ARTIFICIAL PERFORATION 
OF THE 
MEMBRANA TYMPANI. 
BY 
LAURENCE TURNBULL, M.D.,. 
AURAL SURGEON TO THE JEFFERSON MEDICAL COLLEGE HOSPITAL, PHYSICIAN TO THE DEPARTMENT 
OF DISEASES OF THE EYE AND EAR OF THE HOWARD HOSPITAL, VICE PRESIDENT 
OF THE MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA, ETC. 
PHILADELPHIA: 
JAMES A. MOORE, 1224 SANSOM STREET. 
1877. ARTIFICIAL PERFORATION 
OF THE 
MEMBRANA TYMPANI. 
LAURENCE TURNBULL, M.D, 
AURAL SURGEON TO THE JEFFERSON MEDICAL COLLEGE HOSPITAL, PHYSICIAN TO THE DEPARTMENT 
OF DISEASES OF THE EYE AND EAR OF THE HOWARD HOSPITAL, VICE PRESIDENT 
OF THE MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA, ETC. 
(Reprinted from the Medical and Surgical Reporter, of November 10, 1877.) 
The subject of the safe removal of foreign 
substances or fluids from within the cavity of 
the tympanum or middle ear, in cases of deaf- 
ness, is one which has always attracted the 
attention and exercised the ingenuity of many 
careful observers. 
These intra-tympanal substances may be, for 
convenience, divided, according to their nature, 
into three classes or groups, viz- 
First. Serum, mucus, muco-pus, pus, and 
blood. 
Second. Fibrin (semi organized), polypoid 
granulations and growths, and phosphatic de- 
posits. 
Third. Connective tissue, and fibrin (or- 
ganized). 
It is almost unnecessary to dwell upon or to 
state the amount of danger that the above con- 
ditions may cause, but, as we pass from the 
first to the third, we observe that the ratio of 
risk to the organ of hearing proportionately 
increases. 
The question as to the source of these products 
then arises. Why are such substances found 
in the tympanum ? Simply as the retained 
products of inflammation. Retained, because 
of their being rapidly poured out while the 
surrounding parts are swollen, or the Eustachian 
tube may be occluded, either permanently, as in 
stricture, or temporarily, from congestion or 
oedema of its mucous investment. 
If we consider, for a moment, the small size 
and peculiar construction of the middle ear, as 
well as its highly important function, we can 
measurably estimate the injurious influences of 
even a stasis of the natural secretion of the parts. 
In acute " otitis media," we have, as is well- 
known, the pouring out of the fluid portion of 
the blood. It is not necessarily accompanied 
by aching pain, but always associated with un- 
usual sensation and swelling. 
If it should be, as is frequently the case, 
catarrhal, then we have what aurists generally 
call " otitis media plastica," or " exudativa." In 
the course of a few hours the intra-tympanal, 
as well as the tubal mucous membrane be- 
comes swollen, the blood vessels pour out serum, 
which, with the extra amount of the natural 
secretions of the p irts, completely fills up the 
middle ear, and sudden deafness is the result. 
While the patient feels a fullness in the ear or 
ears, unconsciously he attempts inflation by the 
Valsalvian method, or accidentally he forces 
some air into the tympanic cavity, and the fluid 
or semi-fluid substance therein contained be- 
comes filled with air-bubbles, whose successive 
escape subsequently causes a continuous crack- 
ling sound, which is very distressing to the 
patient. Pain, as has been already indicated, 
is not always present, and was wanting in at 
least one-half the number of cases coming under 
my observation. 
Such acute cases call for immediate treat- 
ment, by operative interference, and, moreover, 4 
are also among the most successful, and yield 
the most brilliant results. The cure follows 
quickly, on the favorable prognosis, and re- 
dounds greatly to the skill of the aurist. 
If the inflammation is of a higher grade, 
and the secretion assumes a purulent character, 
" otitis media suppurativa," mere local applica- 
tions are of little avail; it becomes our duty, 
when the tympanum is full of pus, to provide 
it a means of escape. Such cases are accom 
panied by more swelling than those just con- 
sidered, and are always accompanied by pain. 
