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ARCHIVES OF OTOLOGY. 


RE-EXAMINATION OF THE HEARING OF DEAF. 
MUTES ORIGINALLY TESTED IN 1893. 


By Pror. F. BEZOLD or MunicH. 
With Plates I, and II, of Vol. XXX. of Germ. Ed. 


Translated and Abridged by Dr. J. A. SPALDING, Portland, Me. 


HE examinations of the hearing of deaf-mutes, which 
ea I made some years ago in Munich, have been care- 
fully investigated by the Ministry of the Interior in the 
Kingdom of Bavaria, and the Minister of Education has 
lately given me an opportunity to demonstrate before him, 
personally, by means of the continuous series of tones as well 
as by the voice, the presence of some remnants of hearing in 
a number of scholars in our Deaf-Mute Institute. Whilst 
making this demonstration, I found that twenty-eight of the 
scholars whom I had tested before still remained in the In- 
stitute, and it then occurred to me to extend my former in- 
vestigations into this very interesting province of otiatrics, 
by means of Prof. Edelmann’s improved series of tones. 

It was with a good deal of anxiety that I began this re- 
examination, for although I exercised ‘the greatest care 
originally, the possibility of many errors having unintention- 
ally crept in could not be absolutely excluded. For, in the 
first place, the tone-series originally employed was imperfect 
(especially in the twice-scored octave) in comparison with 
the other octaves, a defect which Prof. Edelmann has 
avoided by making much more intense the upper portion of 
the scale, the very space which is so often preserved in deaf- 
mutes. In the second place, I was afraid of the extreme 
youth, the defective replies, and lack of self-reliance in those 

107 





108 F. Bezold. 


pupils who were now to face me for re-examination, for all 
the older pupils had graduated, only the youngest were left, 
and amongst the notes attached to their names, at the first 
examination, were such remarks as these: ‘“ Apparently 
total deafness,” “‘ Answers far from trustworthy,” and so on, 

However, in order to verify the condition of those who 
were then the youngest, to carry the question of the hearing 
of deaf-mutes still farther along, and for other reasons which 
shall soon appear, re-examination seemed not only desirable 
but even a necessity. 

The first point to investigate was the different results 
likely to be obtained by Prof. Edelmann’s new tone-series, 
with their powerful and reinforced tones in those regions 
especially in which my former series had been noticeably 
defective. Some authors, for example, have asserted that 
equally powerful pure tones do not produce the same results 
on the hearing when produced by different instruments. 
The falsity of this assertion I saw plainly enough at my origi- 
nal examination, and additionally I expressed the opinion 
that we might later on find some perception still present for 
a series of tones which had at that time escaped my obser- 
vation, because in certain regions the intensity of my tone- 
series was too weak to get all possible results. 

Furthermore, we are not positively sure whether the remnant 
of hearing tn deaf-mutes remains on the average enttrely sta- 
tionary. We must assume in most cases defects in the per- 
cipient apparatus, between which a few districts are still 
preserved, and that the morbid process producing these de- 
fects has long since terminated. At the same time we can 
additionally represent to ourselves, that, for example, a cica- 
tricial contraction, a calcification, or an ossification in the 
cochlea might, after years, extend in circumference and so 
destroy farther portions of the hearing spaces, particularly 
former islands of hearing. The inverse theory of return of 
the function by later zmvolution must be regarded as ex- 
tremely improbable, considering the basal morbid process, 
and the long time which has elapsed since it ceased to be 
active. 

Finally, in answer to the question whether some defects 





Re-Examination of the Hearing of Deaf-Mutes: 109 


might not depend solely on torpidity of the auditory nerve 
elements, and might be improved by hearing exercises by 
means of tones corresponding with the defective regions, 
we can only reply that, judging from the successful results 
which Urbantschitsch and others think that they obtained by 
exercises with speech and simple tones, only practical ex- 
perience can decide. 

From such points of view the results obtained from the 
re-examination of these twenty-eight deaf-mute children 
seem important enough to guarantee a graphic representa- 
tion, and comparison with the results originally obtained. 

Much to my gratification, the variations are less than I 
thought they would be. 

Plates I. and II., at the end of this number of the AR- 
CHIVES, give a plain idea of the hearing remaining, the red 
lines showing what was originally present, and the blue, the 
results of the re-examination. The numerals with the ear 
named at the foot of both tables, as well as those in the re- 
mainder of this paper, refer to the cases successfully ob- 
served, and the same numbers refer to both examinations. 

The greatest errors were discovered in the fifty-four ears 
belonging to twenty-seven re-examined children amongst 
those first noted as totally deaf.’ For amongst these fifty- 
four ears twenty-five belonging to eighteen deaf-mutes were 
originally noted as totally deaf, whilst re-examination showed 
that four were by no means totally deaf, two having an 
island of hearing, and two an extensive district. 

One island in Case 62 R (Plate I., Group I.) extended from 
a" to a'’, but was only discovered on blowing very forcibly 
with Edelmann’s organ pipes, and the other one (38 L, 
Pl. 1., Gr. I.) from f" to e’, and was only discovered by 
Edelmann’s whistle and Lucae’s forks c'Y to f'¥. 

Case 73 R and L (PI. II., Gr. IV. and VI.) was at first with 
difficulty tested and noted as “ apparent totally deaf,” and, 
although now exhibiting an extensive region for hearing, can- 
not be induced to speak. With exception of these four, 
twenty-one were totally deaf at both examinations. 





'Case 28 was not amongst those first tested, and proved to belong to those 
having the best hearing. 





i F. Besold. 


On the contrary, amongst the twenty-nine ears which orig. 
inally showed a remnant of hearing, only one was found in 
which formerly an island (c’Y to a'’) was present, but which 
has at the re-examination given way to total deafness 
(Case 44 L, Pl. I., Gr. I.). 

The right ear of this same patient (44 R, Pl. I., Gr. IL) 
is very interesting in comparison with the left, because in the 
former we found in the midst of a remnant of hearing, of 
about the same extent as originally with exception of a 
trifle at the lower tone-limit, am island from e" to e™ about 
as at first. The patient’s trustworthiness past and present, 
as demonstrated by the similar results obtained in the right 
ear, shows us that there can be hardly a doubt that the 
island of hearing originally present in the eft ear ts now 
totally submerged. 

A somewhat similar case is seen in 39 L (PI. I., Gr. I.), in 
which, at the first examination, two hearing regions were 
discovered, one from b™ to d’ and one from f*to g', the 
latter disappearing in the interval between the two examina. 
tions. For this reason the case was taken from the group 
of defects and placed in that of islands. The upper end of 
the hearing region was also abbreviated by seven semitones, 
despite the more powerful forks employed, whilst in the 
other ear (39 R, Pl. I., Gr. I.) the island present at both 
examinations terminated at the second testing, just as origi- 
nally at the upper end, whilst at the lower end, dependent 
on the more powerful sources of tone employed, it extended 
a little lower down. 

These new defects probably signify an increased destruc- 
tive process in Corti’s organs, rather than an error in the 
examination. 

Amongst twenty-eight ears there were but two in which 
the original upper tone-limit exceeded the later by more than a 
semitone, a difference which might be ascribed to mistakes 
in observation. In all the others, owing to the loudness of 
Edelmann’s apparatus, the newly discovered regions for 
hearing were a trifle more elongated than the old, not only at 
the upper tone-limit, but generally at all places where the hear- 
ing region ts interrupted, as well at the lower as the upper, or 
even at both ends. 











Re-Examinatton of the Hearing of Deaf-Mutes. 111 


I here emphasize the fact that despite the great differences 
in power between the old and the new apparatus, just about the 
same tone-limits (or within a semitone) were found at both 
examinations. 

Leaving aside the examinations for Galton’s whistle, 
which cannot be expressed in semitones, we find in twenty- 
eight ears that the region for hearing ceased at the same 
tone or within a semitone at the upper limit in seven cases, 
and at the lower limit in twelve cases, and, in the six 
cases with defects, twice at precisely the upper end of 
the defect, and twice at the lower. Moreover, there are 
eleven coincidences for Galton’s whistle at the upper end 
of the hearing region. So that, taking all in all, thirty-four 
regions for hearing coincide substantially. Having found 
that the re-examination with the new apparatus exhibits the 
same tone-limits as those in the first examination, we must 
take it for granted that a district of nerve elements provided 
with relatively normal functions joins directly on to another 
district which pathologically and anatomically has lost tts for- 
mer functions. 

These sharply defined pathological alterations are in all 
probability to be sought for in Corti’s organs. They give us 
a well-defined picture of the situation of the districts de- 
stroyed, and we are justified in assuming that these pictures 
are better defined and more perfect than we could obtain by 
microscopic examination of the labyrinth, just as the deter- 
mination of the visual field of the eye teaches us more 
precisely the form and extent of visual defects than a micro- 
scopic examination of the retina could do. 

In contrast with this uniform coincidence of perception at 
thirty-four localities in twenty-eight ears, and partly at some 
other district in the same ear, we find more or less increase 
in the tone space discovered by the more intense new appa- 
ratus in twenty-six localities, the excess being but three 
times, more than one octave, averaging six tones, and from 
one to two mm by Galton’s whistle. 

Variations like these cannot be explained by mistakes in 
testing, but must be due to the greater power of the new 
apparatus. This condition must therefore appear at all 





112 F. Bezold. 


those spots where the transition from the hearing- to the 
deaf-region in Corti’s organs is gradual, the result of diffuse 
destructive foci in the percipient organs. 

Of the four regions which varied greatly three were in 
the same person (69 R and L, PI. II., Gr. IV. and V.), and in 
the fourth (26 R, Pl. I., Gr. I.) Edelmann’s fork and organ 
pipe were only heard when blown or struck most forcibly, 
Besides this, the lower portion of the newly discovered 
region lay in the weakest portion of my first tone-series. 

The chief differences lie in the ower border of the region 
for hearing, the one in which middle-ear processes, tubal 
catarrh, etc., in children with hearing, good, bad, or none at 
all, chiefly exercise their morbid influence, and it may be 
that this disease was present in some cases at the original 
examination, or, for reasons cited in my former paper, these 
deaf-mutes were tested by aérial conduction alone. 

The result of the re-examination with new instruments 
may be summed up in this way: Zhe number of totally 
deaf ts less than before. Two deaf-mutes, however, lost con. 
siderable hearing in the interval, and tt would seem as tf we 
were justified in assuming that some cases always show slow 
advance of the destructive processes in the cochlea. Two 
children had more hearing than at first test, which may be 
ascribed to defective repliés originally in one case, and in 
the other to the greater power of Edelmann’s apparatus. 
The other twenty deaf-mutes showed about the same hearing at 
both tests, or a moderate increase averaging six semitones. 

