Cases exhibiting the Results 
of Multiple Paracentesis of 
the Drum Membrane on the 
Hearing in Chronic Aural 
Catarrh, with Remarks. 
BT 
OREN D. POMEROY, M. D. 
UEP1UNTED FROM 
die 'Neto York fttetiical Journal 
for February 12, 1887. Reprinted from the New York Medical Journal 
for February 12, 1887. 
CASES EXHIBITING TIIE RESULTS OF 
MULTIPLE PARACENTESIS OF TIIE DRUM MEMBRANE 
ON THE HEARING IN CHRONIC AURAL CATARRH, 
WITH REMARKS* 
By OREN D. POMEROY, M. D. 
Paracentesis of the drum membranes in very chronic 
cases of aural catarrh, where there is not only no increase in 
the secretion but an almost total absence of even the nor- 
mal amount, has been done for some years. The object so 
far has been to relieve deafness and tinnitus aurium. It 
has heretofore accomplished very little for the hearing and 
less for the tinnitus. 
In the “ Transactions of the American Otological So- 
ciety ” for 1873 L published some cases in which a single 
puncture of the drum membrane had been made, with only 
very moderate effect on the hearing and somewhat less on 
the tinnitus. I have employed the operation occasionally 
since that time with varying results. 
Within the year one of my assistants, Dr. Dates, hear- 
ing the explanation I gave of the cause of relief to the sunk- 
en membrane—that is, the diminution of the superficial 
area of the membrane consequent on cicatricial contraction 
* Head before the Medical Society of the State of New York at its 
eighty-first annual meeting. 2 
MULTIPLE PARACENTESIS OF 
at the site of the punctures, thus exerting a degree of out- 
ward traction on the more or less impacted stapes in the 
oval window—suggested that several punctures at a sitting 
would be likely to increase this effect. I replied that it 
would, and gave my consent to have the matter tested on 
some of my patients at the Manhattan Eye and Ear Hos- 
pital. The result was sufficiently satisfactory to lead us to 
continue the operation. At about this time Dr. Bates re- 
ported four cases in the “Medical Record” for January 23, 
1886, operated on in a similar manner to what had been 
suggested, and calling it a new method, etc., for curing 
deafness. No acknowledgment was made of what I my- 
self had done in the matter. The method recommended 
by the doctor, however, extended to numerous incisions of 
the membrane, after the manner of Gruber and Politzer, re- 
sulting in an amount of traumatism which I could not 
approve of, and in at least one of the doctor’s cases consid- 
erable inflammatory reaction resulted, which is not likely to 
occur in the method by paracentesis. 
On an average, about four punctures of the membrane 
were made, generally in the postero-superior portion, al- 
though some were made in front of the manubrium. Where 
any part of the membrane was in apposition with the inner 
wall of the tympanum, some other portion for puncturing 
was sought out, for the sufficient reason that little or no 
aperture was likely to be made in the former location. The 
puncture of the membrane opposite to a less sunken part 
would of course allow the knife to penetrate deeper and 
make a larger opening. It has been insisted upon that a 
tolerably distinct perforation whistle should be produced 
after the punctures by inflation. 
In a considerable number of cases it was found that the 
membranes were sunken so as to rest upon the promontory. 
In these instances, in order to make a proper puncture of THE DRUM MEMBRANE. 
3 
the membrane, many points needed to be sought out to 
find where the membrane inclosed a cavity—that is, if a 
puncture were attempted opposite a totally collapsed por- 
tion, naturally no aperture was likely to be made, or, if so, 
it would be too minute for any useful purpose. 