If not evacuated by the surgeon, the pus may 
find its way through the membrana tympani, 
by ulcerative process. 
Time is an important element, as regards the 
prognosis and result of such cases. Should the 
exudation become partly or wholly organized, 
there is but little hope of success from any line 
of treatment. 
Should a small cavity like the tympanum be 
filled with a jelly-like mass, it can be readily 
imagined that the functions of the parts will 
be seriously interfered with, and it will be- 
come self-evident that it is of primary import- 
ance in the treatment to remove the foreign 
substance. 
Where possible, the air-douche of Politzer 
may be used to dissipate fluid collections with- 
in the tympanum, the force of the sudden rush 
of the incoming air acting mechanically in dis 
placing the morbid material. The Eustachian 
catheter may also be employed, but I have found 
it, in such cases, of comparatively little service, 
as sufficient force cannot be given to the 
stream of air injected, while in about two-thirds 
of the whole number of cases treated by the 
first method I have found that a few (two or 
three) blasts of air, from a good Politzer's bag, 
were sufficient at each daily sitting. 
When, however, from the density, or inspis- 
sated character of the contained fluid, we find 
that Politzer's douche is ineffectual, we must 
resort to the operation of incision of the mem- 
brana tympani, and the subsequent use of the 
intra-tympanic catheter, by which means I have 
been successful in several most important cases 
At this place I will report the clinical notes 
of three of the most interesting and instructive 
cases, each treated by a somewhat different 
method. They were not operated upon by 
the myringotome, however, but with a long- 
handled, delicate knife, designed to make 
a round opening; by this expedient we are 
also enabled to enlarge the incision in the 
membrane. This cannot be done so well by 
the ordinary cataract needle, especially in 
cases of plastic inflammation with tenacious 
exudation, as in " otitis media hypertrophica,"* 
but the needle may be conveniently used where 
the secretion is liquid. 
The three cases which are reported will 
illustrate three classes, and are given in detail, 
not for the specialist, but for the benefit of the 
intelligent and well educated general practi- 
tioner, to prove that this is a legitimate and 
justifiable operation, which should not be 
neglected when the proper cases present them- 
selves. In the second case the fact is shown 
that by long and careful treatment good, and even 
successful results may follow without using the 
knife or needle. It must, however, be born in 
mind that if the proper cases are not selected, 
any operation will only increase the patient's 
risk, without any commensurate benefit. In 
certain other cases, by an operative procedure 
the patient will have " acute otitis media" set 
up, which may extend to the brain and 
cause death. Two cases were communicated 
to me recently by a distinguished young 
surgeon. The first was a young lady with 
catarrhal deafness, who, by the use of " Polit- 
zer's " air-douche and local treatment, had her 
hearing increased from four inches to 
twenty ; to hasten this improvement a perfora- 
tion was made, which has never healed, and 
the hearing not only went back to the four 
inches, but has become worse, in spite of all his 
care and treatment. The second was a young 
German, who was going west, and was brought 
for treatment; so desirous was the surgeon to 
hasten this case that he punctured his mem- 
brana tympani at once, with the hope of a 
sudden cure, but instead of cure he unfortun- 
ately lost the little hearing remaining in that 
ear, and had to go west, after ten days' 
treatment, with the wound open, and liable 
to take cold in it, from exposure in traveling. 
Case 1.-Plastic Inflammation of the Mucous Mem- 
brane of the Middle Ear, Involving Eustachian 
Tubes. Removal of a Small Portion of Material 
by Incision of the Membrane, with Decided and 
Continued Improvement. 
M. D., aged 22, a professional male cook in a 
* For full details concerning the symptoms and 
general treatment of this form of ear disease, please 
see "Clinical Manual of Diseases of the Ear." 