The first and very frequent condition (similar, or nearly 
similar limit for tones) proves that the boundaries of morbid 
Joct on the cochlea are often sharply defined. The second con. 
dition (a moderate increase in the extent of the region for 
hearing) gives us an approximate idea of the amount to which 
our results may be influenced by differences in the intensity of 
the various tone-series employed. Nevertheless, this influence 
has been much less than I had expected. 

Although the re-examination discovered a few sertous errors 
that had been made at the first testing, yet the number of co- 
incidences was so great that there can be no doubt that even 
the youngest deaf-mutes in our Institute can be safely employed 











Re-Examination of the Hearing of Deaf-Mutes. 113 


for the collection of statistics of the hearing power of deaf- 
mutes. 

Urbantschitsch has expressed the opinion that even if 
deaf-mutes are exercised exclusively by speech the hearing 
for musical instruments and speech alike is improved, even 
without the use of any of the former; but this opinion I 
cannot endorse. 

Methodic exercises with fones were also tried in a very ap- 
propriate case for three months with an absolutely negative 
result. 

The tests for the voice, vowels, consonants, and words were 
limited to cases in which the extensive hearing-region ob- 
tained in the tests for tones seemed to promise some mini- 
mum hearing forspeech. These cases also had been suggested 
as suitable for such exercises and had already received some 
brief instruction by that method through the ear. More or 
less comprehension for speech was found in about one patient 
inevery four — that is to say, in seven children with nine ears, 
two belonging to the second group (44 R and 58 L), one to 
the fifth group (26 L), and six to the sixth group (58 R, 66 R, 
78 L, 43 R, 41 R, and 41 L). 

At the original examination of these ears four were deaf 
for all vocal sounds except the consonants P, T, R, which 
were perceived by tactile sensation; at the re-examination, 
none were so deaf. Originally, three had hearing for a few 
vowels and consonants, at the re-examination only two. At 
the original examination two had hearing for words, at the 
re-examination seven. 

In my first paper I laid down the upper and lower limits 
in the tone-scale which might be lost for hearing without 
totally destroying the perception for voice, namely the small 
space between b‘ and g”, which is indispensable for the un- 
derstanding of words by the ear. Amongst the scholars re- 
examined there were but two who had lost perhaps from one 
to three semitones at the upper border of this little space 
(58 L and 44 R). The first one possessed the sixth, which I 
regard as necessary for hearing speech, but lowered a semi- 

tone in the scale. He could understand the word “ Eight ” 
and the vowels A and E, with one ear, and with the other 








114 F. Bezold. 


ear the same vowels and all the numerals except Five and 
Six. 

The other one (44 R, PI. I., Gr. II.), who had lost the ¢hree 
upper tones of the sixth for speech, and who was also totally 
deaf in the other ear though having some hearing at the 
original test, could repeat such numerals as Seven, Nine, 
Four, Twenty, and so on when spoken directly into the ear, 
but could not understand any vowel except U. Leaving aside 
the island from f" to e™, this child has a very extensive 
range of hearing, and an unusually long duration for sounds, 
From two points of view the case is interesting ; for, firstly, 
we see how well speech was understood despite the loss for 
all vowels but U. We must assume that the numerals 
were recognized solely by combinations of consonants, 
despite the fact that all of the hissing sounds must have 
been more or less lost. The case is suggestive of what can 
be obtained in attentive children by instruction with the 
voice. 

In the second place, we emphasize the fact that the vowel 
U was perceived although within the patient’s defective 
regions lies the district d" e” in which Hermann has lately 
located* one of the fundamental tones for U, in opposition 
to Helmholtz, who located the only fundamental tone for 
U in the small f, which happens to lie inside the child’s 
region for tones. 

I will next refer to the hearing for the voice, in its relation 
to the situation of the regions for hearing in the tone-scale. 
For the only case which seemed incomprehensible at the first 
examination was 39 R (PI. I., Gr. I.), in which both A and O 
were correctly repeated although the island for hearing lay 
far away from the fundamental tones for these vowels. The 
same island was found at the re-examination though elon- 
gated several semitones downward. Nevertheless A and O 
were no longer perceived, so that there must have been a 
mistake at the first test. 

A single case (26 B, PI. II., Gr. V.) with hearing from f" to 
the middle of Galton’s whistle, and which was at the first 
examination deaf for speech, now perceived the vowel I and 





‘Arch. f. d. Gesammt. Physiolog., vol. liii., 1893. 











Re-Examination of the Hearing of Deaf-Mutes. 115 


the hissing sound “Sh,” a condition which coincides with 
the position of the fundamental tones for the hissing sound, 
and with the upper fundamental tone, at least, of the vowel 
I, 

The sixth group with extensive ranges for hearing is of 
great importance so far as future practice with the voice in 
partial deafness is concerned. Here we found six ears in 
five patients, one case, No. 73, being omitted, as it was not 
tested originally. Basing our opinion on the extensive 
regions for hearing, showing only slight defects at the upper 
and lower ends, it would seem as if such cases did not repre- 
sent labyrinthine destruction in the least, but cerebral dis- 
turbances possibly in the auditory spheres in the temporal 
lobe, and that they therefore indicate “ word-deafness,” in 
the actual sense of the term. Experience alone can tell us 
whether such a central force of deafmutism is accessible to 
instruction through the ear. The slight results so far ob- 
tained are encouraging. 

Four cases in Group VI. (58 R, 66 R, 78 L, and 43 R) 
were at first deaf to words, but re-examination shows an ex- 
tensive comprehension for words, two repeating nearly all 
the numerals and two all of them correctly. The fifth child 
(41 R and L), who could originally perceive all the numerals, 
can now repeat them correctly across aroom and even Latin 
words which are wholly unknown to him. 

This slight experience proves that even the deaf-mutes of the 
VI. group, characterized by excessively defective comprehension 
for speech despite extensive perception for the tone-scale, are 
very accessible to instruction by speech through the ear. We 
know that wherever a satisfactory remnant of hearing exists, 
it can be utilized for the comprehension of the voice by well - 
conducted instruction, no matter whether the pathological alter- 
ations producing the defects of hearing lie in the cochlea or at 
any locality beyond. 

One of the above-mentioned pupils (66) had on the other 
(left) side a very extensive region for hearing, with, however, 
a large defect in the middle, embracing the hearing Sixth 
(f' to g"), but if he closed with his moistened forefinger the 
right ear, belonging to the sixth group and hearing all the 






















116 F.. Bezold. 


numerals, he was unable on the side containing the defect 
to hear or to repeat a letter or word. The same thing 
was noticed in 43 and 78, who on the other side were not 
only deaf to tones but to speech. 

This observation shows that closure of the meatus with the 
Jinger in deaf-mutes is sufficient to exclude all hearing from 
the other ear, even tf it possesses abundant remnant of hearing. 
So that all tests of each separate ear may be considered as 
more reltable in deaf-mutes than in those who are partially 
deaf. 

Case 78 shows that a part of the hearing for speech dis. 
covered at the re-examination is due to the preliminary in- 
struction with the voice through the ear, for the child had 
only been educated with units, could for that reason only 
repeat numerals up to ten, and failed to comprehend the 
higher numerals, although she possessed a region for hearing 
from the upper limit for Galton’s whistle to the middle of 
the great octave. 

Small as are the statistics at my command, the results ob- 
tained for the hearing of speech indicate the surprising 
achievements in the comprehension of speech which brief in- 
struction may produce. 


SUPPLEMENTARY REMARKS. 


A few days after handing in the present MSS. I received 
from the Minister of Public Instruction an edict of great im- 
portance for the future instruction of deaf-mutes in Bavaria, 
dependent on their remnant of hearing and speech. 

In brief the edict says that all deaf-mutes newly entering 
the Institute are to be carefully tested for what remnant of 
hearing they may possess, as well as for any remaining 
capacity for the comprehension of speech; that those who 
still remain in the Institute may at any convenient time be 
re-examined in similar lines by competent aurists ; and that 
those who hear a little or who can speak in the least, in ad- 
dition to general instruction shall, in special hours, receive 
proper and skilled instruction for the preservation and pos- 
sible increase of what hearing and speech they still possess. 
Henceforward, then, we may surely expect that the special 












Re-Examinattion of the Hearing of Deaf-Mutes. 117 


care thus assured to the partly hearing and partly vocal deaf- 
mutesin Bavaria will soon be imitated in other parts of Ger- 
many, and that in a future not distant deaf-mutes of all 
countries will obtain instruction not only to increase what 
hearing and speech they may have, but this fraction of the 
normal hearing power to be utilized as a foundation for un- 
derstanding spoken language such as now prevails, accord- 
ing to Mygind, in several institutions in America, France, 


and Austria. 





FOURTH REPORT ON THE PATIENTS TREATED 
DURING THE YEAR 1898 IN THE HOSPITAL 
AND OUTDOOR DEPARTMENT FOR AURAL 
DISEASES AT THE UNIVERSITY OF STRASS. 
BURG. 

By Dr. F. ALEXANDER. 


Abridged Translation by Dr. MAx TorpLitz, New York. 


“HIS report is based upon the same principles as that 
‘| of the years 1896 and 1897. The abundance of the 
material rendered the writing of a record of the numerous 
small operations performed at the outdoor department im- 
possible. The more important cases only will be given in 


this abstract. The character of the tumors, which are not 
classified, was not ascertained by exploratory excision and 
microscopical examination. 


OUTDOOR DEPARTMENT, 1898.’ 
I.—AURAL DISEASES. 





Disease. Right. | Left. | Both. 
} } 





A. EXTERNAL EAR. 
a. Auricle. 








Foreign bodies 
Otitis externa, circumscribed 
Otitis externa, diffuse 











Periauricular abscess following furuncle 
1 Unimportant diseases omitted in the translation. 