Tn carrying out this procedure it became necessary in 
some cases to make from five to eight essays before a suffi- 
cient number of actual punctures could be made. In not 
more than two or three cases was it impossible to produce 
the perforation whistle. The duration of time between the 
punctures at a given sitting was from three days to three 
weeks. It was not considered proper to repeat punctures 
as long as there was any considerable hyperaemia or tender- 
ness in the membrana. Where there was great collapse of 
the membrane the performance of inflation aided in some 
cases in the operation. The pain of the operation was ordi- 
narily trifling, but when the patient seemed sensitive a few 
drops of a four- to eight-per-cent, solution of cocaine, placed 
upon the membrane by means of a dropping tube, sufficed 
to make the operation tolerable to the patient, or even in 
some cases absolutely painless. It has been urged by some 
that repeated punctures of the membrane were likely to lead 
to adhesions to the promontory. This may be the case 
where active adhesive processes are at work in the tym- 
panum, but I infer that in all the cases operated upon noth- 
ing of this kind existed, the patients being in a too ad- 
vanced stage of inflammation for this to occur. Certain it 
is that nothing of the kind has resulted, but, on the con- 
trary, the membrana in several instances has been drawn 
outward sufficiently to demonstrate by the touch of a probe 
that the membrane no longer rested upon the promontory 
as at first. This in the hands of one at all experienced in 
the manipulation is not difficult. In not a single instance 
has a considerable amount of inflammation of the membrana 4 
MULTIPLE PARACENTESIS OF 
or drum cavity resulted, and the hearing has not been low- 
ered. I could not at first credit the assertion made that the 
hearing was so much improved in some of the cases, hut, on 
a careful examination myself, I was compelled to admit the 
truth of the observation. 
Nothing is more difficult than to make a perfectly re- 
liable test of the hearing; the patient is in a hopeful state 
of mind, and is ready to say he hears better when the facts 
do not always warrant the assertion. Usually the hearing 
was lowered for from two to four days after the opera- 
tion, although, as has been observed before often enough, 
the hearing may be better immediately after the punctures, 
the thickened membrane offering obstruction to sound waves, 
and the puncture at first removing this obstruction. In all 
these cases a Graefe’s very narrow cataract knife was used. 
The reason for this was, first, a straight instrument may be 
used with the infliction of less violence than one with the 
handle placed at an angle with the blade; and, second, the 
Graefe knife punctures with the infliction of less violence 
perhaps than any other instrument. It was not the object 
of the operation to make any large punctures or considera- 
ble incisions, for fear the membrane might be deformed or 
caused to adhere to the promontory; another point was 
carefully kept in mind—not to excite inflammation by un- 
necessary traumatism. It is not necessary to discuss the 
question as to whether the punctures were likely to remain 
open, for this rarely occurs, the tendency of the membrane 
to repair almost immediately being well known. In some 
instances the punctures allowed air to be forced through for 
only a few hours, while in others several weeks elapsed 
before no air could be forced through the membrane. 
One effect of multiple puncture of the membrana tympani 
I hope will be found to be the permanent improvement to 
the hearing resulting from inflation. As is well known, TI1E DRUM MEMBRANE. 
5 
many patients come to us with the hearing much lowered, 
but susceptible of great improvement by inflation. The 
tubes seem pervious enough—nay, in many instances, too 
pervious. The hearing seems not to be at its best unless 
there is a sufficient amount of intra-tvmpanal air-pressure to 
push the membrane outward and in a measure draw the base 
of the stirrup from its impaction in the oval window. The 
membrane, being elastic, presses against this condensed air, 
and the moment the Eustachian tube opens from any cause 
whatever, the excess of air in the tympanum is, so to speak, 
pressed out of the middle ear into the throat by the elas- 
ticity of the membrana tympani (and also by its own elas- 
ticity), and the stapes returns to its former position of im- 
paction. Many devices have been employed to correct this 
faulty position of the membrana tympani, such as exhaustion 
of the air in the meatus, hermetically closing the meatus 
(Politzer), painting the membrane with collodion, division 
of the tendon of the tensor tympani, division of the posterior 
fold, etc., and all with only a measure of success. Some of 
our cases, notably Case II, seem to show that the numerous 
punctures have caused a real diminution in the superficial 
area of the membrana tympani, where the disappearance of 
the excessive movement (bleb-like) of the membrana tym- 
pani during inflation occurred. In those reported cases 
where the membrana tympani rested on the promontory 
previous to the punctures, and subsequently to the opera- 
tions remained some distance from it, as determined by the 
touch of a probe and Siegle’s otoscope, further evidence 
seems to accumulate confirmatory of this proposition. Is 
the improvement to the hearing permanent ? Some of these 
cases have been under observation two years, and there 
seems little or no tendency toward relapse unless we reject 
the recurring cases of catarrhal otitis, which would not in- 
validate this proposition. 6 
MULTIPLE PARACENTESIS OF 
Case I.—J. S., aged forty, otitis media chronica. Mem- 
branes so much sunken that during inflation their movements 
were so considerable as to cause a loud clicking sound easily 
1" 
audible at some distance. II. I). R. n. - (the clicking of the 
finger-nails together may he heard at about sixty feet), L. the same, 
p. 3" 
After inflation, II. D. R. w. —, L. n. — hut this was moment- 
40 60 
ary. On September 24th two punctures were made in the R. 