Philada., J. B. Lippincott & Co. pp. 176-183. 5 
large hotel, where he was exposed at all times 
to a heated and moist atmosphere. In March, 
1875, soon after having his hair cut short, he 
was suddenly seized with deafness and with a 
filling up of his right ear and nose, as he ex- 
pressed it, which gradually increased. He did 
not at that time apply for treatment, but in 
July, 1876, the humming sound became so 
intense that he could not sleep, and he had to 
give up his occupation He was so deaf that 
he was unable to hear, except when spoken to in 
the loudest tones. He then visited ths Univer- 
sity of Pennsylvania, and was informed that he 
had catarrhal deafness ; but finding no relief, he 
soon discontinued his attendance. The man 
employed some domestic ani also quack reme- 
dies, with but little or no relief. He then 
applied at the H >ward Hospital, March 7th. 
1877, when the physician employed Politzer's 
air douche, and also some local remedies to his 
throat, etc. This treatment was continued for 
some time, but not much benefit resulted. From 
his statement, and the annoying subjective 
symptoms, the white or grayish spotted appear- 
ance of the membrane, and the want of the 
moist sounds of catarrh, I made up my 
mind that there was some foreign matter 
there that wanted removal. There was no 
bulging of the membrana tympani. I there- 
fore, on March 7th, assisted by Dr. Gilmer, 
penetrated the membrane with a small delicate 
round-pointed knife, near to the foreign matter, 
which was in the vicinity of the handle of the 
malleus, and enlarged the opening downward, 
so as to give a free exit. There were but a few 
drops of very tenacious mucus forced out by the 
Eustachian catheter. I did not use Politzer's air 
douche, for fear of forcing the secretion from the 
orifice of the tube into the middle ear and 
through the perforation ; nor did I syringe by 
filling the meatus with warm water and soap, 
but employed a weak solution of potash, one 
grain to an ounce of water, from which I found 
much benefit. He had considerable pain at the 
time, which was almost immediately relieved. 
He began to improve, as he stated, immediately 
after the operation, getting rid of that suffering 
and distressed feeling, and experiencing great 
diminution of the noises. On the 8th and 9th 
of March he was treated by my son, Dr. 0. S. 
Turnbull, who found him much improved, and 
reintroduced the catheter, etc. On the 10th 
he had a return of his distress, accompanied 
with dizziness, which was soon relieved by the 
introduction, by means of the catheter, of the 
vapor of chloroform. March 13th, doing very 
well; hearing distance, right ear, watch-, 
ear, ; feels so well that he wants to go to 
work; his hearing, for the human voice, was 
very much improved, but still had some irrita- 
tion and swelling of his tonsils and uvula. 
Compound tincture of iodine and glycerine 
was applied to the tonsils, and a gargle 
for his uvula and throat. Schwartze uses 
alkaline (one 'grain of potash to an ounce of 
water) injections, to insure absorption of any 
remaining mucus, and if the tube is not freely 
pervious, he uses weak injections of zinci sulph., 
to render it so. 
Case 2.-Case of Mucus in the Middle Ear, with 
Deafness, Removed in Part by Politzer's Air 
Douche, and with the Intra-tympanio Catheter. 
Elizabeth L., aged twenty-four, a bright, in- 
telligent young lady ; a seamstress ; residence 
Chester county, Pa.; single; general health 
good; both ears affected, but the left ear the 
most. The presumed cause of the deafness was 
cold. Has had all the diseases of childhood, 
but no severe disease of late. Has pain, with 
dryness and itching in the ears, with noises, of 
a crackling or snapping character. Her physi- 
cian had given her medicines to drop into the 
ear, for the relief of the pain and noises. The 
meatus was found normal, no excess of cerumen, 
membrana tympani opaque, like a ground 
window glass. Left eai* more opaque than the 
right. This opacity changed its position by 
the movement of her head. Eustachian tubes 
plugged with mucus and collapsed. This tena- 
cious mucus extended into the middle ear, as 
determined by the otoscope. Hearing dis- 
tance, right ear; lf£watch- Left ear> Aru • 
Has chronic pharyngitis, and back of pharynx 
the glands were enlarged, and her voice was 
nasal. There are also small ulcerated spots 
near the orifice of the Eustachian tubes. 