118 











Report of the Strassburg Ear Clinic in 1898. 119 





















































Disease. Right. | Left. | Both. | Total. 
c. Membrana Tympani, 
Myringitis HenOrrel, CINE va nin nk oc cece sence I i I 
Hemorrhages,.....eeccesececcccsecseccsusecs 3 4 . 7 
Ruptures os creer eeeceeeceeeeereeeeerercecs ° 3 | 9 12 
B. MIDDLE Ear. 
Heematotympanum... .cececceescees See cee tag ‘ 2 ea aM 2 
Otitis media, catarrhal acute..........+....00- 49 33 20 102 
Otitis media, hemorrhagic acute............. oP ae 5 3 12 
Otitis media, catarrhal chronic, and sclerosis.....}  § 4 | 285 294 
Otitis media, purulent acute.........+++seeee0s 100 97 33 230 
Otitis media, purulent acute with ostitis of 
mastOid PrOCeSS.....cccccscrccccvsvsccces 8 8 oe 16 
Otitis media, purulent chronic.........+.....+. gt 93 81 265 
Otitis media, purulent chronic with polypi...... 22 12 5 39 
Otitis media, purulent chronic with caries....... 4 13 I 18 
Otitis media, purulent chronic with cholesteatoma.| 10 | 8 I 19 
Sequel to Otitis media purulenta.............. mt we 28 44 
C. INNER EAR AND NERVOUS DISTURBANCES, | 
Otalgia....... eecces teen e eres sees eeeeeeees 14 15 7 36 
Neuralgia of the mastoid process............... ia) Sool I 2 
Injury to labyFtME,. 6. es ccc cccescvccocseces hand I 4 5 
Other labyrinthine diseases.............ee200% 2 | 17 19 
Fracture of base Of skull... .cccecscccccecceses un 3 













II.—DISEASES OF THE NOSE AND PHARYNX. 
A. EXTERNAL NOSE. 











Disease 


i 









































HEN DERE ss KhOe ban ads onavehewWrdseaRiseanmses 9 

EARS ican sie aac ooh s 0 teed nanebediween Pep awe E Nae 2 

BEND sd i cccwierctecndssvendecves ce skebeceecs swans I 

POP Noes dh oscccacoseuneesksdosgad i lids its Milani ia I 

CURSING 6'o.< cise sieccenssGtveaens cobs bpearRewenaeeS I 

B. NASAL CAVITY. 
Rhinitis, catarvhal chromie¢. .. 2. icc iccsccseces Bare ae 113 113 
Rhinitis, hypertrophic chronic. ..........++-++ 4 ee 76 80 
Rhinitis, atrophic chronic............0. ere eee I 2 82 85 
ORRNR, 5 Peds PAF EN Re ON eh wie TERRE EOE en <i 64 
LUCS WAGs cies ReRCOE EW aaie Cae eas vauae ees eaaes a < II° II 
Lues BAM COMIN Sic ccs sdcvccccddescusee as we | 4 4 
Papilloma of the turbinated bodies............. i 2 I 3 
eh ERE ee OPE TT EP PPPOE CORR ET OCR TET EL 6 12 | 19 37 
Hypertrophy of the turbinated bodies : 

a, of the middle turbinated body. ........... ps at ge 2 II 
b, of the inferior turbinated body............ as ae ee I 4 
c, of the posterior extremities.............+.. Ps WERK oe 4 6 
Empyema of Highmore’s antrum.............. | 3 | 6 I 10 
Empyema of all accessory cavities.............. et soe I 5 








F.. Alexander. 





Disease. 





C. NAsSO-PHARYNX AND PHARYNX. 


Rhino-pharyngitis, chronic 

Rhino-pharyngitis, chronic atrophic 

Pharyngitis, chronic 

Pharyngitis, granular 

Lues of pharynx 

RE IIS 5 oe ob v0.2 soe olny tee ns teee’s 
Congenital luic defect in the soft palate 

Uvula bifida 

Paresis of velum palati 

Papilloma of the soft palate 

Cavernoma of the soft palate 

Diphtheria of nose and pharynx 

Hypertrophy of faucial tonsils................. 
Hypertrophy of faucial and pharyngeal tonsils. . . 
Hypertrophy of the pharyngeal tonsil 
Hypertrophy of the lingual tonsil 


to 


ouwm 
Ow wnat 





“~~ NWS Ne 














HOSPITAL OPERATIONS. 


Name of Operation. 


Incision of lymphadenitic abscesses. . 

Incision of periauricular abscesses after furuncle 

Extirpation of auricular tumors 

Extirpation of aural polypi 

Paracentesis 

Chiselling of Mastoid according to Schwartze 

Chiselling in perisinuous abscesses 

Chiselling in extradural abscess of both cranial fossz 

Radical operation according to Zau/fal- Fansen 

Radical operation according to Stacke 

Radical operation according to Zau/fal-Fansen with opening of sinus..,.. 
Radical operation in cerebellar abscess 

Radical operation with chiselling of labyrinth 

Excision of carcinoma of external nose 

Extirpation of carcinoma of left nasal cavity 

Extirpation of nasal polypi 

Extirpation of hypertrophied turbinated bodies 

Extirpation of posterior extremities and hypertrophied turbinated bodies. . 
Incision of perichondritic abscesses of the nasal septum 

Ablation of deviations of nasal septum 

Opening of Highmore’s antrum through canine fossa 

Opening of Highmore’s antrum through alveola 

Chiselling of frontal sinus 

Curettement of sphenoid cavity and ethmoid cells 

Removal of tumors of naso-pharynx with cold snare 

Extirpation of faucial tonsils 

Extirpation of faucial and pharyngeal tonsils 

Extirpation of pharyngeal tonsil 

Removal of tumors of vocal cords 

Removal of tumor of Santorini’s cartilage (with cold snare by autoscopy). . 


I may here add a report on an epidemic of erysipelas, 
which appeared in the hospital at two different periods 














Report of the Strassburg Ear Clinic in 1898. 121 


during the summer and late fall. Through an outside 
physician suffering from erysipelas of the head, the infec- 
tion had been transmitted into the operating room. All 
precautionary measures, immediately used (disinfection of 
the operating room and its surroundings, and also of the 
patients’ rooms with formaline, etc.), could not prevent the 
infection with erysipelas of the following nine patients 
operated upon from April 1, 1898, until April 1, 1899, among 
sixty-nine Cases: 


1, Adele St., et. twenty-one. Admitted April 27, 1898. Diag- 
nosis: Otitis media, chronic, bilateral, purulent, with polypi and 
caries of the left temporal bone. April 29th : Radical operation, 
L. She was seized on May 10, 1898, with erysipelas, which soon 
assumed a bullous character and was followed by severe nephri- 
tis. On May 18, 1898: Exitus letalis. 

2. Emilie E., et. thirteen. Admitted March 3, 1898. Diag- 
nosis : Otitis media, chronic, purulent, of R E, with periarticular 
abscess of the joint of the right jaw. April 11, 1898: Radical 
operation with opening of the abscess. June 18, 1898: Erysipe- 
las. June 19, 1898: Transferred to the Children’s Department of 
the hospital ; thence, after implication of the non-operated side 
with erysipelas, transferred back on July g9th—after recovery from 
erysipelas. August 3, 1898: Additional attack of erysipelas on 
the right side, of mild character and of three days’ duration. 
August 9, 1898: Discharged for out-of-door treatment. Begin- 
ning of September: Recovery. 

3. Magdalene Sch., zt. nineteen. Admitted on June 23, 1898. 
Diagnosis : Otitis media, purulent, acute, of R E with mastoidi- 
tis. June 25, 1898: Chiselling according to Schwartze. In the 
beginning, the course of the wound was without reaction. July 
12,1898: On account of rise of temperature and infiltration of the 
jugular region, another operation was performed. The sinus (no 
thrombosis) was exposed and a diseased portion in the apex was 
removed. July 14, 1898: Erysipelas. She was transferred to 
the Department of Internal Diseases and thence discharged on 
August gth for out-of-door treatment. End of September: Re- 
covery. 

4. Magdalene L., zt. forty-seven. Admitted on June 28, 1898. 
Diagnosis: Otitis media, purulent, subacute, of R E, with acute 
mastoiditis. July 2, 1898: Chiselling according to Schwartze. 





122 F. Alexander. 


July 18, 1898: Erysipelas. She was transferred to the Internal 
Department and thence discharged on August 19, 1898, for out-of. 
door treatment. Beginning of October: Recovery. 

5. Marie B., zt. thirty-one. Admitted November 19, 1898, 
Diagnosis : Otitis media, purulent, chronic, of L E, with polypi, 
November 23, 1898: Radical operation. December 5th: Ery. 
sipelas. She was transferred to the Internal Department of the 
“* Biirgerspital,” and thence was discharged for out-of-door treat- 
ment, which is still carried on; however, the wound cavity is 
now (July, 1899) almost entirely epidermized. 

6. Emil O., zt. twenty-nine. Admitted November 24, 1808. 
Diagnosis: Periauricular abscess after furuncle. November 
26th: Opening of the abscess. December roth: Erysipelas, 
He was transferred to the Internal Department of the “ Biirger- 
spital,” and thence discharged for out-of-door treatment. Begin- 
ning of February: Recovery. 

7. Ignaz B., et. thirty-three. Admitted October 31, 13808, 
Diagnosis : Otitis media, purulent, chronic, L E. November 3d: 
Radical operation. December 25th: Erysipelas. He was trans- 
ferred to the Internal Department and on January 17, 1899, trans- 
ferred back to the Aural Department ; on March 1, 1899, he was 
discharged as almost entirely cured for treatment by his own 
physician. 

8. Martha St., et. sixteen. Admitted January 17, 1899. Diag- 
nosis : Otitis media, purulent, chronic, R E. February 17, 1899: 
Radical operation. February 19,1899: Erysipelas. The patient 
was isolated at once. March 23, 1899: discharged for treatment 
by her own physician. She had then a small granulating portion 
in the wound cavity, which was otherwise entirely epidermized. 

9. Emma L., et. thirteen. Admitted January 21, 1899. _Diag- 
nosis : Otitis media, purulent, chronic, bilateral, caries of the left 
petrous bone, abscess behind the L E. January 23, 1899 : Radi- 
cal operation L. After cessation of the incipient rise of tempera- 
ture on January 31, 1899, suddenly 40.2° C. On the following 
day, typical erysipelas of the left aural region ; on February 14, 
1899, implication of the right side. On March 18, 1899: Dis- 
charged for out-of-door treatment ; the wound cavity is now al- 
most entirely epidermized. 