and three in the L. Four days afterward, II. I). R. n. 
2'/ 60 
L. —„ two punctures were made in each drum-membrane. Oc- 
tober 4th, made five punctures in the R. and three in L. 
10" 0" 
October 10th.—II. 1). R. n. —> L. —Three punctures made 
60 60 
in the R. and four in the L. 
14" , 12" 
20th.—II. D. R. n. — „ L. n. ——. This makes a gain in R. of 
14" against 1", and in L. about the same. 
Case II.—Dr. W., aged thirty, has had an otitis media chronica 
in R. for many years. The membrana tympani has a cicatricial 
look as though there had been an old suppurative inflammation. 
The history confirms this. The II. D. is w. 2", after inflation 
36". The Eustachian tube is too pervious, and interchange of 
air between the middle ear and tympanum too frequent, and it 
is also too readily forced by Valsalva’s operation. The act of 
deglutition immediately lowered the hearing to two inches. On 
November 11th four or five punctures were made in the mem- 
brane. Three days after this the hearing was lowered, and was 
not improved by inflation. Before the punctures were made 
the membrane moved outward excessively during inflation, pre- 
senting a bleb-like bulging. 
On November 15th, II. I). w. 4", after inflation 20". Mem- 
brana tympani did not move outward during inflation except 
very slightly. Deglutition with the nostrils closed did not lower 
the hearing as at first. No bulging of the membrana tympani 
has been noticed since the punctures were made. On the 24th THE DRUM MEMBRANE. 
7 
of November the II. D. was w. 8" to 9", not improved by infla- 
tion nor lowered after swallowing. November 27th, II. D. w. 
6" to 7", after inflation 14" to 16"; here was a permanent gain 
from watch 2" to watch 6 to 7". The constant voice-hearing 
was also greatly improved. 
Cask III.—Mary F., aged thirty-three, otitis media chronica 
for several years. On admission, January 4, 1886, II. D. R. w. 
11" U" 
—Tr Left —fn not improved by inflation. 
oU oO 
January 8th.—Punctured both membranes four times each, 
two in front and two behind the malleus handle. The left 
membrana tympani touched the promontory, and the right was 
so sunken that no air escaped after the punctures. 
15th.—Both membranes punctured and perforation whistles 
elicited ; membranes not so much sunken. On January 17th, 
5" 11" 
II. D. R. w. —Tn L. —Tf\ a considerable gain in right and none 
oil oU 
in left. 
Case IV.—Ellen B., aged thirty-five, otitis media chronica 
of long duration. Applied December 16, 1885. II. I). R. w. 
V' If* 
—L. w. —-. On December 28th four punctures were made 
30" 30" 1 
in each membrane, two in front and two behind mal. handles. 
Cocaine was used, which produced some anaesthesia. Hearing 
lowered by the operation. 