Treatment, November 16th, 1875, to Decem- 
ber 6th. Astringent gargle and cleansing 
douche, using warm water and common salt, 
followed by glycerine and water. Internal, 
pills of sulphate of cinchonidia, three grains 
each, on account of pain in her head, with half 
drachm doses of bromide of potassium. Also 
elixir of valerianate of ammonia, for nervous 
symptoms. Local applications to the throat, 
excising the glands, painting them with iodine 
and glycerine, and sulphate of copper. 
December 6. The discharge from the ulcer- 6 
ated surface of the throat collected in the Eus- 
tachian tubes was more tenacious, and we were 
less able to use Politzer's air douche, which, 
nevertheless, increased the hearing to in 
right ear, and left to . The patient then 
left for the country, and wrote as follows :- 
December 13. " I fear I have taken cold 
since returning to my home, as my throat is sore, 
but it does not have any effect on my hearing 
yet, and I hope it will not, as it still continues 
to be better; the noises do not change much, 
though I think they are not quite so persistent, 
and not so far in the head, but more in the 
ear, the left ear, especially (persons cannot help 
admitting that I am benefited by your treat- 
ment). There is not any of that confused feel- 
ing in my head now that was there when I first 
came to you." 
December 27. " When I wrote you last I 
was suffering from a cold, which increased, and 
remains with me yet. If I was only as well 
as when I left you, I should be thankful. I 
think my hearing still better than when I came 
to you. The noises are somewhat louder, but 
they do not annoy me so much. I am still 
using the medicines. There is a very unpleas- 
ant feeling of dryness in both ears; the ulcers 
in my throat I have been watching and trying 
to keep away by using what you gave me (a 
solution of cupri sulph.). They were in my 
throat first, where the Eustachian tube connects 
with the throat, and I could see them, by means 
of a mirror; allowing the sun to shine in 
my mouth and holding my tongue down with a 
spoon, I touched them with a piece of cotton 
moistened with the preparation you gave me. 
By this means I keep pretty clear of them." 
I received no communication from my patient 
until February 14th, 1876. " I am still follow- 
ing your directions, having omitted but one 
day. Shall I continue the use of them until I 
return to the city ? My hearing is about the 
same as when I wrote you last; the noises are 
pretty loud in the left ear." I directed her not 
to return until mild weather. She came on in 
July. After a week's treatment I noted the 
Eustachian tube on right side was swollen at 
its orifice, and was plugged with mucus. Infla- 
tion with the catheter and balloon improved 
the hearing distance on that side to 5SK$-. The 
hearing continued to improve by inflation, with 
now and then application of electricity to the 
tubes. Both membrana tympani are sunken, 
and the tinnitus in right was diminished by 
drawing, with Siegle's pneumatic otoscope, the 
membrane outward. 
After continuing the treatment for some 
time, the result did not satisfy me, so I re- 
sorted to the intra-tympanic catheter, and with 
a closely-fitting brass syringe, withdrew a plug 
of mucus, much to the patient's relief and my 
own satisfaction. She states that the noises 
are so much less that they no longer annoy 
her. The hearing distance is now up to 
right; left a-. There is also more moisture 
in the ear and it feels more comfortable. 
Both membrana tympani look better, both in 
position and color. She was directed to take 
tonics, good diet, and cod-liver oil, which she 
states have acted like a charm ; was also di- 
rected to avoid cold feet or exposure to draughts 
of air. 
Case 3.-Case of Perforation of Membrana Tym- 
pani Following an Acute Attack of "Otitis 
Media Catarrhalis," the Perforation Remaining 
Open Six Months After. 