It is superfluous to give a detailed description of the 
course of the erysipelas in each separate case, since it almost 





Report of the Strassburg Ear Clinic in 1898. 123 


always presented the same or at least a similar picture. 
The temperatures varied between 38.8° C. and 40.9° C. 
The diseased portions of the skin were always intensely 
swollen, highly reddened, their surface shining and mostly 
painful to the touch; in one case (No. 3), the sensibility 
upon pressure was increased to an enormous hyperesthesia. 
The eruption, which started from the operated wound and, 
in all cases, had also implicated the scalp, was always de- 
fined by the well-known sharp, often serrated, boundary 
line from the surrounding parts. In three cases the hair 
fell out profusely, in two cases almost entirely. In two 
cases (Nos. 2 and g), even the non-operated side was im- 
plicated. The urine contained albumen in three cases; 
albumen, cylinders, epithelia, etc., in two cases. Vesicles 
(erysipelas miliare) were present in two cases (Nos. 7 and 9); 
bullze (erysipelas bullosum), in one case (No. 1). This case, 
which ended fatally, began and ran its course under the se- 
verest symptoms. The patient was extremely delirious and 
apathetic from the third day of sickness. Extreme apathy 
was also at times present in three cases (Nos. 3, 4, and 5). 
At any rate the intensity of the disease decidedly decreased 
during the course of the epidemic. For the treatment of 
the wound during the erysipelatous disease, dressings mois- 
tened with a two-per-cent. solution of carbolic acid were 
almost exclusively used. 7 

Ever since the Aural Department, from the beginning of 
this year, has two rooms which are completely isolated from 
the other sick-rooms and received the cases of Nos. 8 and 9 
as soon as the very first signs of erysipelas presented them- 
selves, until to-day, no erysipelatous disease has appeared. 








A CASE OF BEZOLD’S MASTOIDITIS SECONDARY TO 
FACIAL ERYSIPELAS; OPERATION; RECUR. 
RENCE OF THE ERYSIPELAS WITHIN TWENTY. 
FOUR HOURS; CURE. 


By JOHN DUNN, M.D., RicHmonp, Va. 


On January 13, 1900, I was asked to see Mr. A., aged fifty- 
nine. Previous history as follows: about December 10, 1899, 
facial erysipelas developed. It began at the bridge of the nose, 
spread across his face, involving finally the whole scalp, including 
the external ears. About the 2oth of December Mr. A. experi- 
enced severe pain in the left side of his head ; three or four days 
later his left ear began to discharge, without, however, being fol- 
lowed by any diminution of the pain in the aural region. This 
continued with great severity until I saw him on January 13th. 
At this time the patient’s general appearance did not suggest grave 
intracranial complications. Appetite excellent. Pulse 90. 
Temp. 99$°. He was, however, suffering intensely with pain in 
the region of the left ear, which was discharging copiously a 
whitish-gray fluid. The left mastoid region was so swollen and 
cedematous, and so sensitive to pressure that little information as 
to the condition of the bone beneath could be obtained by palpa- 
tion. On either side of the sterno-mastoid was a large swelling 
extending two inches below the mastoid tip. As the patient had 
just finished a rather hearty dinner when I first saw him, he was 
not operated upon until the following morning at g o'clock, at 
which hour his pulse was 84; temp. 984°. The operation revealed 
the fact that practically the whole of the mastoid process had been 
destroyed. A small portion of its external surface was present, 
and attached to the fibrous portion of the sterno-mastoid about the 
tip were a few spicules of bone. The inner plate was also exten- 
sively destroyed, laying bare a large area of dura mater, whose 
surface was much roughened. 


124 


























A Case of Bezold's Mastotditts. 125 


An incision was made through the skin, including the posterior 
one fourth of the sterno-mastoid, about two inches below the tip. 
Through this hole I inserted my middle finger, passing it beneath 
the sterno-mastoid muscle into the hole left by destruction of 
the mastoid process. The attic was not examined ; the operation 
being brought to a close after removal of the remaining roughened 
pieces of bone about the process, and all the more quickly as 
there was considerable bulging of the brain membrane into the 
large hole in the inner-table. I could get no history of symptoms 
pointing to sinus thrombosis, so left the sinus unexamined. The 
usual dressings were applied. At eight o’clock the next morning 
I saw Mr. A., who had passed a fairly comfortable night. At this 
time his pulse was 90; temp. 984°. At ten o’clock I received a 
message from the nurse that the temperature had gone up to 
102°. [at once went to the hospital and removed the dressings to 
find that the auricle was immensely cedematous, being nearly half 
an inch thick and fiery red. Erysipelas had set in. Its blush 
could be seen to extend about three quarters of an inch over the 
skin anteriorly to the auricle ; posteriorly it had reached the lip 
of the wound. The whole of reddened area, including the auricle 
and the external auditory canal, which was nearly impervious from 
the swelling, down to the drum membrane, was painted over three 
times with pure carbolic acid. The whole surface was then left 
covered for twenty-four hours with gauze saturated in pure alco- 
hol ; the external auditory canal being filled with alcohol every 
two hours. Quinine and tincture of iron were administered in- 
ternally. By four o’clock next morning the temperature was 
down to 99 °, which point it did not reach again during the course 
of the convalescence. The discharge from the external canal 
ceased entirely within forty-eight hours. The dressings of the 
mastoid wound were changed twice daily for three weeks. The 
wound, which steadily grew smaller, to-day, March 30, 1900, 
closed up finally. 


The case has been reported because mastoiditis, occurring 
in the course of erysipelas, is rare, and because of the rapid- 
ity with which the recurrent attack of erysipelas subsided 
under the prompt and thorough use of carbolic acid and 
alcohol. 












NASAL EMPYEMA AS AN ETIOLOGICAL FACTOR IN 
THE ESTABLISHMENT AND CONTINUATION OF 
POST-NASAL CATARRH AND CATARRHAL IN- 
FLAMMATION OF THE MIDDLE EAR, WITH AN 
ESPECIAL CONSIDERATION OF THE ENLARGE- 
MENT OF THE POSTERIOR END OF THE ‘MID- 
DLE TURBINATE AS A PREDISPOSING CAUSE. 


By CAROLUS M. COBB, M.D., Boston, Mass. 


MEMBER OF THE MASSACHUSETTS MEDICAL SOCIETY, MAINE MEDICAL SOCIETY, AMERICAN 
MEDICAL ASSOCIATION, AND LYNN MEDICAL FRATERNITY. 


HE widespread prevalence of catarrhal inflammation 

of the middle ear and the relentless course it pursues 

when once established, make the study of the disease of 
fascinating interest. That chronic catarrhal inflammation of 
the middle ear is caused, or at least unfavorably influenced, 
by catarrhal diseases of the nose and naso-pharynx is a fact 
which has been accepted by otologists for many years, and 
it is the relation, or perhaps identity, of the catarrhal 
inflammation of the ears to the general, or local catar- 
rhal condition of the respiratory tract, which we wish to 
study in this paper. We will not consider in this connection 
those diseases of the nasal mucous membrane which are 
closely allied to diseases of the skin, of which the relation 
between eczema and asthma furnishes an example. This 
omission is made with a full appreciation of the relation of 
such diseased conditions of the respiratory mucous mem- 
brane to the chronic inflammatory process of the membrane 
lining the middle-ear cavity, but it has seemed preferable 
at this time to deal with the more common diseased con- 
ditions which are usually known as catarrhal—z. ¢., accom- 
panied by a discharge. Nor shall we consider such diseases 

126 











Nasal Empyema. 127 


at suberculosis, syphilis, and new growths of the upper 
respiratory tract only in so far as they are a causative factor 
in the establishment or continuance of the catarrhal dis- 
charge. With this brief explanation of the scope of this 
paper, we will proceed to the consideration of the catarrhal 
disease condition of the upper respiratory tract and the 
chronic catarrhal inflammations of the middle ear which are 
caused by it. 

Politzer states what is very probably the general belief 
among otologists when he says that ‘“‘ The diseases of the 
naso-pharynx, and of the nasal cavities, are not only fre- 
quently the forerunners of affections of the middle ear, but 
also exert an important influence upon the course and re- 
sults of these affections. Their knowledge and treatment 
appears the more important to the ear specialist, as in the 
middle-ear disease, by the occurrence or continuation of a 
naso-pharyngeal affection, the ear disease is continued, and 
the return to the normal prevented.” The recognition and 
removal of adenoid vegetations from the naso-pharynx has 
given, by the relief of catarrhal inflammation of the middle 
ear in children, abundant evidence that disease of the naso- 
pharynx is closely associated with middle-ear disease, and in 
this particular class of patients the naso-pharyngeal disease 
is without doubt the cause of the ear disease. If the other 
disease conditions of the naso-pharynx bear the same rela- 
tion to middle-ear disease that adenoids do, then the study 
of the naso-pharynx and nasal cavities is of the utmost im- 
portance. It is important to inquire in what way a naso- 
pharyngeal or nasal disease affects the middle ear. The 
generally accepted opinion has been that the aural disease is 
caused by an obstruction to nasal breathing, and the nega- 
tive pressure (Toynbee experiment) resulting from this. It 
is now known that adenoids produce aural disease in many 
cases in which they do not cause nasal obstruction, and that 
it is the location of the adenoid growth in or around the 
Eustachian tube, rather than’ the interference with nasal 
respiration, that causes the middle-ear disease. The location 
of an adenoid growth, as well as the changes which it under- 
goes from time to time, are very well seen in cases of cleft 














128 Carolus M. Cobb. 


aladte. In these cases there is evidently no nasal obsttuc- 
tion, but the obstruction of the Eustachian tube by the 
adenoid growth can be plainly seen. In other diseased con- 
ditions of the naso-pharynx associated with middle-ear dis- 
ease, the same relation may exist between the two, though 
perhaps not always in the same way, that exists between 
middle-ear disease and adenoids. Adenoids may cause Eus- 
tachian obstruction in a purely mechanical way, while in 
other naso-pharyngeal diseases the mucous membrane of the 
Eustachian tube, and often that of the middle ear, is affect- 
ed by an extension of the disease of the naso-pharynx. It 
is very rare for the other diseases of the naso-pharynx to 
cause the purely mechanical obstruction that adenoids do. 
The question naturally arises, what are the causes of naso- 
pharyngeal disease and what makes it so intractable? The 
naso-pharynx is subject to any of the acute diseases of mu- 
cous membranes in general, but these attacks should, and in 
most cases do, run the course of acute inflammation of the 
mucous membrane in other situations. Acute naso-pharyn- 
gitis is a self-limiting disease, and there is nothing about the 
naso-pharynx that should cause an acute disease to pass 
over intoachronic one. The drainage is good, being in 
fact an inverted basin, and there are no pockets to retain 
the products of inflammation and so act as a source of re- 
peated infections. The only pocket that was ever seriously 
claimed to exist in the naso-pharynx was Thornwaldt’s 
bursa, and this is now known to be a depression in a neg- 
lected adenoid. Neglected adenoids may also cause bands 
of tissue, which evidently limit motion in the upper part of 
the pharynx, but these bands can hardly be said to form 
pockets which could retain infective material. Chronic naso- 
pharyngitis is not often, if it is ever, the result of an acute 
attack, although the acute exacerbations occurring in the 
course of the chronic disease are very deceptive and often 
pass as acute primary naso-pharyngitis. Acute disease of 
the naso-pharynx is probably always of bacterial origin. 
This opinion is held by Lennox Brown and many other 
competent observers. The different ways in which infection 
may reach the naso-pharynx are, first, as a part of the 