2" 4" 
January Ifth.—II. D. R. w. , L. w. . January 6th, four 
30 30 
punctures made in each as before; caused some pain. January 
8'/ 3// 
llth, II. I). R. w. —L. w. —-. On same date did four punct- 
’ 30" 30" 1 
ures as before. Cocaine was used, which relieved any pain 
which might otherwise have resulted from the operation. This 
showed a gain of six inches and a half in the right and two 
inches and a half in the left. 
Case V.—Peter McE., aged forty-six, otitis media chronica. 
Applied for treatment November 18,1885. II. I). R. w. contact, 
2" 
L. n. —r Paracentesis of right membrana tympani as done in 8 
MULTIPLE PARACENTESIS OF 
previous instances. On December 6tb, left done in the same 
manner. On the 16th of December the left meinbrana tympani 
somewhat reddened. On same date botli membranes again were 
punctured, four times in each; tinnitus somewhat diminished. On 
5" 4" 
December 18th, H. D. R. w. L. n. On 23d, H. D. R. w. 
5" 6" 
—, L. n.—■_ On this date repeated the punctures in each. In 
30"’ 60' 
this instance the right gained five inches and the left two inches. 
Case VI.—Edith II., aged thirty-five, otitis media chronica 
and desquamative inflammation of meatus externus. Was treated 
in the usual way until December 4th, when each membrane 
x" 
was punctured. Previous to this the H. D. was R. w. —^ 
41" 1" 41'' 
after inflation — ; L. w. —, after inflation —Tr On December 
ou oO oO 
8" 6" 
14th H. D. R. w. after inflation, w. the same. L. w. —-n 
8" 
after inflation —By January 27th both membranes had 
oO 
been punctured three times, and the hearing had risen to 6"-8" 
in each ear, and was unaffected by inflation. 
February 5th.—Both membranes punctured ; no change in 
hearing. 
March 17th.—Recorded that the tinnitus had been relieved. 
12" 11" 
April 28th.—II. D. R. w. —L. ; neither improved by 
oO oU 
inflation. 
15" 
May 21st.—R. and L. hear the watch about „ not per- 
oO 
ceptibly modified by inflation. Here was a gain from 1" in 
each, increased to 41 after inflation, to 15" in each, not im- 
proved by inflation. The treatment wras continued five months. 
At first there was great difficulty in making her hear ordi- 
nary spoken words, but at the termination of the treatment 
ordinary conversation could be heard with great comfort. In 
this instance the maintenance of the improved hearing by 
inflation was accomplished, and considerable hearing added to 
this. THE DRUM MEMBRANE. 
9 
Cask VII.—Mr. G., aged fifty-eight, a porter, lias had 
chronic middle-ear disease for several years, although he has 
never noticed that the right ear was affected. Right hears w. 
in contact, left not at all; not improved by inflation. Has had 
tinnitus in the left for three months, which came on suddenly 
from having caught cold. Bone-conduction weakened in left. 
The tinnitus was not relieved, though potassium bromide, hydro- 
bromic acid, and paracentesis were employed. The left mem- 
brane was punctured on three different sittings at intervals of 
from four to six days, four punctures being made each time. No 
cocaine was used; the operation was scarcely painful at all, and 
no inflammation or soreness resulted from the operations. The 
improvement was from w. 0 with poor voice-hearing to w. con-- 
tact and comparatively good voice-hearing. Eustachian tubes 
at all times pervious, and could be inflated by Valsalva’s opera- 
tion more easily than in normal cases. 
Case VIII.—Miss K. L. F., aged twenty-six. Otitis media 
catarrhalis chronica in both for the space of three years. Tin- 
nitus constant in left ear; never any in right. Signs of excessive 
sinking of drum membranes. 
2 
Hearing, right w. —; left, not hear watch at all. Little or 
4o 
no improvement on inflation. 
