Clinical Contribution to the 
Study of Aural Syphilis. 
BT / 
MAX TOEPLITZ* M. D., 
Aarlst lo the New York Ophthalmic and Aural Imtltute ; 
Surgeon to the New York Nose, Ear, and Throat 
Dispensary; and Laryngologist to the 
Montefiore Home. 
REPRINTED FROM 
ctje "Neto Yorft fHefitcal Journal 
for October 7, 1893. Reprinted from the New York Medical Journal 
for October 7, 1893. 
CLINICAL CONTRIBUTION TO 
TIIE STUDY OF AURAL SYPHILIS.* 
By MAX TOEPL1TZ, M.D., 
AURI8T TO THE NEW YORK OPHTHALMIC AND AURAL INSTITUTE ; 
8UKOEON TO THE NEW YORK NOSE, EAR, AND THROAT DISPENSARY J 
AND LARYNOOLOUI8T TO THE MONTKFIORE HOME. 
Aural syphilis may be manifested during the second- 
ary and tertiary stages, and some rare cases also even of 
primary induration of the auricle have been reported. 
Secondary affections are, as a rule, transmitted from 
the pharynx and nasopharynx through the Eustachian 
tubes into the middle ear, or they appear in the external 
meatus as condylomata or ulcers. 
Tertiary syphilis is characterized by chronic inflamma- 
tion of the periosteum of the labyrinth with subsequent 
hyperostosis or exostosis of the petrous bone, or of the 
cavities of the labyrinth, leading to stenosis or even occlu- 
sion of the latter. 
All cases, however, exhibiting syphilitic affections of 
the labyrinth are due to hereditary or to acquired syphilis 
of long standing. 
* Head before the Otological Section of the Pan-American Medical 
Congress held at Washington, September 5, 1893. 
Copyright, 1893, by D. Appleton and Company. 2 
TIIE STUDY OF AURAL SYPHILIS. 
The case which I have but recently observed is remark- 
able by the fact that the labyrinth was affected primarily 
in the course of a freshly acquired case of syphilis, and 
that the aural affection began simultaneously with the ap- 
pearance of roseola. 
The patient, a physician, aged forty-one, married, of excel- 
led; repute and standing, presented himself at the Aural De- 
partment of the New York Ophthalmic and Aural Institute on 
August 1, 1892, with the only complaint of deafness in the left 
ear, other symptoms being absent. 
Otoscopy revealed moderate congestion of Shrapnell’s mem- 
brane, which seemed to have disappeared on the following day 
upon application of two leeches to the tragus. Politzerization, 
used for diagnostic purposes, did not improve the bearing. 
Hearing power, horologium, A. S. = ; A. D. = 
On August 2d bearing had improved to A. S. = J6. 
August 3d.—Hearing worse; leeches to the mastoid. 
On the fourth day of observation the right ear, which had 
been endowed with very acute hearing, bad also become 
affected. 
The examination with tuning forks, which did not give any 
distinct results in the very beginning as to the relation of bone 
and air conduction and seemed to be leaning more toward a 
decrease of bone conduction, revealed on August 4th positive 
Rinn6 in both ears, but there existed almost as much bone con- 
duction as air conduction, the former having decidedly de- 
creased. 
My diagnosis of otitis interna was now fully justifiable, on 
account of the sudden development of deafness and the great 
difference of the course of the affection from that of otitis 
media. 
In order to ascertain the aetiology, I questioned the patient 
about former attacks of syphilis, but with entirely negative re- 
sult. After repeated inquiries for fresh lesions, the doctor pre- 
sented the middle finger of bis left hand, which bore in the 
center a round, hard tumor of the size of a large cherry, repre- 
senting a genuine, primary chancre contracted during gyme- THE STUDY OF AURAL SYriIILIS. 