Nasal Empyema. 129 


general involvement of the whole of the upper respiratory 
tract, in coryza, influenza, and the beginning of pneumonia; 
secondly, by infection from chronic nasal disease ; thirdly, by 
an extension upwards of an acute inflammation of the oro- 
pharynx, and lastly from such general systemic infections as 
tuberculosis, syphilis, general septicemia, and the exan- 
themata. In those cases in which acute naso-pharyngitis 
occurs during the course of an acute coryza, the naso-phar- 
ynx may be involved at once or the inflammation may exist 
in the nose several days before it affects the naso-pharynx. 
During an attack of acute naso-pharyngitis from whatever 
cause, the lymph tissue of the pharyngeal vault is involved, 
but the inflammation should run the course of inflammation 
in simular tissue elsewhere and end in recovery. This 
is undoubtedly the result in a large majority of the cases, 
and it would be the result in all if the lymph tissue of the 
naso-pharynx were not subjected to repeated reinfection. 
If the naso-pharynx is examined with the post-nasal mirror 
in cases of post-nasal catarrh, the mucous membrane will be 
found red, swollen, and uneven. This condition may in- 
volve the whole post-nasal space in acute cases, while in the 
chronic cases, the redness and swelling may be limited to 
circumscribed patches varying in size from a few millimetres 
to several centimetres in diameter. The lymph glands are 
always involved, not alone in the vault of the pharynx, but 
those on the posterior and lateral walls of the oro-pharynx 
as well, and appear as solitary follicles (follicular pharyngi- 
tis), as bands or stripes (lateral pharyngeal hypertrophy), or 
as a slightly raised granular surface. There is very little se- 
cretion to be seen except in those cases where an atrophic 
rhinitis has extended to the naso-pharynx or in cases in 
which the post-nasal catarrh has existed for years and the 
acinous glands have become involved. In the latter class 
of cases the discharge is thin, glairy, and very tenacious, 
and it often gives a shiny appearance to the mucous mem- 
brane. The cases which havea large amount of secretion 
in the naso-pharynx are either cases of atrophic disease or 
neglected cases of sinus disease. In those cases in which 
the pharyngeal vault is free from secretion the patient can 











130 Carolus M. Cobo. 


by sniffing and clearing the throat obtain more or less secre- 
tion, thus showing the source of the discharge to be in the 
nasal cavities. Except in the cases noted above and in 
cases where either syphilitic or tuberculous ulcers exist in 
the post-nasal space, there is no evidence that any consider- 
able amount of the discharge in cases of post-nasal catarrh 
originates in any part of the pharynx. On the other hand, 
the appearance of the naso-pharynx, the absence of secre. 
tion on inspection, and the method of clearing the throat 
shows that the discharge comes from the nose and that the 
lymph tissue is infected by this discharge. In other words, 
the inflammation of the mucous membrane of the naso- 
pharynx and the involvement of the lymph tissue is a secon- 
dary disease caused by an irritant discharge from the nasal 
cavities. That the discharge from the nose is irritant we 
have abundant evidence in the excoriations around the nos- 
trils and extending to the lips in cases of acute rhinitis and 
the purulent catarrhs of children. If a condition similar to 
that which is found in the naso-pharynx existed in any other 
part of the body, no one at the present day would consider 
it a primary disease, but every surgeon would at once search 
for the source of the infection. 

The effect of this condition of the naso-pharynx on the 
ears is very evident, the ears are especially liable to suffer, 
indeed they can hardly escape, if the lymph tissue in or 
around the Eustachian tubes is involved by repeated infection 
from an irritant nasal discharge. There is every reason to 
believe that the inflammation of the naso-pharynx may ex- 
tend to the middle ear itself, either by continuity of tissue 
or by the forcible blowing of the irritant discharge through the 
Eustachian tube into the middle-ear cavity. The appearance 
of the membrane of the middle ear in cases of chronic 
catharrhal inflammation, as described by Politzer, resembles 
so closely the appearance of the mucous membrane of the 
naso-pharynx in cases of post-nasal catarrh as to suggest a 
common origin. The same solitary follicles and the same 
circumscribed patches of red, raised, granular mucous mem- 
brane exist in both and would seem to indicate that the 
disease was the same in one situation as in the other. For 














Nasal Empyema. 131 


reasons that are obvious, the results of the inflammation are 
much more serious in the middle ear than they are in the 
naso-pharynx. It is not the purpose of this paper to discuss 
the pathological changes that take place in chronic catarrhal 
inflammation of the middle ear but simply to show the re- 
lation of the two diseases and to find a rational explanation 
of chronic post-nasal catarrh. 

If the assumption is correct, that to establish a chronic 
post-nasal discharge, with all its attendant symptoms, it is 
necessary to have a pocket which acts as a reservoir to retain 
the products of inflammatory action, and further if the 
normal naso-pharynx does not contain such pockets then it 
is necessary to examine the surrounding parts in search of 
such pockets. If we do this we find a large number (the 
nasal accessory sinuses) which open into the nasal cavities 
as a common drainage way. In the normal condition these 
sinuses communicate by free openings with the nose and 
whatever secretion there may be from them is carried, to- 
gether with the secretion from the other parts of the nasal 
cavity, by the action of the cilia, to the naso-pharynx. It is 
only when the sinuses become the seat of chronic disease 
that they assume any importance as an etiological factor in 
the production of the chronic catarrhal condition. Disease 
of these sinuses may be so extensive and so_ severe 
as to menace the health or even the life of the patient, 
or they may be so slight that the only symptom is an inter- 
mittent discharge into the naso-pharynx. Whether we 
accept the statement of Hajek that “the whole chain of 
catarrhal symptoms of the nose, naso-pharynx, larynx, 
trachea, bronchi, and of the lungs themselves is dependant 
upon nasal empyema, we must, I think, admit that there is a 
close relation between the disease of the accessory sinuses 
and chronic catarrh of the upper part of the respiratory 
tract. I am fully convinced that there is no other explana- 
tion of chronic catarrhal naso-pharyngitis but this. I came 
to this conclusion from clinical experience, some time before 
I saw Hajek’s statement, and further observation has only 
confirmed me in this belief. A daily discharge from a nasal 
empyema passing through the naso-pharynx is sufficient to 











132 Carolus M. Cobb. 


cause all the symptoms of post-nasal catarrh and I know no 
other condition that is.’ 

To establish a nasal empyema it is necessary to have 
certain predisposing causes which may exist either singly or 
combined in a given case ; they are: 

First. Congenital defective formation of the bony walls 
of the nasal cavities, such as a middle turbinate which is 
strongly rolled outward, so leaving a small space for drainage, 
small openings to the cavities, cavities badly placed for 
drainage, and an extremely narrow nasal cavity. 

Secondly. Partial or complete closure of the normal 
openings of the cavities. This stenosis may be the result of 
disease or of acquired deformity, such as polypoid degenera- 
tion of the mucous membrane and new growths of all kinds, 
syphilitic, tuberculous, and nonspecific osteitis and periosti- 
tis, a bullous middle turbinate, spurs, deviated septum, and 
general or local vascular or fibrous hypertrophy of the nasal 
tissue. The last condition is very often the result of nasal 
empyema, and cannot therefore in many cases be considered 
as a Cause. 

Thirdly. Unhealthy surroundings which increase the 
liability of infection. Also the virulence of the infection and 
often the lowered resistance of the patient. 

If we examine the predisposing causes more in detail, we 
find that deviated septi and spurs are causes of nasal em- 
pyema, post-nasal catarrh, and catarrhal deafness only when 
they are so located or are of such degree that they interfere 
with the drainage from the accessory sinuses. It follows 
therefore that operations for the relief of these conditions 
will have a beneficial effect upon the deafness only in those 
cases in which the more affected ear corresponds to the 
more occluded nasal cavity. 

The chief predisposing cause of nasal empyema is the 
position, size, and diseased condition of the middle turbin- 
ate or of the tissues surrounding it. The middle turbinate 
varies in size from a mere ridge to a body several centimetres 





! When this paper was nearly ready to go to press I found that this opinion 
of the origin of post-nasal catarrh is held by Griinwald and Moritz Schmidt. 
Grinwald’s Nasal Suppuration, 2d ed. page 108. 











Nasal Empyema. 133 


in thickness. It usually extends only to the posterior third 
of the nasal cavity, but when diseased it may reach as far as 
the Eustachian tube. . 

We expect to find nasal empyema in all cases of polypoid 
disease in the region of the middle turbinate and the same - 
holds true of new growths in this region. After all the cases 
in which there is evident disease of or around the middle 
turbinate have been eliminated, there still remains a vast 
number of cases which have nasal empyema. These cases 
are caused by a middle turbinate which approaches too 
close to the nasal wall, by cells which are badly placed for 
drainage, or by focal disease within the cell itself. The space 
between the middle turbinate and the nasal wall, through 
which the drainage from the antrum, the anterior ethmoid 
cells, and frontal sinus passes, may be much narrowed and 
still serve its purpose until the cells and the nasal mucous 
membrane have been subjected to repeated and prolonged at- 
tacks of inflammation, or the first severe attack may estab- 
lish a nasal empyema. An acute inflammation may entirely 
close the natural openings of the cavities and thus cause the 
products of inflammation to become encysted or, as occurs in 
a large proportion of the cases, after the acute congestion 
has partially subsided, the inflammatory thickening only 
partially closes the openings and thus allows a discharge of 
mucous or muco-pus to escape into the nose and naso-phar- 
ynx, either constantly or at irregular intervals. In many 
cases there is never any discharge visible in the nose on ex- 
amination, because of the middle turbinate being so closely 
rolled outward that it forms a sort of gutter which conducts 
the discharge to the naso-pharynx without it ever appearing 
in the nose. In this way the discharge from the antrum of 
Highmore or from the anterior ethmoid cells or frontal 
sinuses may reach the naso-pharynx and appear as a post- 
nasal catarrh. 

