A Remarkable 
Akgeiokeitrosis oe the Tokgue, 
Z*we to toe Application of Chromic Add 
to Granulations on the Upper and 
Posterior Portions of the 
Tympanic Membrane. 
A COHTEIBTJTIOH TO THE PHYSIOLO&Y OE 
THE CHOEDA TYMPANI NERVE. 
BT 
EOBEET LEWIS, Jr., M. D., 
Instructor in Otology, College of Physicians and Surgeons, 
Medical Department of Columbia University, New York. 
REPRINTED PROM THE 
Neto Yorfe J&ptifcal Journal 
for October 9, 1897. Reprinted from the New TorTc Medical Journal 
for October 9, 1897. 
A REMARKABLE 
ANGEIONEUROSIS OF THE TONGUE, 
DUE TO THE APPLICATION OF CHEOMIC ACID 
TO GRANULATIONS ON THE UPPER AND POSTERIOR PORTIONS 
OP THE TYMPANIC MEMBRANE. 
A CONTRIBUTION TO 
THE PHYSIOLOGY OP THE CHORDA TYMPANI NERVE.* 
INSTRUCTOR IN OTOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS, 
MEDICAL DEPARTMENT OF COLUMBIA UNIVERSITY, NEW YORK. 
ROBERT LEWIS, Jr., M. D., 
Mrs. , of German birth, superintendent of one 
of our city hospitals, aged about forty-eight years, of 
average good health, not of a nervous temperament, 
certainly with no hysterical tendency, active, though 
weighing over one hundred and eighty pounds, consult- 
ed me about a year ago for a left chronic otitis media 
purulenta, which had existed for a number of years. 
She had been treated both here and in Germany a 
number of times, and this was an exacerbation of the 
disease, in character similar to a number of previous 
attacks; a muco-purulent discharge, slightly offensive, 
and a dull evanescent pain being the only symptoms 
of which she complained. On examination, I found in 
the tympanic membrane, after cleansing the canal, a 
* Read before the American Otological Society at its thirtieth annual 
meeting. 
Copyright, 1807, by D. Appleton and Company. 2 
ANGEIONEUROSIS OF THE TONGUE. 
perforation about two by three millimetres in diame- 
ter, the superior margin of which was formed by the 
posterior fold, the anterior margin by the malleus han- 
dle, the posterior margin by the posterior edge of the 
annulus tympanicus. The opening was filled with 
granulation tissue. 
Under cocaine anaesthesia, I removed, by curetting, 
as much of the granulation tissue as possible, then 
cauterized the base with chromic acid, and ordered the 
patient to use a bichloride solution (1 to 6,000) as an 
aural douche three times daily, to be followed by the 
instillation of a few drops of a solution of fifty-per- 
cent. alcohol (afterward increased to seventy-five per 
cent). Later, the solutions were stopped and insuffla- 
tions of powdered aristol were used. Finally, after the 
third application of chromic acid, I did not see my 
patient professionally for some time, but when I did 
meet her casually she informed me that her ear was all 
right, but that during the night of the same day on 
which she made her last visit to my office her tongue 
became so swollen that she could hardly breathe for a 
few hours. I paid but little attention at the time to 
her account of this occurrence. 
About six months later Mrs. again visited my 
office, complaining of a renewal of the discharge, I 
found a little granulation tissue present, and used the 
chromic acid as on the previous occasion. The next 
day I learned that, about twelve hours after I had made 
this application, her tongue began to swell very rapidly 
—indeed, so rapidly that in two hours she could not 
protrude it, nor could she shut her jaws; and the 
swollen parts interfered so markedly with her breath- 
ing that Dr. George F. Little, of the house staff, had 
seriously considered the advisability of performing a 
tracheotomy. Happily, by the administration of purga- 
tives and by the local employment of ice, tannic acid, 
and leeches (the latter applied near the angle of the 
jaw), about three hours after the oedema first showed 
itself the swelling began to subside, and within twenty- ANGEIONEUROSIS OF THE TONGUE. 
3 
four hours after the application of the chromic acid 
the oedema had practically disappeared. Accompany- 
ing the glossal oedema and the oedema in the submaxil- 
lary region were small areas of oedema over the right 
frontal eminence, over the halls of both thumbs, over the 
internal malleolus of one ankle joint, and under the 
ball of the right foot. I also learned that the first 
attack which she had (to the recital of which I had 
paid so little attention) came on about the same length 
of time after my application of the acid and followed 
about the same course as that which I have just de- 
scribed. Dr. Frederick J. Schoenberger attended her in 
the first attack and also saw her during the second 
one, and found them in every way very similar. On the 
second occasion, thirty hours after she had visited my 
office, there was no evidence of abnormal irritation in 
or about the membrana tympani, the external auditory 
canal, the pharynx, or the buccal cavity. 