3 
cological examinations. Dr. Sigmund Lustgarten confirmed my 
diagnosis of syphilis. At the same time, pharyngeal mucous 
patches and a beginning roseola were found. Energetic treat- 
ment with inunctions of blue ointment were immediately re- 
sorted to, and injections of pilocarpine were independently 
made by the patient. 
The further course of the affection ran as follows: 
10th.—Patient experienced a tendency to fall upon rising in 
the morning, and especially when awakened out of sleep. 
The walls of the building seemed shaking. He felt once or 
twice, for a minute, as if he would like to put his hands against 
the wall, but the phenomenon was not very marked. 
16th.—Hearing power, horologium, A. U. = c0g'*ct. Tuning 
fork perceived as above. 
Ordinary conversation is well understood, but the patient 
has to pay strict attention. 
Whisper: A. D. = £,; A. S. = #. 
Conversation: A. I). A. S. = 
17th.—Result of examination with tuning forks unchanged. 
Weber’s experiment: Tuning fork perceived in either side 
eqaally well. Tuning forks, both high and low, are perceived 
when placed upon right mastoid in A. S., hut when right ear is 
closed, in A. I). R. E. does not hear all the high notes of the 
piano above g'. 
L. E. does not hear all the high notes of the piano above 
last e; the high notes were perceived as mere taps without the 
faintest musical sound. 
October.—In the beginning of October the hearing of A. 1). 
was almost normal, A. S. somewhat improved. 
November 28<l.—Whisper: A. S. = |-A. 
Watch: A. S. = 
Conversation : = jj ®-. 
Iiinn6: A. S. negative. 
Weber’s experiment: Diapason vertex not perceived in 
either ear. 
High and low tuning forks equally well perceived. T. F. 
placed upon right mastoid, best perceived in A. S. Hearing for 4 
THE STUDY OF AURAL SYPHILIS. 
the watch, whisper, conversation, and tuning fork, and musical 
hearing were normal. 
Mucous patches of the soft palate were not quite healed. 
The special features of this case are as follow's: 
1. The affection of the labyrinth occurred after the ap- 
pearance of the pharyngeal mucous patches and simultane- 
ously with the appearance of roseola. 
2. The aural lesion took place during the secondary 
stage without attacking the middle ear. 
3. The diagnosis of syphilis was made from the ear. 
It may be doubted that the affection was located in the 
labyrinth, and, in its stead, the outer wall of the labyrinth, 
and more especially the region around the oval window 
may be preferred for its location. The entire course of the 
disease, however, contradicts such an assumption, and also 
the suddenness of the beginning, the well-nigh entire ab- 
sence of inflammatory signs in the membrana tympani, the 
mutual relation of both ears during the attack, the relation 
of bone conduction and the vertiginous attack—all speak 
in favor of labyrinthine disease. 
The pathological changes produced by the syphilitic 
poison, which entered the lymphatic and blood current of 
the labyrinth from the pharynx through the aqueduct and 
the blood-vessels, probably consisted in inflammatory al- 
terations of the membranous portion, the periosteum and 
the surrounding lymph of the vestibule, and the first turn 
of the cochlea, with an increase of cellular elements and 
hemorrhages. All these changes disappeared after ener- 
getic antiluetic treatment. 
I have looked over the literature on the subject and 
have not found a similar case of labyrinthine disease due 
to secondary syphilis in its early stage without implicating 
the middle ear. THE STUDY OF AURAL SYPHILIS. 
5 
Politzer * only mentions in general that “ in affections 
of the middle ear due to syphilis the perception of the 
tuning fork through the skull may be lessened or absent 
(complication with syphilitic disease of the labyrinth), a 
fact which essentially supports the diagnosis of specific 
aural affection when other syphilitic symptoms are pres- 
ent,” but he does not mention the early appearance of laby- 
rinthine disease during the secondary stage of syphilis. 
123 East Sixty-second Street. 
* Politzer. Text-book, first edition (German), p. (59‘6. The New York Medical Journal. 
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