In this connection I wish to call attention to a malform- 
ation of the middle turbinate which is almost constantly 
present in cases of post-nasal catarrh. So far as I know 
the relation of this particular malformation of the middle 
turbinate to post-nasal catarrh has not previously been 


















134 Carolus M. Cobo. 


reported. The malformation consists of an enlargement 
and downward prolongation of the posterior end of the mid- 
dle turbinate.' It is often large enough to nearly or quite 
fill the space between the septum and the nasal wall. It 
rarely reaches to the lower meatus, but is confined for the 
most part to the middle meatus. Owing to its situation far 
back in the nasal cavity, and also at times to the presence of 
a tortuous or narrow nasal chamber or, what is still more 
common, the presence of hypertrophy of the nasal mucous 
membrane, it may be easily overlooked, unless it be searched 
for after the tissues have been shrunken by the application of 
cocaine. The enlargement of the middle turbinate often 
contains a cell of some size which may be the source of some 
discharge, but the larger part probably comes from the pos- 
terior ethmoid cells or the sphenoid sinus, although, as pre- 
viously stated, the drainage from any one of the sinuses may 
be concealed by the middle turbinate. The openings of the 
posterior ethmoid cells and sphenoid sinus are partially and 
probably at times wholly closed by this part of the middle 
turbinate, and it thus acts as a predisposing cause for the 
formation of an empyema inthem. The formation of a gut- 
ter by the middle turbinate which has been alluded to before 
should not be forgotten in connection with this enlargement 
of the posterior end. This part of the nasal cavity is in- 
flamed during each attack of acute rhinitis, from whatever 
cause, and often the inflammatory process is not apparent in 
any other part of the nasal cavity. This is especially notice- 
able in those patients that suffer from a succession of colds 
during the winter and spring months. If this part of the nose 
is carefully examined during the progress of an attack of this 
kind, the enlargement of the middle turbinate will be found 





'In many of these cases the anterior part of the middle turbinate is not de- 
veloped, so that which I have described as a malformation is the only portion 
which is visible by rhinoscopic examination, but even in those cases in which 
the enlarged posterior end comprises the whole of the middle turbinal, an essen- 
tial malformation exists. It is well to bear in mind that in these cases the 
drainage from the antrum, the anterior ethmoid cells, and the frontal sinus 
probably still takes place through the space between the middle turbinate and 
the nasal wall and that it would therefore be much nearer to the naso-pharynx 
than in the normal nose. 








Nasal Empyema. 135 


swollen and dusky red in color, the rest of the nasal cavity 
perhaps being free from all appearance of inflammation. 
This swelling gives rise to a sense of stuffiness and to more 
or less headache. As the attack begins to subside it is often 
possible to see a mucous or muco-purulent discharge flowing 
down around this part of the middle turbinate and this visi- 
ble discharge may persist for some time. It is very proba- 
ble that the repeated colds from which these patients suffer 
are not fresh attacks, but rather exacerbations of an already 
existing nasalempyema. A patient that has a collection of 
fluid in one or more of the accessory sinuses generally suf- 
fers from what he considers to be a succession of colds in the 
head. During the warm months or in an atmosphere that 
is practically free from germs, the nasal empyema may give 
only slight annoyance, but during the colder weather, or in 
unhealthy surroundings, it will be the cause of a persistent 
catarrhal condition of the upper respiratory tract. The pres- 
ence of this inflammatory condition in the cells renders the 
patient more susceptible to attacks of acute rhinitis from in- 
fection, but by far the greater annoyance comes from in- 
creased secretion, which resembles a cold in the head, and 
which may last from a few hours to several days. This in- 
crease of secretion may be the result of anything that causes 
congestion, such as indigestion, constipation, draughts of air, 
wetting the feet, dust- or smoke-laden atmosphere, menstru- 
ation, etc. 

It is just this class of patients that have chronic catarrhal 
inflammation of the middle ear and in whom the deafness is 
made worse by each increase in the inflammatory condition 
of the nose or naso-pharynx. The enlargement of the pos- 
terior end of the middle turbinate, which I have described, is 
constantly present in these cases and I have been able to tell 
by the presence or absence of inflammation in this part of the 
nose, whether the deafness was worse or better. The in- 
crease of the deafness is coincident with the increase of the 
inflammation of this part of thenose and it may precede the 
increase of the post-nasal discharge, probably for the reason 
that the congestion from the increased inflammation extends 
to the Eustachian tube at once, while the same congestion 














136 Carolus M. Cobb. 


may lock up the discharge for several days. I am convinced 
that the malformation of the middle turbinate, which has 
been described, is the predisposing cause of the nasal 
empyema which produces a large percentage of the cases of 
post-nasal catarrh and catarrhal deafness. The reasons for 
this conclusion are briefly, that it practically always exists in 
cases of post-nasal catarrh, that an inflammation here pre- 
cedes by a few days or is coincident with an increase of the 
inflammatory process in the naso-pharynx and middle ear, 
that it is often the only part of the nasal cavity which is in- 
flamed in cases of acute rhinitis, that it is often possible 
to see the secretion flowing down around this part of the 
middle turbinate, and finally that it is possible to cure long- 
standing cases of post-nasal catarrh and relieve the ears from 
the danger of repeated attacks of inflammation, by the re- 
moval of enough of this malformation of this middle turbinate 
to give good drainage to the cells which may be diseased. 

If the predisposing causes exist what is necessary to estab- 
lish a nasal empyema? Unquestionably bacterial infection. 
According to Hajek every inflammation, of the accessory 
sinuses, either acute or chronic, is due to this cause. We 
will briefly pass in review the different diseases during the 
course of which infection of the accessory sinuses may occur. 
Among these diseases acute coryza takes the first rank on 
account of the frequency of its occurrence. While it cannot, 
as yet, be demonstrated with certainty that the so-called cold 
in the head is due to bacterial infection, nevertheless its 
evident contagiousness, its clinical course, complications, and 
sequelz leave no doubt but that such is its origin. 

Next in frequency to acute coryza comes influenza. 
Weichselbaum was the first to demonstrate the influenza 
bacillus in accessory sinus disease. Later Lindenthal found 
the influenza bacillus almost constantly present in the acces- 
sory sinuses during the course of influenza and he found that 
it alone was sufficient to produce pus without the admixture 
of any other bacteria. Lindenthal was also led to believe 
from his investigations that in many of the cases where other 
bacteria were found with the influenza bacillus, that they 
were a secondary infection. 














Nasal Empyema. 137 


Next in frequency after influenza come croupous pneu- 
monia, scarlet fever, diphtheria, measles, typhoid fever, 
facial erysipelas, cerebro-spinal meningitis, variola, etc. 
(Hajek). 

Frankel has called attention to the frequent occurrence of 
accessory sinus disease during the course of croupous pneu- 
monia, and his researches, together with those of Weichsel- 
baum, clearly establish the connection between the two 
diseases. Frankel also found the pneumococcus of Fried- 
lander in the normal accessory sinus. 

The relation of diphtheria of the throat or nose to sinus 
disease presents itself in one of two ways—either there may 
be a true diphtheritic membrane formed in the accessory 
sinuses, particularly in the antrum (Weichselbaum, E. Fran- 
kel, Dmochowsky), or the sinuses may be intensely inflamed 
during the course of the diphtheritic attack without true 
diphtheritic infection, the inflammation in these cases being 
due to asecondary infection by other bacteria (Zuckerkand)). 

The relation between facial erysipelas and sinus disease 
has been observed and reported by Zuccarini, Weichselbaum, 
Zuckerkandl, Killian, Griinwald, Hajek, and others. Whether 
the facial erysipelas or the sinus disease is the primary disease 
has not as yet been settled. It is quite probable that one 
may be the primary disease in one patient and the other 
in another. The other bacteria most often found either 
alone or accompanying the influenza bacillus, in accessory 
sinus disease, are the staphylococcus pyogenes aureus and 
albus, the streptococcus pyogenes and the bacillus coli. 
(Weichselbaum, E. Frankel, O. Lindenthal.) Whether the in- 
flammation of the accessory sinuses occurring during the 
course of the above-mentioned diseases is due to the primary 
or to secondary infection by other bacteria, has not as yet 
been definitely settled only so far as relates to pneumonia, 
influenza, and diphtheria. 

The frequent occurrence of nasal empyema as a sequel of 
scarlet fever and diphtheria is very noticeable. Equally so 
is the empyema following what is evidently a purulent rhini- 
tis in children. Children may have a purulent rhinitis even 
from birth, as, perhaps, the nasal mucous membrane may be 














138 Carolus M. Cobb. 


infected in the parturient canal. Those cases which are not 
infected at that time generally suffer from infection sooner 
or later. This is so common that it is expected as a matter 
of course by the parents that the child will have a nasal dis- 
charge, and some parents are alarmed if the child does not, 
thinking perhaps that it is not like other children. This in- 
fection is not to be wondered at when we remember the 
perfect indifference with which the child puts everything into 
the nose or mouth. The regurgitation of the contents of 
the stomach, a part of which often comes through the nose, 
may be another source of infection. The child has relatively 
a much smaller passage through the nose than the adult, 
and this, together with its inability to clear the nose, in- 
creases the liability of the establishment of a purulent dis- 
charge. As these patients reach the age of puberty the 
increased breathing space in the nose and throat, and often 
the atrophy of the adenoid tissues, in the naso-pharynx, 
gives better drainage, and many of them recover. All, how- 
ever, are not so fortunate, as the history of many cases of 
post-nasal catarrh will show. 

In every case of acute rhinitis, from whatever cause, the 
accessory sinuses are involved. The inflammation results 
from an extension of the disease of the nasal mucous mem- 
brane by continuity of tissue, and it would be very hard to 
understand why this extension should not take place. The 
accessory sinuses are really a part of the nasal chambers and 
why, it may be asked, should an inflammation reach a certain 
arbitrary line and refuse to go farther? 

A description of Rome which failed to mention the Forum 
would hardly be considered complete and a mention, at 
least, should be made of adenoids before leaving the subject 
of the predisposing and exciting causes of nasal empyema. 
This condition has been more closely studied than any other 
disease of the naso-pharynx, because it was early demon- 
strated that the presence of adenoid tissue in the naso- 
pharynx had a direct causal relation to ear disease in 
children. It is quite possible that the brilliant results 
obtained by the removal of adenoids may have led us to 
overlook other disease conditions which are of importance. 














Nasal Empyema. 139 


I wish at this time to call attention to a few erroneous be- 
liefs which are prevalent in regard to adenoids. The first of 
these is the explanation that adenoids cause ear disease by 
obstruction to nasal respiration; every otologist of any ex- 
perience knows that it is the location of the adenoid tissue 
around or in the Eustachian tube, and not the obstruction to 
nasal respiration, which produces the ear disease. Again, in 
regard to suppurating adenoids, that the uneven surface of 
an adenoid growth may retain pus or mucus, or that the 
removal of this tissue may lessen the amount of the dis- 
charge, or perhaps stop it entirely, no one denies; but that 
this suppuration originates in this tissue I do not believe: 
a, because the suppurative process would at once break 
down and destroy the soft tissue of an adenoid growth; 4, 
because the discharge does not cease at once after the re- 
moval of the adenoid, as it undoubtedly would if this tissue 
were the seat of the suppuration. The explanation of the 
collection of pus on the surface of the adenoid tissue is that 
the situation of the growth high up in the vault of the 
pharynx, and often in the posterior nasal chamber, interferes 
with the drainage from the posterior ethmoid cells and the 
sphenoid sinus, and we have in addition to the adenoids an 
empyema of these cells. 