Both Dr. Beck and Dr. Collins of the visiting staff, 
who were informed of the symptoms on the next day, 
pronounced it to be, in their judgment, a case of an- 
geio-neurotic oedema. 
Dr. Joseph Collins (in the Reference Handbook of 
the Medical Sciences, William Wood & Co., 1893, vol. 
ix, p. 42) defines angeio-neurotic oedema as “ a vaso- 
motor neurosis, characterized by the appearance of 
circumscribed swellings on various portions of the body, 
by preference the face, throat, and extremities, without 
apparent cause or premonition and non-inflammatory 
in character. . . ” 
“ Of the directly exciting causes, cold and trauma- 
tism are the most obvious. . . . The period in the twen- 
ty-four hours when attacks are most liable to show 
themselves is during the time between 1 and 5 a. m., 
when the tide of life is at its lowest ebb and the parts 4 
ANGEIONEUROSIS OP THE TONGUE. 
are the least resistant.” In the case nnder discussion 
the oedema arose somewhat earlier than this. 
Dr. Collins, in the article above quoted, relates that, 
in a total of seventy-one cases collected, the swelling 
showed itself for the first time: in the face, in twenty- 
nine cases; in the larynx, in five; on the gums and pal- 
ate, in one. In the remaining cases various other parts 
of the body were affected, but no mention is made of 
its occurrence in the tongue. 
To quote further from Dr. Collins’s article: “ The 
nature of the lesion is unquestionably that of a non- 
inflammatory oedema circumscribed in form. ... It is 
probable that, although the lesions or the irritants upon 
which the disease is dependent may attack the other parts 
of the system, yet the result directly appears through 
the sympathetic system of nerves. Furthermore, the 
nerves affected are undoubtedly the vasomotor nerves. 
The disease, in its development, has a close relation 
to other vasomotor neuroses, such as morbid blushing 
and flushing, exophthalmic goitre, and many of the 
arthropathies as yet not well understood.” 
It seemed as if, in the present case, there must 
have been some connection between the application of 
the chromic acid and the oedema. Mrs. had never 
experienced a similar attack before, nor did she have, 
so far as I could learn, any hereditary tendency to such 
attacks. The mere fact that on two separate occasions 
she manifested these peculiar phenomena, each time 
within fourteen hours after the chromic acid had been 
applied, could scarcely be interpreted as a mere coin- 
cidence. It certainly looked as if the two things were 
related to each other as cause and effect. But how to 
explain it? I never myself encountered anything of a ANGEIONEUROSIS OF THE TONGUE. 
5 
similar nature, and Dr. A. H. Buck, with, whom I talked 
over the case, said that he also had never heard of a 
similar occurrence. I made a careful search through 
an index of otological literature covering a period of a 
number of years hack from the present time, but 1 
entirely failed to find a single report of anything re- 
sembling the present case. 
The conclusion, however, seemed to be warranted 
that the oedema must in some way be due to the active 
stimulation of the chorda tympani nerve; and, although 
the text-books on physiology only speak of the symp- 
toms which arise from electrical stimulation of the 
chorda tympani nerve, nevertheless it must be possible 
for such phenomena as are here under consideration to 
occur from the stronger stimulation supplied by an irri- 
tant like chromic acid. In answer to the question, "Why 
did not the oedema manifest itself immediately after 
the application of the irritant? I may state that the 
nerve was doubtless surrounded by granulation tissue, 
and that consequently a considerable period of time 
might readily have elapsed before the acid (which, as is 
well known, spreads slowly through the living tissues) 
could exert its irritant effect upon the nerve. The first 
few applications, it may be assumed, gave rise to no 
oedema simply because the granulations were too ex- 
uberant at the time to permit the acid to penetrate the 
nerve filaments. But when we consider how frequently 
chromic acid is employed for the destruction of granula- 
tion tissue in this very neighborhood, it seems remark- 
able that phenomena of a similar character should not 
have occurred in the past and have been reported in 
medical literature. I might, as a matter of course, 
fall back upon the supposition that this particular pa- 6 
ANGEIONEUROSIS OF THE TONGUE. 
tient possessed an idiosyncrasy as regards the effects 
of this drug; but this would not he, it seems to me, 
either a satisfactory or a scientific way of disposing 
of the question. 
Although previous to the first attack she never 
had any similar oedema, yet very lately there has been 
a swelling of the left hand and of the ball of the left 
foot, but no glossal oedema. Undue mental excitement 
was the only cause to which I could attribute this last 
attack. The discharge from her ear, I might add, had 
in the meantime entirely ceased, and no evidence of ac- 
tive inflammation remained. 
In the belief that they may be of interest to the 
reader of this paper I will introduce here, without com- 
ment, a few quotations from different authorities in 
regard to the functions of the chorda tympani nerve. 
Foster, in his Text-book on Physiology (Macmillan 
and Company, New York, 1889, Book 111, chapter v, p. 