F. M. T., aged twenty-two years, student. 
Resides in Connecticut; single ; both father 
and mother living, but has lost two brothers 
with phthisis, and the mother's family more 
than one member by the same disease. Gen- 
eral health good ; robust. The patient is well 
developed, yet subject to cold, followed by a 
bronchial cough. The ear most affected is the 
right; presumed cause, influenza. This was 
followed by intense pain, fever, bulging of the 
membrane, and blowing noises. Treatment, 
acute stage; pain relieved by hypodermic of 
morphine; leeching, hot water application, 
with Politzer's air-douche, to inflate ther middle 
ear, and ultimately puncture of membrana 
tympani, with discharge of muco-purulent 
secretion for some weeks ; by the use of mild 
astringents, and cleanliness, the discharge 
diminished, so as not to be at all offensive, but 
is sometimes troublesome, and if neglected the 
hearing becomes diminished on that side. Six 
months after, membrana tympani opaque, 
cicatricial tissue, with small, irregular perfora- 
tion along the handle of the malleus. By force, 
air passes through the perforation, with a whist- 
ling noise. The right Eustachian tube is 
obstructed, so that the patient cannot inflate it, 
on account of mucous plugs, etc. Right ear 
hearing distance, Ak"™tch- Left ear' 
By careful treatment, cleansing the ear 
with a solution of bicarbonate of soda 
in warm water, and inflating the ear by means 7 
of Politzer's air-douche, the hearing was in- 
creased to double the distance ; also, by the use 
of an artificial membrane and a solution of 
zinci sulphas, the ear has assumed a 
much improved character, but, owing to the 
tuberculous tendency of the patient, it is diffi- 
cult to heal the perforation. 
It should be remembered that a thickened 
condition of the membrana tympani, which 
prevents its vibration to sound, may also 
involve the whole mucous membrane of the 
middle ear, or may extend still deeper, and in- 
clude the membranes of the fenestras. 
Perfect closure of the Eustachian tubes would 
be a true indication for this operation, but, 
unfortunately, this condition is very rare. I 
have met with only a few such cases in many 
years of practice, these being generally pro- 
duced by syphilis or small-pox.* 
One of the most difficult conditions, after an 
operation, is to keep the opening patulous, if 
the opening be in a healthy membrana tympani. 
In the last edition of the work of Von Trolsch,f 
he gives the report of the following modification 
of the operation. 
" In one case I have tried the following method, 
with a view of securing a permanent opening 
in the drumhead: I eut out a triangular flap 
with my paracentesis needle, the base of the 
flap being above. This flap I folded back, and 
pressed against the drumhead, which I had 
scarified. The flap united to the membrane in 
healing. The opening had not decreased at the 
end of two weeks, when I lost sight of the 
patient. I think this method worthy of a fair 
trial. Repeated puncturing of the flap, and of 
that part of the membrana tympani to which it 
is fastened, would, perhaps, ensure the result 
aimed at." 
The pain of the operation of perforation is, 
for the time, sharp, but is usually of very short 
duration. In a few cases the operation has 
been followed by severe inflammatory symptoms. 
It must not be hastily concluded that the 
patient is permanently relieved after the opera- 
tion. As relapses are apt to occur, the patient 
should be kept under observation for some time; 
many clinical histories are incomplete on this 
account. 
Conclusions.-Since publishing my views, on 
p. 242, in my manual, in which I state that " the 
author has resorted to the operation of punct- 
uring, incising, or making a flap in the mem- 
brana tympani, in chronic cases of catarrh of 
the tympanum, I find so far my success 
has not been what I could have wished." 
By a happy combination of operative pro- 
cedure with the use of Politzer's air-douche, 
solutions of various strengths of caustic potash, 
to soften the secretion, the careful use of the. in- 
tra-tympanic catheter, and above all in import- 
ance, the proper selection of cases, and the use of 
the spray of carbolic acid, to prevent suppuration 
and entrance of septic matter into the middle 
ear, my success has been much more satisfactory. 
* A case of this kind is reported in the author's 
work, pp. 224, 337. Philada., 1875. There is also one, 
by Lindenbaum, In Archiv fur Ohrenheilkunde, pp. 
295, et seq. 
f Von Trblsch, "Lehrbuchder Ohrenheilkunde." 
Leipzig, 1877. pp. 413.