REPORT OF THE COMMITTEE 
ON 
OPHTHALMOLOGY AND OTOLOGY 
BY 
SETH S. BISHOP, M. D., 
OF CHICAGO. 
Reprinted from the Transactions of the Thirty-Seventh Annual Meeting 
of the Illinois State Medical Society, held in Rock 
Island, May 17, 1888. REPORT OF THE COMMITTEE ON OPHTHAL- 
MOLOGY AND OTOLOGY. 
Seth S. Bishop, M. D., Chicago. 
OTOLOGY. 
A New Otoscope (Pneumatic} for the Diagnosis and Treat- 
ment of Middle-Ear Affections under Passive Motion. 
Preliminary to a discussion of pneumatic experiments 
upon the ear, it will be a natural proceeding to describe 
the instrument by means of which we may produce and 
observe the effects of passive motion in the drum. 
The pneumatic otoscope, which I have devised for the 
purpose named, consists of a small milled cylinder, with an 
ear-funnel of the most serviceable pattern at one end; and 
an eye-piece, containing a lens, around which revolves an 
adjustable mirror, at the other end. In the side of the 
cylinder, a spacious aperture admits the light to the illum- 
inating surface beneath. At the funnel end of the instru- 
ment, is a pueumatic chamber provided with a flexible tube, 2 
ending in a rubber bulb, or a diminutive syringe, or a lip 
piece, as one may prefer. Objection might be made to 
using the lip piece for producing suction, for fear that the 
air from the external auditory 'meatus might enter one's 
mouth, but it cannot do so if the funnel is properly adjusted 
to the canal, for the air chamber of the otoscope represents 
many times the volume of the column of air contained in 
that part of the meatus that lies between the end of the 
funnel and the drum. It is necessary to exert only slight 
suction force to cause excursions of the drum membrane 
sufficient for our purpose. The tip of the funnel should be 
covered with a section of the thinnest, soft rubber tube, 
nearly an inch in length, to insure an air-tight fit into the mea- 
tus. If the opening of the canal is very large, the rubber tube 
should be rolled back upon itself, so as to form a shoulder 
on that part of the funnel which closes up the mouth of the 
meatus when the otoscope is inserted. The rubber not 
only secures a perfect adaptation of the parts to each other, 
but prevents the funnel from pressing uncomfortably against 
the walls of the canal. If the meatus is very narrow, a 
small section only of the rubber should be slipped well up 
on the funnel to form the shoulder, leaving the end free to 
enter about half an inch. When it is to be employed as an 
ordinary otoscope, without the pneumatic experiment, the 
rubber tip need not be slipped over the funnel. 
This instrument is the result of a considerable exper- 
ience with Siegle's pneumatic speculum, improperly called 
an otoscope. The advantages of the pneumatic otoscope 
over the speculum are: First, it is self-illuminating, not 
requiring the aid of a hand mirror, or forehead mirror, the 
light being accurately focused on the drum; secondly, it 
affords a magnified view of the drum; thirdly, the object 
mirror presents a perfect picture of the interior of the ear, 
and without the necessity of looking through a lens; 
fourthly, it can be operated in a smaller canal than will 3 
admit the speculum; fifthly, the bright reflection of light 
into your eyes by the glass of the speculum, the black 
background of which converts the glass into a mirror, can 
be avoided in the otoscope, by the proper and unvarying 
relations and the color of its various parts. 
The teaching of otology is much facilitated by means of 
this instrument, in that the instructor may be sure that 
students are looking upon the field of vision which is being 
described. Heretofore it has been necessary to bend closely 
over patients to look through an otoscope while it was 
being adjusted, then, in rising to afford students the oppor- 
tunity of inspecting the drum, the necessary movements of 
your body, or of the patients, would throw the drum out of 
the field, or darken it, and compel a re-adjustment of the 
instrument. These disadvantages made demonstrations 
uncertain, long, and tedious. The object mirror allows the 
teacher to stand, or sit erect by the patient, while he 
takes observations, then by a slight movement of his 
head only, or by a turn of the mirror, he may allow any 
number of students to pass in line, each viewing what is 
being commented upon. If one pays attention to the light- 
ing up of the end of the funnel, as he can do by looking 
obliquely through the aperture over the reflector, he may 
be sure that the drum is illuminated and within sight. 