On March 17, 1886, did double multiple paracentesis. Two 
weeks after, repeated the operation on the left. This was re- 
peated, at intervals of ten days, four times, making six opera- 
tions in all. At each sitting five punctures were made. Co- 
caine was used, which diminished the pain of the operations, 
but did not render the patient insensible to them. After the 
third series of punctures on the left ear, the hearing rose to 
watch in contact, with voice-hearing very much improved. The 
voice was readily heard at two feet. The noise is still constant, 
hut does not trouble as much as formerly. At first she could 
not sleep in consequence of it, but now there is no difficulty in 
sleeping. Bromides and hydrobromic acid had no effect on the 
tinnitus. Pharyngeal catarrh has been treated, more, however, 
for the benefit of the right ear. Hearing fluctuates in both ears 
with atmospheric changes, less so in the left than the right. 10 
MULTIPLE PARACENTESIS OF 
Cask IX.—J. Van L)., ;iged thirty, otitis tiled, cliron.; tin nit. 
in both. R. hears finger-nails at 2", and L. at 2U". li. mem- 
brana tympani touched the promontory. 
Four punctures made in each membrana tympani on January 
11, 1886, and January 29th, II. D. R. n. 30", L. n. 30". 
Case X.—llenry V., aged twenty-eight, applied June 3, 
1885, with otitis med. chron. for five or six years. Tinnitus in 
both. Had syphilis five years ago. Hearing, R. and L. n. 
Paracentesis was done on each membrana tympani (four to six 
punctures each) on November 25th, November 30th, December 
4th, and December lGth. No special reaction from the punct- 
ures, and as a result the tinnitus was diminished and the hear- 
ing somewhat improved. 
Cask XI.—Bridget R., aged filteen, applied for treatment 
June 26, 1885, with chronic middle-ear catarrh since early 
childhood. II. D. R. n. 4", after inflation 10"; L. n. 1", after 
inflation 8". Ordinary treatment not succeeding in accomplish- 
ing anything, paracentesis of both membrarue was done on Oc- 
tober 4th. This was repeated on October 7th on the R., and on 
the L. on October 9th. On October 12th paracent. of R. Para- 
centesis was done three times on each membrana tympani be- 
tween this date and October 30th, when II. I). R. was n. 5", 
after inflation 8" ; L. n. 1", alter inflation 4". The result here 
was altogether nil, and, in spite of the large number of paracen- 
teses in each (nearly forty), the hearing was not lowered nor 
was there any considerable reaction. 
Case XII.—Jane L., aged twenty-five, has chronic middle- 
ear disease in both, with tinnitus in R. Commenced treatment 
on January 4, 1880. II. I). R. w. c. not improved by inflation ; 
L. w. 3", and not improved by inflation. On January 6th para- 
cent. on R., and on January 11th paracent. on L. On February 
5, 1886, H. D. R. w. c., after inflat. w. 1"; L. unchanged. Pa- 
tient says hears voice better in R. There evidently was no im- 
provement in L. Did not return for further treatment. 
Case XIII.—Mary B. Van II., aged sixty-eight, has chronic 
middle-ear disease in both, with tinnitus; the latter seems to 
cause headache. Malleus-handles almost horizontal, with other 
signs of sinking of membrana tympani. Applied for treatment TilK OKI M MEMBRANE. 
11 
January 8, 1888. II. D. R. and R. n. contact. On January 
lfitb paracentesis in both. January 22d, II. I). R. and L. 
n. 1". Noises much less, and do not cause headache as be- 
fore. The gain to the hearing in this case is almost too slight 
to record. 
Case XIV.—August K., aged twenty-seven, otit. med. cat. 
chron. January -1, 1880, II. I). R. w. pressed, after inflat. V'; 
L. n. 2", after inflat. 4". January 15th, paracent. of II., aud on 
20th both were punctured. On January 25th both membranse 
again punctured ; R. membrana tympani resting on promontory. 
Punctured again on February 5th. On February 8th II. D. R. 
w. J", slightly improved by inflation. L. w. contact, increased 
to w. J", which was at first n. 2", increased to 4" by inflation. 
There was a decided increase in L. In this ear bone conduction 
was reported to be somewhat weak. 
Case XV.—J. J. F., aged thirty-five, otitis med. cat. chron. 