Lastly, in regard to those cases of adenoids where the 
operation for their removal is a success, but the patient is 
not relieved. In this class of cases I have found the mal- 
formation of the middle turbinate, which I have described in 
this paper. Since I have been alive to the importance of 
this condition I have made it an invariable rule to examine 
for it every case of adenoids, and, when found, to give a 
guarded prognosis, z. ¢., I have told the parents that the 
removal of the adenoids was the first step to be taken, and 
that the operation might improve the drainage to such a 
degree that nothing more would be required, but that there 
was disease of the nose which might still give trouble. I 
have found that the parents were much better pleased to 
know this before than to learn of it after they found that 
the operation was not a complete success. 

Treatment: This will of course vary with the condition 











140 Carolus M. Cobb. 


found and the length of time which the disease may have 
been in existence. A large proportion of the acute cases, 
practically all of the lighter ones, will recover without any 
treatment or even with treatment which is distinctly injur- 
ious and it is only with the chronic or those acute cases 
which are very severe that we need concern ourselves at the 
present time. In general these cases may be said to have 
received inefficient rather than insufficient treatment. There 
are always two things to do in the management of these 
cases, one is to remove the discharge, and the other, which 
may be called the principal one, to improve the drainage to 
such a degree that the affected cavity will heal. 

The removal of the secretion is not always the simple 
matter that it appears to be. The secretion is very often 
concealed by the middle turbinate and, to remove it, it is 
necessary to shrink the nasal mucous membrane and then to 
introduce a small canula between the middle turbinate and 
the nasal wall and wash out the accumulation. If the secre- 
tion is above the middle turbinate, it should be washed out 
by placing the canula in the upper meatus. The ordinary 
spraying of the nasal cavities is almost absolutely useless as 
a curative agent. After the secretion is removed it is often 
possible to see small masses of granulation tissue around the 
openings of the sinuses, which are the result of the inflam- 
mation within the cells. This granulation tissue may be the 
cause of the stenosis, or it may be the source of some secre- 
tion, and its removal by cauterization or by the curette is 
often all that is required to effect a cure. The thorough 
washing and the removal of granulation tissue should be 
given a fair trial before proceeding to more heroic measures ; 
for, contrary to accepted belief, the nasal accessory sinuses 
have a strong predisposition to free themselves of inflamma- 
tion and will often do so with but slight assistance. These 
are evidently the cases which recover spontaneously or by a 
change of climate, after a variable length of time. It is 
always well to keep these patients under observation for 
some time, because it is a well-known fact that a diseased 
accessory sinus may remain free from secretion for months 
and then relapse. This may be on account of focal disease 














Nasal Empyema. 141 


within the cell or on account of the anatomical construction 
of the cells or the parts surrounding them. 

It is needless to add that these simple measures are not 
sufficient to cure those cases in which the drainage from the 
cells is interfered with by more permanent forms of obstruc- 
tion. I shall not discuss the surgical treatment of nasal 
empyema in detail, except in so far as it relates to the mal- 
formation of the middle turbinate which I have described in 
this paper. In general, surgical treatment of nasal em- 
pyema should aim to restore the nasal chambers to as 
near their natural condition as possible. To help nature 
and not to improve her should be the end sought by the rhin- 
ologist. It should make no difference to us whether we can 
understand why the natural openings of the sinuses are at or 
near the top of the cavities or not. It is safe to assume that 
those openings performed their functions so long as they were 
free from obstruction and as a rule we shall not improve the 
situation by making others, unless there is extensive diseased 
tissue which must be removed. Even in these cases the 
natural openings should be freed from obstruction, because 
it is a noticeable fact that the artificial openings are not 
maintained for any length of time and the drainage from the 
cavities again takes place through the openings provided by 
nature. Again there is every reason to believe that focal 
disease of considerable extent, within the cell itself, will 
gradually heal if the natural drainage is made perfect. All 
focal disease will not disappear in this way, but it is always 
well to wait a time for nature in cases in which the urgency 
of the symptoms does not demand immediate operative 
measures. This advice applies to the further extensive 
operative measures after the obstruction to the free drainage 
from the cells has been removed. On the other hand it is 
useless to wait for atrophy to take place to improve the 
drainage in those cases in which the drainage from the cells 
is interfered with by a diseased or badly placed middle tur- 
binate. The diseased middle turbinate and the diseased tis- 
sue around it should be removed without delay and the cells 
which are uncovered by the operation should be curetted. 
In the cases in which the middle turbinate is so closely 











142 Carolus M. Cobb. 


applied to the nasal wall that a probe can only with difficulty 
be inserted between them, enough of the middle turbinate 
should be removed to give free drainage, for even if atrophy 
does take place in ten or fifteen years and so improve the 
drainage, the post-nasal catarrh which is caused by the ob- 
structed drainage has in that time usually done all the harm 
that was possible, and so far as the ears or the general health 
of the patient are concerned the cure has come too late. 
The same holds true in regard to the special malformation 
of the middle turbinate which I have described. It is 
necessary fo remove enough of this to free the drainage. I 
have usually operated under cocaine with a small pair of 
Griinwald’s forceps. It is not necessary to remove the 
whole of this part of the middle turbinate, but if there is a 
cell in the enlargement, as there usually is, it should be 
broken into. In a few cases the space available to operate 
in is so small that it is impossible to reach the part to be 
removed with the forceps or the middle turbinate may be so 
closely applied to the nasal wall that it is impossible to in- 
troduce a blade of the forceps between them. In these cases 
I have often succeeded in introducing a small saw and by 
sawing into the turbinate have made room for the blade of 
the forceps. Various expedients will readily suggest them- 
selves to the operator. 

If the assumption is correct that post-nasal catarrh is a 
symptom of nasal empyema and not a disease fer se, then it 
is evident that it will be cured by the healing of the acces- 
sory sinus disease on which it depends. In attempting to 
prove this by a summary of cases which have been treated 
by improving the drainage from the accessory sinuses, I 
must of necessity rely upon the records of my own cases, as 
I am not aware that any cases have been reported which 
have been treated on these lines. 

Within the last two years I have operated on 231 cases 
for the relief of chronic post-nasal catarrh; 123 of these 
cases had deafness of varying degree. Of these cases, 84 
were operated on during the first year in which I did any 
work on these lines, and as a year or more has elapsed since 
they were treated we will analyze these cases for the reason 











Nasal Empyema. 143 


that the relapse of the disease can be better eliminated. Of 
the 84 cases, 

78 had the enlargement of the posterior end of the middle 
turbinate. 

23 of these cases had in addition diseases of other parts. 

6 of the 84 cases had no enlargement of the posterior end 
of the middle turbinate, but did have obstruction to drain- 
age around the anterior end. 

The result of the operations to improve the drainage in 
the 84 cases was: 

49 of the cases of post-nasal catarrh were permanently 
cured. 

20 cases suffered relapse, but were finally cured. 

7 were much benefited, but not cured. 

8 were not benefited. 

I have included in these records those cases which are 
known as post-nasal catarrh and have excluded those in 
which there was apparent extensive sinus disease. These 
cases were not included for the reason that there was no 
discharge into the naso-pharynx, but because they are 
usually classed as sinus disease, and not as post-nasal 
catarrh. 

In regard to the effect upon the catarrhal inflammation of 
the middle ear which the relief of the post-nasal catarrh af- 
fords, in general, it may be said that it keeps pace with the 
condition of the naso-pharynx, although the improvement 
of the aural condition is much slower than the improvement 
of the condition of the naso-pharynx. It is evident that even 
after the source of infection has been removed, that some 
time may be necessary for the inflammatory process in 
the middle-ear cavity to subside. I have records of many 
cases in which the improvement in the hearing was immedi- 
ate, but as a rule it is slow but fairly constant until the limit 
of improvement for each case is reached. A good rule for 
prognosis is this: by the cure of the post-nasal catarrh the 
hearing can be improved to rfearly the hearing capacity 
which the patients enjoy under the most favorable con- 
ditions, 2. ¢., in regard to climate and freedom from post- 
nasal catarrh, and that this improvement can be held. It is 











144 Carolus M. Cobb. 


not claimed that the hearing is improved in all cases, for, of 
course, no one expects the hearing to be much improved if 
pathological changes of any extent have taken place in the 
middle-ear cavity. What is claimed is this, that those cases 
of chronic catarrhal inflammation of the middle ear which 
depend upon or are made worse by chronic catarrhal naso- 
pharyngitis can be prevented from growing worse, #. ¢., freed 
from the danger of repeated exacerbations of the inflamma- 
tory process, by the treatment of the post-nasal catarrh on the 
lines which I have laid down. I have gone as fully into this 
subject of Bost-nasal catarrh as the limits of a journal article 
seem to permit. If I shall have directed attention to a new 
line of thought in regard to these cases, I shall be content. 

In closing I wish to call the reader’s attention to the fol- 
lowing conclusions : 

1. That the whole chain of catarrhal symptoms of the 
nose, the naso-pharynx, and of the ears is due to empyema 
of the nasal accessory sinuses. 

2. That this empyema is the result of an infective inflam- 
mation of the accessory sinuses in which the drainage is 
insufficient. 

3. That the malformation of the posterior end of the 
middle turbinate which I have described in this paper plays 
an important part in the establishing of the nasal empyema 
which causes post-nasal catarrh. 

4. That chronic catarrhal inflammation of the middle ear 
may result from the catarrhal condition of the naso-pharynx, 
either by extension of the disease, by continuity of tissue, 
by the forcible blowing of the irritating secretion into the 
middle-ear cavity, or by closure of the Eustachian tube from 
involvement of the mucous membrane in or around its 
entrance. 

5. That there is no evidence that chronic catarrhal inflam- 
mation of the middle ear is caused by obstruction to nasal 
respiration, unless the obstruction is associated with empy- 
ema of the accessory sinuses. 