This is made practicable by dispensing with the large funnel 
fixtures that project from the sides of other otoscopes, and 
that prevent the teacher from knowing whether the drum is 
illuminated properly or not, except while he is looking 
through the lens. The advantage of dispensing with this 
attachment is not diminished in the least by sacrificing any 
of the brilliancy of illumination. The objection which 
some physicians have urged against magnifying otoscopes, 
that they were compelled to look through a lens, is met in 
this instance, for one needs only to look at a plane mirror 
to examine the drum and canal. Should it not be desired 4 
to use the object mirror, except in demonstrations, it can 
be turned back, or removed by slipping the adjustable ring, 
to which it is attached, off from the cylinder. 
THE PNEUMATIC TREATMENT. 
The value of passive motion in the treatment of stiff 
joints and atrophied tissues is well recognized in general 
surgery. The application of the same principle to the 
same conditions in aural surgery is attended with equally 
beneficial results. But this is a neglected fact, for you 
rarely see or read of its use in ear treatment. So little has 
been written upon the subject, as compared with its 
importance, that no apology is needed for speaking some- 
what minutely in respect to the behavior of the drum head 
and ossicles, under such experiments as the following: 
In examining and treating the middle ear with the 
pneumatic otoscope, the instrument should be introduced 
into the auditory canal with the longitudinal axes of both 
corresponding, just as any otoscope should be placed. If 
the instrument is correctly adjusted, a slight suction on the 
rubber tube will cause the little column of air, which lies 
between the drum and the funnel, to move outward to the 
air chamber. The examiner is supposed to be inspecting 
the drum at the same time. If the drum is healthy, he will 
observe the membrana tympani perform an excursion 
toward his eye, carrying the handle of the mallet with it, 
while the triangular light spot changes position as the rela- 
tive concavity of the membrane changes. Release the 
column of air and it moves inward again, allowing the 
drum head, manubrium and light spot to resume their former 
positions. Press upon the column of air and it moves 
inward, carrying the membrane and mallet handle with it, 
causing motion in the joints of the ossicles; the short pro- 
cess projects outward prominently, the light spot changes 
with the increasing concavity, and the ossicles become 
more prominently visible as the membrane presses around 5 
them. By alternately rarifying and condensing the air in 
this manner the amount of mobility in the drum head and 
the chain of bones may be determined, under brilliant 
illumination and magnified inspection. If anchylosis of the 
joints of the ossicles, or if bands of adhesions between the 
bones and the walls of the tympanum exist, the handle of the 
malleus will seem to be impeded in its movements, or it 
may remain fixed, while the membrane about it may be 
quite flaccid. At this point I wish to anticipate criticism 
by interjecting the statement that I have never known any 
ill effects to follow this line of treatment. If the membrane 
is greatly thickened in patches, or if it contains calcareous 
deposits, these portions will be seen to resist the action of 
the vibrating column of air, while normal parts, and areas 
of thin cicatrical tissue that indicate the locations of former 
perforations, may respond readily to the experiment. In 
cases where the drum head is very thick, or where the 
ossicles are bound down by adhesions to the walls of the 
tympanum, no perceptible movement may be obtained at 
first, but decided improvement often follows a persistent 
use of the pneumatic treatment. 
In obstinate cases, the process may be hastened by 
making pressure directly upon the processus brevis by 
means of a probe covered with a soft rubber tip. Stiffness 
in the joints may be overcome in this way so as to facilitate 
the action of the otoscope. One should press gently on the 
process until the handle moves, then retract the probe, until 
the malleus resumes its former position; press again, and so 
repeat the movement several times. Then the pneumatic 
principle of the otoscope should be applied until one is sat- 
isfied that the advantage gained will not be lost. The 
pressure need not cause pain, but the mallet should be 
moved until the patient experiences a sensation of move- 
ment or of sound. In several patients in whom I have 
applied passive motion in this manner during the last few 6 
months, I have increased the hearing distance for my watch, 
from contact, to three, twelve, twenty and thirty-two inches, 
or one-half the normal distance. 