265), states that “ The chorda tympani... ends partly 
on the tongue and partly in a small nerve which, leav- 
ing the lingual nerve before reaching the tongue, runs 
along the duet of the submaxillary gland, and is lost 
in the substance of the gland; a small branch is given 
to the sublingual gland.” Again, in chapter v, page 
265: “ The chorda tympani contains afferent fibres 
which have a remarkable effect on the nutritive pro- 
cesses of the tongue, and the loss of taste due to the 
destruction of the chorda might be due to disordered 
nutrition of the tongue, and so be analogous to the 
loss of smell, which may follow injuries of the fifth 
nerve.” 
Dr. C. N. Stewart, in his Manual of Physiology 
(London, 1895, p. 129), states: “The best-known ex- ANGEIONEUROSIS OF THE TONGUE. 
7 
amples of vasodilator nerves are the chorda tympani 
and the nervi erigentes. The chorda tympani contains 
vasodilator and secretory fibres for the submaxillary and 
the sublingual glands. ... A most marked vascular 
change is produced by stimulation of the peripheral end 
of the chorda tympani nerve: the glands flush red; more 
blood is evidently passing through their vessels. Al- 
lowed to escape from a divided vein, the blood is seen 
to be of a light arterial color and shows a distinct pulse. 
The small arteries have been dilated by the action 
of the vasomotor fibres in the nerve. . . , These vaso- 
dilator fibres are apparently not in constant action, for 
section of a nerve, as a rule, produces little or no 
change.” 
In Kirkes’s Handbook of Physiology (American edi- 
tion, William Wood and Company, 1896, p. 305 et seq.) 
the following statements are made: “ The chorda . . . 
joins the lingual or gustatory nerve, proceeds with it 
for a short distance, and then passes along the duct of 
the submaxillary gland, to which it is distributed, giv- 
ing branches to the submaxillary ganglion and sending 
others to terminate in the superficial muscles of the 
tongue. ... If this nerve be exposed and divided any- 
where in its course from its exit from the skull to the 
gland, the secretion, if the gland be in action, is arrest- 
ed, and no stimulation either of the lingual or of the 
glosso-pharyngeal will produce a flow of saliva. But, 
if the peripheral end of the divided nerve be stimulated, 
an abundant secretion of saliva ensues, and the blood 
supply is enormously increased, the arteries being 
dilated. The veins even pulsate, and the blood con- 
tained within them is more arterial than venous in 
character. 8 
ANGEIONEUROSIS OF THE TONGUE. 
“ When, on the other hand, the stimulus is applied 
to the sympathetic filaments (mere division producing 
no apparent effect), the arteries contract and the blood 
stream is, in consequence, much diminished, and from 
the veins there escapes only a sluggish stream of dark 
blood. The saliva, instead of being abundant and wa- 
tery, becomes scanty and tenacious. If both chorda 
tympani and sympathetic branches be divided, the 
gland, released from the nervous control, may secrete 
continuously and abundantly (paralytic secretion). 
“ The abundant secretion of saliva which follows 
stimulation of the chorda tympani is not merely the 
result of filtration of fluid from the blood-vessels, and 
in consequence of the largely increased circulation 
through them. This is proved by the fact that, when 
the main duct is obstructed, the pressure within may 
considerably exceed the blood pressure in the arteries, 
and also that when into the veins of the animal ex- 
perimented upon some atropine has been previously 
injected, stimulation of the peripheral end of the di- 
vided chorda produces all the vascular effects as before, 
without any secretion of saliva accompanying them. 
“ Again, if an animal’s head be cutoff and the chorda 
be rapidly exposed and stimulated with an interrupted 
current, a secretion of saliva ensues for a short time, 
although the blood supply is necessarily absent. 
“ These experiments serve to prove that the chorda 
contains two sets of nerve fibres, one set (vasodilator) 
which, when stimulated, act upon a local vasomotor cen- 
tre for regulating the blood supply, inhibiting its ac- 
tion, and causing the vessels to dilate, and so producing 
an increased supply of blood to the glands; while an- 
other set, which are paralyzed by injection of atropine, ANGEIONEUKOSIS OF THE TONGUE. 
9 
directly stimulate the cells themselves to activity, where- 
by they secrete and discharge the constituent of the 
saliva which they produce. These latter fibres very 
possibly terminate in the salivary cells themselves. If, 
on the other hand, the sympathetic be divided, stimula- 
tion of the tongue by sapid substances, or of the trunk 
of the lingual, or of the glosso-pharyngeal, continues 
to produce a flow of saliva. From these experiments 
it is evident that the chorda tympani nerve is the prin- 
ciple nerve through which efferent impulses proceed 
from the centre to excite the secretion of this gland.” 
14 East Forty-fifth Street. The New York Medical Journal. 
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