January 18, 1880, II. I). R. n. 1J", after inflat. 2"; L. n. 4", after 
inflat. 20". January 20th paracent. done on both. This opera- 
tion was repeated on January 25th, February 14th, and Feb- 
ruary 28th. Cocaine, a four-per-cent, solution, used without 
relieving the pain from the operation. The II. D. in this case 
was unaffected by the punctures. 
Case XVI.—Henry Van I)., aged twenty-eight. January 
3, 1885, applied on account of a chronic otitis med. with laby- 
rinthine complications. Hears neither watch nor nails in each 
ear, but the tuning-fork may be heard six seconds in each by 
aerial conduction. Bone-conduction absent in R. and just per- 
ceptible in L. Suspected syphilis. October 10th, both mem- 
branes punctured. October 10th, punct. R. Again punctured 
R. on October 21st. October 24th, both were punctured. On 
February 8, 1886, II. I). R. n. 1", after inflat. L. n. 1£", 
after inflat. 1J". On December 18th the record places the II. I). 
R. n. 10", after inflat. 0"; and of the L. n. 20", after inflat. 30". 
I conclude that this patient might have been still further im- 
proved had treatment been continued. The signs of labyrinth- 
ine disease in this case seemed to indicate that it was secondary 
to middle-ear disease, and possibly connected with a syphilitic 
condition, 12 
MULTIPLE PARACENTESIS OF 
The following cases are from the practice of Dr. Neil J. 
Hepburn, assistant surgeon to the Manhattan Eye and Ear 
Hospital, who has kindly placed them at my disposal: 
Case XVII.—J. F., a lawyer, aged thirty-five, has a chronic 
otitis media, presenting the usual appearances on examination. 
_ g" 15" 3" 20" 
H. D. R. w. L. w. after inflation, R. w. L. w. -T/. 
Two minutes after the last observation the hearing dropped to 
the first statement. Treatment of the Eustachian tubes failing 
to maintain the improvement gained by inflation, paracentesis 
of the membranes was tried on September 20th, when five 
punctures were made in each membrane with the temporary 
effect of lowering the hearing, but one week afterward there 
was improvement. On October 25th four punctures were 
24" 22" 
made. On November 1st the H. D. R. was w. L. w. —7 
40 40 
After two months the patient again reported with II. I). R. w. 
20" 26" 
40"’ k* 46"’ much le99 retracted in right, not attached to 
the promontory, fewer signs of sunken membrana tympani; 
other in similar condition. 
Case XVIII.—C. S., tobacco-wrapper, aged twenty-one, 
was first seen September 15, 1886. Both membranes much re- 
tracted, but under inflation moved outward promptly with a 
1" 
click-like sound. R. heard the snapping of finger-nails at — /, 
3" 
after inflat, heard the w. pressed on auricle; L. nails —. 
Punctured membranes on September 24, 1885, September 28th, 
October 4th, October 10th, and October 20th. On December 
20" 14" 
13th the hearing was R. w. L. w. —77. (This improvement 
seems to me almost unaccountable, and, as will be seen, is fur 
above the average.—O. D. P.) 
Case XIX.—W. II. G., aged twenty, has otitis med. chron. 
of three years’ duration, mostly of the right ear. The left soon 
rose to perfect hearing by other treatment, so it is not recorded. THE DRUM MEMBRANE. 
13 
The right membrana tympani mucli sunkeu in front and behind 
the malleus handle, so that the latter appeared as a ridge divid- 
ing the membrana tympani into two unequal portions. There 
was a light reflex in front and another behind the manubrium. 
1" 
Hearing, w. not improved by inflation. On October 10th 
made three punctures in the membrana tympani. It was found 
adherent to the promontory (or in contact with?), there being 
no movement under inflation, and the touch of the knife 
showed no yielding of the membrana tympani. October 17th, 
8" 
hearing of the li. w. —; four punctures made in the posterior 
20" 
portion. October 24th, bearing w. TqT). Membrana tympani no 
longer resting on promontory, but may be freely indented on 
pressure with a probe. November 21st hears the watch at 25", 
and is so satisfied with the result as to discontinue further treat- 
ment. 