The otoscope may reveal an opaque membrana tympani, 
so hypertrophied and stiff that it does not yield to the pneu- 
matic treatment. In such a case it is nothing less than a 
barrier to the admission of sound waves to the perceptive 
apparatus, and would seem to justify the complete removal 
of this barrier, when the auditory nerve is not diseased. 
For if the perceptive apparatus is in condition to do its 
work, while the conducting apparatus is a hindrance instead 
of a help, the sooner the obstruction is removed, and sound 
admitted, the better. It should be understood that this 
statement is made on the supposition that the condition 
referred to has proved intractable under the usual treatment. 
Thus it will be seen that the pneumatic otoscope becomes 
an indispensable factor in determining the precise condition 
of an organ, so hidden away by nature in a deep recess of 
the head, that any auxilary to our present helps in diag- 
nosis and treatment ought to be welcome. We are not 
able without it to judge intelligently when so delicate and 
important an operation as resection of the drum head may 
be necessary as a last resort. And, while I am conscious 
of the strong sentiment of opposition to such operations, I 
venture to improve this opportunity to urge the occasional 
necessity, and the justifiableness of such an operation, and 
to invite the most searching criticism of the logic of this 
procedure. 
AN IMPROVED TONSILOTOME. 
.Any physician who has had a considerable experience in 
tonsilotomy with the various tonsilotomes will not be likely 
to deny that these instruments are generally too compli- 
cated. They are armed with needles, barbs or sharp 
toothed forceps for piercing the tonsil and dragging it 7 
through the fenestra before any cutting is done by the 
blades. A tonsilotome constructed after the pattern I have 
made, renders the barbs unnecessary. It reduces the pain- 
fulness of the operation by one-half; it divests the procedure 
of any danger of an accident to the operator or patient; it 
makes a skillful and easy operation possible with a minimum 
amount of experience; it resembles a large folding tongue 
depressor so closely that children usually offer no opposition 
to its introduction for the removal of the first tonsil; and it 
combines strength and compactness with simplicity of con- 
struction. It is made on the principle of a guillotine, the 
blade of which is propelled by the thumb of the same hand 
that grasps the handle. The latter is set at such an angle 
to the shaft as will permit the most perfect co-ordinate ac- 
tion of the muscles of the hand and arm of the operator. 
All the work may be done with one hand. This advantage 
is not a small one, for two reasons: The powers of co- 
ordination and antagonism of muscles are far more perfectly 
under control in operating an instrument which requires but 
one hand, than they are when both hands must co-operate; 8 
and one hand of the operator is left free to hold the head of 
the patient, if necessary, as the dentist does in extracting a 
tooth. The advantages of a tonsilotoine that can be op- 
erated entirely by one hand are about the same as in a tooth 
forcep that does not require two hands to manipulate. I 
have had two sizes manufactured, the smaller having a 
fenestra of the calibre ordinarily found in such instruments, 
the other supplied with an aperture larger than the largest 
Mackenzie tonsilotome, while it is so compactly constructed 
as to require less space in which to operate. I have used 
the larger size to extirpate enormously hypertrophied ton- 
sils in children as young as two and one-half years, .where 
it was impossible to insert the Mackenzie instrument of the 
necessary size. The smaller one is sufficient for the majority 
of cases, but the fenestra is not capacious enough to admit 
the bases of the extraordinary glands we occasionally see. 
It is advisable to remove the whole tonsil, and as the tops 
only of the largest tonsils can be severed with the smaller 
instruments, it may be better to have the larger size, if but 
one is to be kept. 
