RESTORATION 
OF THE 
Tyir\|>aqi. 
By S. O. RICKEY, M. D., 
Assistant Aural-Surgf.on to the Illinois Charitable 
Eye and Ear Infirmary. 
Extracted from the Transactions of the Illinois State 
Medical Society, Springfield, May, 1878. 
CHICAGO : 
II. Wilt.son & Co., Printers. 170 Clark Street, 
1878. kTOpOH OF THE MeMBR/NA lYMP^Nl. 
BY S. O. RICHEY, M. D., 
Assistant Aural Surgeon to the Illinois Charitable Eye and Ear Infirmary, 
Chicago. 
In commenting upon chronic suppuration of the middle ear, 
under the head of prognosis Dr. D. B. St. John Roosa says: 
“ T1 ie membrana tympani has a regenerative power second to 
no other membrane of the body. I have repeatedly seen it 
restored alter all but a narrow rim had been entirely swept 
away. When the membrana tympani is entirely removed, 
and one or more of the ossicula lost, the prognosis is grave.” 
It was stated by Dr. Turnbull, in 1872, that “If more than 
half the membrane be destroyed, it rarely heals.” Mr. Dalby, 
of London, in 1873, said: “To how great an extent large 
losses of substance in the tympanic membrane may, under 
favorable circumstances, be replaced by new tissue, seems un- 
certain ; at any rate, to the extent of half the membrane.” 
According to the observation of the writer, the cases in 
which the perforation can not be healed are rare, if proper re- 
gard be had for cleanliness, and the patient is persistent in his 
efforts. I have moreover observed that in case of a large per- 
foration of the membrane, the membranic tissue is more rap- 
idly renewed at first than after the perforation has become so 
small as to render it difficult for the surgeon to make local ap- 
plications to the middle ear. This stage of the process is the 
most trying to the surgeon and the patient, for when the per- 
foration has become small and the discharge has ceased, the 
vital activity of the parts may have so much diminished as to 
again require stimulation. This excitation, though slight, 
may be rendered so severe by some unexpected circumstance, 2 
as exposure to cold and dampness, as to renew the suppura- 
tion, which in turn keeps open the small perforation. This is 
one of the conditions which make the treatment tedious. 
A perforation originally small is often not easily healed for 
the same reasons. Mr. Dalby has found “ that a perforation 
of large or moderate size receives greater benefit from treat- 
ment than a very small one.” 
If we bear in mind that the middle ear is the part diseased, 
and that from it the vitality of the rnembrana is or the most 
part derived, it is a reasonable conclusion that the tympanum 
should be the part stimulated, and not the rnembrana tympaid 
itself. When, therefore, the perforation is large, it seems ra- 
tional treatment to give an impetus to the reparative action in 
the membrane before the new tissue interferes with the appli- 
cations to the middle ear. 
In these cases, nitrate of silver appears to be the best stim- 
ulant that can be used upon the diseased surface, and the first 
application of it should be very thorough. This will usually 
give considerable pain for several hours, and the excitement 
of the parts should not be allowed to get beyond control. Its 
subsequent use rarely gives much annoyance, as it seems to 
change the nature of the surface to which it is applied. The 
severity of the application should be governed by the previous 
duration of the affection, being stronger the greater the length 
of time the suppuration has lasted. 
In regard to the method of using nitrate of silver, it is nei- 
ther necessary nor justifiable to give into the hands of a pa- 
tient a solution of it to be instilled into the ear, as staining of 
the face and clothes is an almost certain result. It is one of 
the applications which should be made by the surgeon himself, 
and even then, with usual care, the auricle and the outer por- 
tion of the meatus will at times become blackened. It may 
be used in any strength, from ten grains to an ounce of water 
to a saturated solution ( 3 i. tof. 3 i.), as the case may require, 
and should be applied by means of a cotton holder. In this 
manner the application can be made to any part to the exclu- 
sion of other parts. Where the membrane of the drum had 3 
all sloughed away, in the eases observed by me, the process ot 
reparation began in the upper and anterior segment, and ex. 
tended downwards and backwards, the last of unrenewed tis- 
sue being in the post-inferior quadrant. 
The patient should wash the ear frequently with warm wa- 
ter and a syringe; but this will not always remove the pus 
from the interior surface ot the membrana tympani. This ob- 
ject can best be accomplished by means of a warm alkaline 
solution, forced through the eustachian catheter into the mid- 
dle ear. This farther assists the purpose of keeping open the 
eustachian tube, for in many ot these cases the non-suppura- 
tive form ot inflammation has preceded the suppuration, and 
if, under these circumstances, the membrane is entirely re- 
stored- while the eustachian tube remains diminished or closed, 
tinnitus and oppression at once result. This method has the 
advantage over forcing water from the external meatus through 
the tympanum and the eustachian tube, in that there is not 
the same danger to the internal ear or the brain; it does 
not produce a like faintness and dizziness, nor does it wash 
the pus from the middle ear into the throat. It forces the pus 
into the external meatus, whence it may be removed by the 
surgeon. In the case of an irritable child, for whom the cath- 
eter can be used oidy at disadvantage, if at all, the progress of 
repair is usually more protracted than in one whose middle 
ear is easily cleansed in this manner, thus proving the advant- 
age of the procedure. In any event, a healthy state of the 
tympanum is a requisite to a satisfactory result, for though 
the suppuration may have ceased, and the perforation may be 
closed, yet if the tympanic mucous membrane continues irrita- 
ble, a very slight exciting influence may at any time cause a 
return of the previous condition. 
Dr. Roosa reports a case similar to those recorded below, in 
which the membrana tympani and the ossicula auditus had 
sloughed away. The left membrane was restored, with 
marked improvement in hearing, in the space of ten months. 