Case XX.—E. F., a domestic servant, applied November 11, 
1885, with chronic middle-ear disease dating back to childhood. 
Treatment by ordinary means failed to improve, so she had to 
1" 11" 
leave her place. R. hears w. L. nails No special im- 
40" 60' 
provement on inflation. November 25th, five punctures of left 
5" 
membrana tympani; one week later heard a watch at — 
40 
Subsequent to this two punctures were made in the right and 
10" 
three in the left. December 12th, R. heard the watch 
12" 
L. w. ~—r Some tinnitus in left. She returned to service with 
40 
sufficient improvement of hearing to retain her place, but was 
unable to continue treatment. Bone-conduction was at first 
better in the ear with the better aerial hearing, but I do not 
conclude that the examination was complete enough to prove 
that the worse ear had labyrinthine complication. 
Case XXI.—Mrs. M., aged forty-eight, chron. otitis media 14 
MULTIPLE PARACENTESIS OF 
for several years, for which she has been treated without bene- 
4" 6" 
tit. R. hears the watch L. —7-.. Inflation does not irn- 
40 40" 
prove, and the membranes move only slightly. December 7th 
made three ])unctures in each membrane, which lowered the 
hearing. By December 18th the hearing had increased to R. 
14", L. 20", when two punctures were made in each membrane. 
Ten days subsequent the hearing of the R. was w. 24", L. 30". 
AY as ordered to return if hearing lowered. 
Cask XXII.—Miss CL, with chronic middle-ear disease of 
R. Left normal. Commenced treatment December 8, 1885. 
14" 3" 
Hearing w. After inflation, No further improve- 
ment could be gained by ordinary treatment, so on Decem- 
ber 15th two punctures were made. On the 19th hearing 
8" 
was vv three more punctures were made. On the 22d 
the hearing rose to 18", when two more punctures were made. 
On December 29th heard a watch at 21", and wan not imjtroved 
23" 
by inflation. Reported on January 17th, with II. D. w. —7/, 
but wan rendered lower by inflation. Dismissed. 
Case XXIII.—Mrs. M., aged thirty-one, applied September 
20, 1880, for a tinnitus, vertigo, and hardness of hearing in the 
left ear; right nearly normal. The symptoms of vertigo have 
worried her very much, she fearing brain trouble. The mem- 
brana tympani is much retracted, and adherent to the promon- 
tory. 
Hears a watch at 14", increased to 24" after inflation. Two 
punctures were made in the membrana tympani with little effect 
on the hearing, but by October 5th the vertigo was much less- 
ened. 
October 18th.—Again punctured, and by November 1st the 
hearing was w. 54", and there was no vertigo. 
December lflh.—About as on last note. Patient refuses 
further treatment, as she thinks 3he hears well enough, and has 
no unpleasant symptoms; moreover, the pain of the operation 
seems to have intimidated her. She has the impression that THK DRUM MKMRKANK. 
15 
tiie hearing is constantly improving. Result, permanent im- 
provement, from watch H" to 5", the latter not affected by 
inflation, and the vertigo completely relieved. 
Case XXIV.—11. McG., aged thirty, applied October 17, 188b. 
Right ear suppurating; left, chronic middle-ear disease for a 
long time; hears w. 3", increased to 7" by inflation, but, on 
swallowing, the hearing returned to former distance. Mt. 
sunken, but movable during inflation. Five punctures were 
made; these were two in front and three behind malleus- 
handle. 
October 2Jfth.—Hears u watch 5" before and 9" after infla- 
tion. On October 31st, H. 1). w. 10", increased to 14" by infla- 
tion. Two punctures made. 
November lJfth.—II. I), w. 15"; not improved by inflation. 
Subsequent punctures were made, but no further improve- 
ment was gained. 
The patient did not return. Here was a permanent gain of 
from w. 3" to w. 15", and no loss of hearing on emptying the 
tympanum of air by the act of deglutition, as at first. 