The blade is so protected as to make it impossible to 
wound the ascending pharyngeal, or the internal carotid 
artery. The shaft that propels the blade is of such a width 
as to make the use of a gag unnecessary, for it protects 
the finger of the operator from the patient's teeth, if it is 
placed in the mouth to ascertain when the fenestra is in such 
position as to embrace the whole tonsil, as it is necessary 
for one to do when operating in children with other tonsilo- 
tomes. Since I have used this guillotine I have not had my 
finger bitten, while it was not an uncommon occurrence 
before to come off second best, so far as pain was con- 
cerned. With the shank wide enough to afford protection, 
it is unnecessary to introduce the finger into the mouth, for 
the teeth and lips cannot close enough to prevent the 
operator from seeing plainly the field of operation. There 9 
is no working in the dark, or fear of damaging structures 
you do not wish to attack. 
The handle is firmly fixed to the shank with a hinge 
joint and self-acting spring lock, so that the fenestra can be 
pressed down about the base of the gland with any degree 
of power desired. This feature dispenses with any necessity 
for hooks, forceps, needles or barbs for spearing the tonsil. 
The latter being a soft, fleshy mass, adapts itself to the 
shape of the fenestra, and protrudes through it the instant 
its base is pressed around. The pain of spearing or tearing 
the tonsil by toothed or barbed accessories, designed to 
drag the gland through the fenestra before the blade cuts, 
excites the most vigorous struggling and resistance on the 
part of a child. Even when the utmost care has been exer- 
cised, the barbs have pierced the soft palate or the surgeon's 
finger, instead of the tonsil. Moreover, the gland always 
comes out with the instrument, the same as though barbs 
were used. There is another important advantage in having 
the handle attached to the shank with a hinge, provided 
with an automatic lock, for the cutting extremity of the 
instrument cannot be thrown out of your control by a dis- 
turbance of the coaptation of its parts. The last time I 
operated with a Mackenzie tonsilotome, the child jumped, 
just as I was placing the fenestra about the tonsil. The 
shank revolved upon the handle, leaving the latter in my 
hand, while the cutting end was entirely displaced and 
removed from the vicinity of the gland. It is impossible 
for this improved tonsilotome to play you such a trick. 
The handle is made of rubber, gnarled so as to afford a 
firm grip, and it contains a concealed spring lock operated 
by a convenient thumb-plate. When this is moved down- 
ward, the hinge-joint is unlocked, and the instrument folds 
upon itself like a pocket-knife, occupying the space of about 
an inch and a quarter in width and thickness, by six and 
one-half inches in length. Another pertinent point that 10 
should not be neglected in this age of antisepsis is the pro- 
vision for cleansing and disinfecting the three pieces of 
which the instrument consists. By raising the proximate 
end of the horizontal top-spring of the shaft and swinging 
it 90° to either side it becomes disengaged from its lock, 
and it liberates the blade from the shank. This arrange- 
ment makes it as simple as possible for taking apart, 
cleansing and putting together again. 
In amputating the apex of a relaxed and elongated 
uvula, the tonsilotome should be used with the handle 
directed upwards. It should occupy just the reverse posi- 
tion as a uvulatome to the one it occupies when used as a 
tongue depressor. 
Another merit that is not too small to mention, is that 
its simplicity of construction renders it inexpensive. 
A NASAL SPECULUM. 
The nasal speculum that I have constructed will require 
but a moment to describe. It is made of spring-wire, is 
self-retaining and as simple as such a thing can be made. 
The surfaces that come in contact with the mucous mem- 
brane are flattened so as to relieve the pressure of its 
accompanying discomfort as far as possible. The amount 11 
of pressure exerted by expansion may be accurately modi- 
fied by the counter thumb-screws. When the speculum is 
in position, entirely within the vestibule, for examination 
or operation, the handle is directed at such an angle as to 
be out of the way of the operator. The tendency to slip 
out of place is overcome by its lightness, and by a nice 
adjustment of its set-nuts. 
A nasal speculum is a disagreeable tool at best, on 
account of the sensitiveness of the nasal cavities, but this 
one carries as little discomfort with it as any efficient specu- 
lum can. 
These instruments are manufactured for me by Charles 
Truax & Co., of Chicago. 
719 W. Adams Street.