The patient was young, and the inflammation was recent. 
Appended are the histories of two out of five cases of re- 4 
storation of the mem bran a tympani. In one of the five eases 
there was necrosis and removal of the cochlea ol the left side,* 
three of those referred to having lost but one membrane. 
Case 1.—Feb’y 1st, 1877, Henry Blass, aged 51 years, 
claimed that he had been afflicted with purulent discharge 
from both ears for twenty years, and that during the whole 
time his hearing had been no better than I found it to be upon 
examination. The watch could not be heard when pressed 
upon either ear. Words spoken slowly and distinctly, and in 
a raised voice, could scarcely be comprehended. The vibra- 
tions of the tuning-fork were heard when it was placed upon 
the vertex, or upon either mastoid process. Each external 
meatus contained a quantity of green pus, the removal of which 
by syringing the ear exposed a raw and ulcerated surface in 
the tympanum of the right side. Enlarged blood vessels 
could be seen passing over the promontory of the left middle 
ear, which contained numerous polypoid granulations. The 
membrana tympani were both destroyed, nothing remaining 
except the annulus tendinosus. A small knuckle of bone, 
the short process of the incus, clung to the upper and anterior 
portion of the tympanum. The malleus was gone. Cleans- 
ing the ears and inflating them with air did not improve the 
hearing. Frequent syringing and an astringent lotion were 
prescribed. 
He complained at subsequent visits that syringing bis ears 
gave much pain. Nitrate of silver was used topically. 
By June 28, 1877, the suppuration had ceased in the left 
middle ear, and the membrane of the drum of this side was 
entire. The right membrane did not at the time show any 
disposition to follow the course of its fellow, and there was 
still suppuration from the right middle ear. H. D. Ik E.— 
0 • TT T) r F 2 inch. 
watch, 12 ft. * ... watch, 12 ft.* 
September 15, 1877, suppuration from the right middle ear 
had stopped, and the right membrana tympani was restored, 
*Reported in the Chicago Medical Journal and Examiner for April, 
1878 5 
except a small perforation, such as could be made by a pin, in 
the post-inferior quadrant. H. D. R. E. —wat(!l'1—J''lt ; L. E.— 
101"ch- The right membrane occupies nearly the normal 
position of the membrana tympani, though unsupported by 
the manubrium mallei. The left membrane is attached to 
the annulus tendinosus anteriorly; posteriorly, it adheres to 
the inner wall of the tympanum. The annulus may be seen 
external to the new membrane posteriorly. The left mem- 
brane reflects from a spot in its post-inferior quadrant. The 
patient has had tinnitus aurium in the left ear since the restor- 
ation of the membrane, which was relieved by the treatment 
usual in the noil-suppurative form of inflammation of this 
organ. 
Case 2.—Henry Foesch, of Chicago, aged 21 years, was 
first seen Nov. 6, 1877, and then stated that when 18 months 
old he had measles, followed bv suppuration of both ears, 
which continued for sixteen years. Three years ago he had 
another attack of inflammation, which pained so much that 
he did not sleep for two weeks.” 
An examination showed about the same structural condi- 
tion as in the former case. Both membranse tympani had 
been destroyed, leaving only the annulus tendinosus; the 
malleus was absent from each ear, and the other ossicles 
seemed bound to the roof of the tympanum by adhesions. 
The tympanic blood-vessels were very large, and tire posterior 
and inferior part of the inner wall of the left middle ear was 
covered with granulations. The patient had no pain in either 
ear. Pie could hear the sound of the voice read- 
ily, but could not distinguish words without an 
effort. H. D. R. E. L. & — 
December 20th, about six weeks later, the 
membranes were nearly restored, the perfora- 
tions being very small, and situated in the post- 
inferior quadrants of the new membranes, which 
were convex externally, the convexity increas- 
ing towards the perforation. 
FIG. 1.—The inside 
white ring, the an- 
nulus tendinosus. 
The process Of the 
incus, and the carti- 
laginous socket of 
the malleus head in 
front and above; the 
black space was oc- 
cupied by the mem- 
brane which is lost. 6 
Fig. 2 represents the appearance of both membranes at 
that time. 
Two weeks later he had acute inflammation of 
the right middle ear, with suppuration, which 
enlarged the perforation of the right membrane, 
which then appeared as in Fig. 3. The left membrane had 
more vitality, and perforation then very 
small, fmt gradually increasing. 
Jan. 10, 1878, there was very little discharge 
from' the right middle ear, and the perforation 
of the right membrane resembled that seen in Fig. 4. The left 
membrane was entire. II. D. II. E. 64nch- ; 
L# e. 10>nch- 
watch, 12 If" 
March 21st: H. I). R. E. 25‘nch, ; L. E.— 
watch, 12 ft. - 
34 inch, 
watch, 12 ft. 
April 30th: H. D. R. E. ; L. E.— - 44lnch- . 
l watch, 12 ft. 7 watch, 12 ft. 
The eustachian tubes wTere free; there was no tinnitus, no 
suppuration from either ear, and his hearing was sufticient 
for ordinary purposes, conversation in the usual tone being 
readily heard and understood. 
Though the progress in the first case was essentially the 
same, yet it was not so rapid as in this one. This fact may 
be attributed to the difference in the ages of the two patients, 
as the inflammation had existed for a like time in each, and 
the structural changes were virtually the same. In each case 
the left membrana tympani grew more rapidly than the right, 
and the hearing distance is proportionately greater in the 
left ear. 
Fin.2. 
Fin. 3. 
Errata.—Page 4, 18th line, first word, for “ membrana ” read “mem- 
bran®.” Page 5, 2nd line, for “watch, 13 ft.” read “watch, 12 ft.”