This series of cases seems to me exceptionally good, 
but it will be observed that none of them belong to the 
order of somewhat desperate cases for which the operation 
is thought to be more applicable. 
Summary.—There were in all twenty-four cases, of 
which eleven showed decided improvement to the hearing 
in both ears, namely, Cases I, IV, V, VI, IX, XVI, XVII, 
XVIII, XIX, XX, XXI. 
There was considerable gain in the hearing of one ear 
in Cases III, XII, XIV, but no improvement in the other. 
In Case II there was great improvement to the hearing in 
one ear by inflation, but it was not maintained until after 
the punctures, when the hearing permanently rose from 
2" to 15” (this was the case where the bulging of the mera- 
brana tympani during inflation ceased after the punctures 
of a single sitting). In Cases V and XIII the tinnitus was 
somewhat diminished. 16 
MULTIPLE PARACENTESIS OF 
Case VI showed most extraordinary improvement to 
hearing, which was maintained without the necessity of in- 
flation. The observation was made in this case with great 
care, and is undoubtedly reliable. 
Case VIL showed decided improvement in the hearing 
of the one operated on, but the tinnitus was unaffected. 
Case V III showed considerable improvement to the hear- 
ing, and some diminution of the tinnitus. 
Case X showed some improvement to the hearing in each 
ear, and the tinnitus was diminished. 
In Case XI there was no improvement whatever; but 
no diminution of hearing followed, although more than 
forty punctures were made. 
Case XIII showed little or no improvement, and Case 
XV was not improved at all. In Cases XVII and XIX, 
where the membranes were in apposition with the promon- 
tory, the operations resulted in removing them from con- 
tact with the inner tympanic wall. 
In Case XXII, where one membrane only was operated 
on, the hearing rose from watch 3" to watch 23". Similar 
observations for Case XXIV. 
In Case XXIII the one ear operated on was much im- 
proved in the hearing, and a very unpleasant vertigo was 
relieved. 
Gruber and Politzcr, who have written more on the sub- 
ject of similar operations on the drum membrane than per- 
haps any other, seem to exhibit some confusion in stating 
conditions—one insisting that the membrane is relaxed, while 
the other speaks of it as in a state of tension. I believe 
both are right, under certain limitations. When the mem- 
brane is at first sunken from closure of the tube, there is 
great pressure on its outer surface, and naturally it is put 
upon the stretch—is in a state of tension. Subsequently, 
when the tube becomes pervious, as in most of my cases, THE DRUM MEMBRANE. 
17 
there certainly is no more tension of the membrane, al- 
though it undoubtedly is stretched and increased in its 
superficial area; there is, then, at this stage relaxation. 
During the stage of active collapse of the membrane the 
stapes must be driven more or less into the oval window, 
and, if this continues long, impaction results. After res- 
toration of the intra-tympanal air-pressure from restored 
perviousness of the tube, the stapes may still be driven into 
the oval window, requiring a certain amount of tractile force 
to draw it sufficiently outward ; this the membrane no 
longer can accomplish, as it is stretched and unable to fall 
into a normal position, which would practically result in 
drawing the stapes from its impaction in the oval window. 
This seems clear enough from the condition of many of my 
patients where the hearing was good so long as air was 
forced into the tympanum ; but, on opening the tube by the 
act of deglutition, the air would escape, and collapse of the 
membrane result, with the previous deafness. The improved 
position of the membrane, with augmented hearing, seems to 
almost prove that the drum membrane had been shrunken 
up to a degree, consequent on cicatricial contraction, the re- 
sult of the punctures. 
I have followed Politzer and Gruber somewhat in these 
operations, but they are not quite identical; neither is the 
explanation thereof. I believe this operation is a justifiable 
one, and entirely free from danger. I am indebted to Dr. 
J. L. Barnes, of the Manhattan Eye and Ear Hospital, for 
carefully prepared notes of many of these cases. REASONS WHY 
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