the act of mounting a fence, he fell and thrust an oak 
stub into his right ear. Slight bleeding occurred, with immediate 
deafness. A bloody discharge soon occurred, with deep pain in 
and around the injured ear. The hearing distance is now : 
watch, right ear, 8 inches ; left ear, t6 inches. The tuning-fork 
placed on the forehead is heard more distinctly in the right ear. Clinical Contributions to Otology. 
339 
Inspection shows an opening through the membrana tympani be- 
low the end of the handle of the malleus. 
Some pieces of bark and dirt were washed out of the ear by 
syringing with warm water. The middle ear was gently inflated 
three times a week by Politzer’s method, and in the course of 
three weeks the perforation healed with little or no impairment of 
hearing. 
Case 3.—Double rupture of the membrana tympani from a blow. 
Jan. 27, 1875. Mrs. N. H., set 37, says that four days ago she 
received a blow of an open hand on her left ear. A noise like 
the roaring of the sea came on immediately, and has continued 
ever since, but is gradually growing less distinct. She has had 
absolutely no pain in the ear since that passed away which was 
the immediate effect of the blow, and she has not noticed any 
deafness. There has been no discharge from the ear. Her hear- 
ing for the watch was found to be acute and equal in both ears, 
nor was there any difference in the ears by the tuning-fork test. 
Upon looking into the injured ear we found that there were 
two ruptures of the drum-head distinctly visible. One was situ- 
ated in front of the handle of the malleus, was nearly parallel 
with it, and extended about two thirds of its length. The other 
extended from the end of the handle horizontally backward 
nearly to the periphery of the membrane. The air passed through 
both these openings readily when the ears were inflated by Val- 
salva’s method. The drum-head was reddened and slightly 
swollen. 
The patient was treated on the expectant plan, nothing being 
applied except, on one or two occasions, the warm aural douche 
to allay irritation, and the ruptures healed in the course of a fort- 
night, leaving almost invisible cicatrices. When the patient was 
last seen the hearing was unimpaired and the roaring had entirely- 
passed away. 
Case 4.—Supposed foreign body in the tympanum. 
Augusts, 1574. C. G., set. 3, came to his mother five days ago and 
asked for a pin, saying he had got a stone in his ear which caused 
pain. There was some dirt seen in the meatus. His father passed a 
darning-needle and “ sounded ” the external auditory canal and 
“ struck something.” The child was then taken to the office of 
Dr. D., who syringed the ear with warm water and got out some 
earthy matter, after which he introduced a blunt probe and felt a 
substance low down in the canal, filling the cavity so that he 340 
Agnew and Webster. 
could not pass the probe beyond it. It sounded “gritty.” He 
then placed the child under ether and tried to pry it out. He 
did get hold of it, but could not pull it out with his forceps. The 
child was then taken to Dr. E., who probed the ear, used the ear- 
spoon and ear-forceps without extracting the foreign body. Yes- 
terday morning he gave an anaesthetic and broke away a piece of 
bone, but still failed to remove the foreign body. Some paresis 
of the seventh nerve occurred early in the manipulations. Exam- 
ination now shows what seems to be a foreign body pushed 
through the membrana tympani and stuck immovably in the 
middle ear. 
We syringed the ear freely and then advised to desist from fur- 
ther active interference as a choice of evils, believing that we 
could not remove the supposed foreign body by any means that 
we were willing to employ, and hoping that at a later stage the 
discharges might dislodge it. Indeed, the parts were so altered 
by the lacerations occasioned by the attempts to remove the sup- 
posed foreign body that we could not say positively that any ex- 
isted in the middle ear, but feared that the bony wall of the mid- 
dle ear had been so denuded and broken as to beget the appear- 
ance of a foreign body. 
In this connection it may be well for us to say what we 
believe to be the proper line of treatment to be pursued in 
such cases. When a foreign body is lodged in the external 
auditory canal the first means to resort to for its removal is 
syringing with warm water. We should use for this pur- 
pose a syringe having a large barrel and small nozzle, and 
endeavor to throw the stream of water not against the 
foreign body but the wall of the canal, so as to press past 
the foreign body and thus to discharge it by the recoil of 
the water. 
If syringing does not discharge the foreign body the 
patient should be put profoundly under ether and very 
careful attempts made by the use of instruments to accom- 
plish the object. A very thin steel scoop, or the Daviel 
spoon, is the best instrument for the purpose, and this 
should be gently insinuated between the foreign body and 
the wall of the meatus, while the body is held by a hook, 
like the cystotome used in cataract extraction, from press- 
ing inward against the drum membrane. Clinical Contributions to Otology. 
341 
If bleeding occurs time must be allowed for it to cease, 
otherwise the proper direction of instruments cannot be 
preserved. 
It is possible, also, to pass a delicate sickle-shaped knife 
down through the skin of the meatus, past the foreign 
body, and use it as a vectis after its point shall have been 
passed beyond the foreign body, care being exercised not 
to push the body deeper into the canal. No one, however, 
should attempt such operations unless he is familiar with 
the anatomy of the parts, and understands the methods of 
examining the ear sufficiently well to see the foreign body he 
is attempting to extract. 
In practice, the syringe is usually effective unless meddle- 
some and clumsy interference has pushed the body down 
upon, or through, the membrana tympani. 
Forceps are not available. When the foreign body fills 
the canal they cannot be applied, and in all cases where 
they can be applied the syringe will do the work, and with 
less danger to the organ. 
In all cases the greatest care must be exercised not to 
press the foreign body deeper into the canal, and not to 
attempt to dislodge it with any instrument that does not 
pass between it and the wall of the canal. 
No harm can be done by passing an instrument through 
the skin of the meatus, provided the operator really knows 
the depth of the canal and, by the exercise of the “ learned 
touch,” can tell when the distal end of his instrument has 
gone beyond the foreign body. 
Cases 2 and 3 are given, not because they exhibit any 
striking novelty, but because their histories seem to prove 
that the best results in practice are often reached by the 
absence of what is called, and very properly, active interfer- 
ence. g. p. putnam’s sons, printers 
NEW YORK