6. That those cases of chronic catarrhal inflammation of 
the middle ear which are caused or made worse by naso- 
pharyngitis cannot be cured until the nasal empyema which 





Nasal Empyema. 145 


causes the naso-pharyngitis is first cured, and that mechani- 
cal treatment directed to the ears is only palliative and does 
not free the patient from the danger of an acute exacerba- 
tion of the disease. 

7. That many cases of nasal empyema may heal sponta- 
neously under favorable conditions, and the more recent the 
case the more probable it is that this will occur. 

8. That the accessory sinuses have a tendency to free 
themselves of inflammation, and that treatment should be 
directed to assist nature to this end. 

9. That it is possible to cure practically every,case of na- 
sal empyema and therefore every case of naso-pharyngitis 
depending on it. 


419 BOYLSTON STREET, BosTON, 





THREE CASES OF DIABETIC MASTOIDITIS. 


By Pror. E. P. FRIEDRICH, Kiet. 


Translated and Abridged by Dr. MAx ToEpLitz, New York. 


ASES of aural disease due to diabetes have not been 
frequently reported and then almost exclusively 
by Koerner, who has published four observations. This 
apparent rareness is contrasted by the fact, that during the 
course of the year 1898 I have seen and operated three 
cases of this kind, which are now fully reported, and con- 
firm the views of Koerner on primary mastoiditis of 
diabetics. | 
The three cases are as follows: 


CasE 1.—Agent, aged fifty, well developed, has for years suffered 
from diabetes ; the amount of sugar never exceeded one or two 
per cent. to the utmost and was easily suppressed by dieting. 

On January 20, 1898, he was seized with ear- and headaches in 
the left side, associated with intense sensibility upon pressure over 
the mastoid apex. I found the surrounding parts of the outside 
of the ear unchanged, the mastoid apex quite painful upon pres- 
sure, the soft parts of the external auditory meatus swollen, but 
without secretion. The drum membrane was swollen, its surface 
softened, gray-red, except at a dark-red bullous bulging in its 
upper posterior half. Whispered voice: R normal; L=o; B.C. 
not decreased, and more accentuated towards the L E ; low T. F. 
extremely, high T. F. less, decreased. 

Upon paracentesis, a thin, sanguinolent fluid continued to es- 
cape during the following days, while the pain decreased. How- 
ever, on January 26th, after cessation of discharge, it increased, in 

146 














Three Cases of Diabetic Mastotditis. 147 


order to decrease again after another paracentesis. The exami- 
nation of the urine yielded with Fehling and Nylander a slight 
reduction only, owing to the strict sugar diet of the patient from 
the beginning of the present disease. 

Until February rst, the subjective symptoms had more and 
more abated, the sensibility upon pressure upon the mastoid had 
ceased, the external meatus was free; the second paracentesis, 
however, had been followed by persistent profuse suppuration. 
This condition remained unchanged for several weeks, until, 
towards the end of February, with dull headache and sleepless 
nights, the upper wall of the external auditory meatus was sinking, 
without external changes of the mastoid and without sensibility 
upon pressure. There was no sugar demonstrable. On February 
28th, he was operated under chloroform. After exposing a dis- 
colored portion of the mastoid planum, from which chiselling was 
carried out, a widely branched system of pus containing osseous 
cells with a few granulations was laid bare. The bone was of 
dirty gray color, brittle and partially sequestrated, and was re- 
moved with spoon and rongeur as far back as the sinus, and 
downward to the extreme end of the mastoid apex. The antrum 
was spacious and filled with pus. With preservation of the tym- 
panic ring and the ossicles, a wide opening was made into the 
recessus epitympanicus. The wound was left open. 

On the day following the operation, the amount of sugar in- 
creased to 1.85 per cent., but disappeared after two days. The 
course of after-treatment was retarded by the detachment of a 
sequestrum from the tegmen tympani. The membrana tympani 
was cicatrized on March 8th, after entire cessation of suppuration 
after the operation ; end of May, 1898, the wound closed ; hear- 
ing faculty for conversation is preserved. 

CAsE 2.—Sch.’s wife, aged forty-six, was admitted to the aural 
clinic at Leipzig on October 10, 1898. 

The robust patient suffered for two weeks from an acute sup- 
puration of the left ear, and for a few days from intense pain be- 
hind the ear. The left external meatus was filled with pus and 
the posterior wall bulging, the mastoid process sensible upon 
pressure, its soft parts slightly infiltrated. Whispered voice, L 16”. 
The examination of the urine yielded 5.85 per cent. of sugar. 

A medium diabetic diet was instituted and the operation post- 
poned. Since on the following day the swelling of the upper 
wall of the external meatus had so much increased as to obstruct 












148 E. P. Friedrich. 


the entire lumen of the external meatus, and the infiltration over 
the mastoid had also considerably increased, the operation was 
performed on October 12th. 

The narcosis was instituted with chloroform and continued 
with ether. After chiselling the cortex, slightly offensive pus 
emanated from a large bone cavity, with brittle discolored walls, 
communicating with the spacious antrum, which contained as 
small a number of granulations as the recessus epitympanicus 
and the middle ear. The posterior osseous wall of the external 
meatus was carious and contained here and there small cavities 
filled with pus. The mastoid process was abundant in cells, the 
bone brittle, gray-brown, without much pus in the cells. The 
radical operation was completed by the formation of Koerner’s 
flap. The wound was sutured in the evening. T. 37.2° C. 

October 13th.—2.42 per cent. of sugar. Vomiting, lack of ap- 
petite, thirst, refusal of solid food. Evening T. 37.2°C. Quantity 
of urine, 2200 ccm. 

October 14th.—Change of dressing in the evening. The lower 
angle of wound was reddened and swollen, and pus discharged 
after removal of two sutures. Quantity of urine, 3100 ccm. 

October 15th.—Since preceding night, deep, labored breathing, 
with the picture of beginning diabetic coma of dyspneeic character. 
Under slight dulness, the patient answered questions correctly 
with slow, scanning speech, but was otherwise completely apathetic. 
Pulse was small and accelerated. The somnolence increased during 
the day more and more, leading to complete loss of consciousness. 
The breathing became more labored, loud, and rapid. At noon, 
T. 36.0° C.; evening, 38.9° C. Quantity of urine, 800 ccm. 

Death October 16th at 2 a.m. 

The autopsy, made at the Pathological Institute of Leipzig, re- 
vealed: Intense cedema of the soft meninges and a markedly 
firm brain. From the suppurative wound at the left mastoid 
process a phlegmon of the superficial cervical muscles extended down 
to the clavicle, and laterally from the left lobe of the thyroid an 
encapsulated small abscess was found. The sinus and jugular 
were free. The lungs presented old pleuritic adhesions, extreme 
hyperemia of both lower lobes, and cedema of the upper ones. 
The heart showed a dilatation of both ventricles and pale myo- 
cardium in fatty degeneration. Atrophy of pancreas, hyper- 
trophied kidney with cortex in fatty degeneration, and dull 
swelling of spleen and liver completed the picture. 




















Three Cases of Diabetic Mastotditis. 149 


CasE 3.—Merchant, et. forty-two, was admitted on December 
18, 1898, to the aural clinic at Leipzig. 

Patient, an inveterate drinker, was seized two years ago with sup- 
puration from the left ear, which persisted ever since with varying 
improvements and aggravations. On December 11, 1898, he sud- 
denly became worse, with simultaneous pain and swelling behind 
the ear, forcing him to call for admission to the hospital. The robust 
patient had a small, irregular, unequal pulse. The urine contained 
albumen and five per cent. of sugar, as was accidentally found. 

The ft maxillo-mastoid fossa was filled out by an elastic, 
uniform swelling, which extended upward over the mastoid pro- 
cess to the temporal line and down the posterior edge of the sterno- 
cleido-mastoid muscle, with reddened skin and deep-seated 
fluctuation. The walls of the external meatus were diffusely swol- 
len, the membrana tympani invisible, and profuse non-offensive 
purulent discharge issued from the ear. The radical operation 
was not performed owing to the high percentage of sugar and the 
weak heart action. 

On December roth, the abscess was incised, under local anzs- 
thesia, with an ether spray. The incision was made from the 
mastoid apex forward and downward, and reached the abscess 
only very far inward, when a large quantity of pus escaped. The 
abscess cavity extended far forward and downward ; the probe 
met upward rough bone at the mastoid apex. During the after- 
treatment the daily quantity of sugar varied between 4 and 1} 
per cent., and the quantity of urine between 1000 and 1500 ccm, 
and, one day only, 1800 ccm. ‘The action of the heart continued 
to be weak, the urine contained much albumen, and, in addition, 
profuse diarrhoea appeared. 

On December 28th the patient left the hospital ; the wound 
discharged pus profusely during the following weeks, the soft 
tissues remained infiltrated even after the incision was closed, 
and the otorrheea ceased at times. 


The serious aspect of aural disease in diabetics is the rapid 
extension of osseous caries, which should be early and ex- 
tensively removed. During the operation it is found, as a 
rule, that the subjective and -objective symptoms of the 
patient are out of proportion to the extreme extent of the 
disease. Early operations are often followed by difficulties 
based upon the nature of diabetes mellitus. 















150 E. P. Friedrich. 


The danger from operating on diabetics consists in the sub- 
sequent appearance of sepsis and coma. Both complications 
depend upon the amount of sugar and the acidity of the 
urine, which, when found together to a high degree, form a 
contra-indication of the operation. 

The danger from sepsis is greater in aural operations 
which present septic wounds and often give rise to mixed 
infections, owing to the communication of the pus from the 
diseased osseous parts with the external meatus through 
the middle ear. The above reported second case illustrates 
the rapid development of a burrowing abscess along the 
superficial cervical fascia. 

The appearance of diabetic coma is not due to the opera- 
tion or to shock, but to the narcosis. In some of Becker's 
cases it did not set in until the second day after the 
operation. The kind of narcotic used is not of so much im- 
portance as the metabolic change thereby produced through 
the increased acidity. This is well illustrated by my second 
case, while the first one presented an increased amount of 
sugar on the day following the operation. 

In all cases in which the aural disease requires an early 
operation, the general health of the patient and the condition 
of his circulatory apparatus, lungs, and kidneys should be con- 
sidered. In the third case, the nephritis associated with 
myocarditis and arterio-sclerosis forbade the operation in 
narcosis. 

In some cases it is difficult to determine the proper treat- 
ment, since a serious aural disease, which urgently requires 
an operation, is complicated with a constitutional disorder 
which may eventually lead to a fatal issue. 

The operation of the robust woman of our second case 
was a mistake, and its unfavorable course may serve as a 
warning to be cautious in future cases, but not restrict us 
from all operations, since simple incisions, as in the third 
case, are in themselves not of great importance. 

In touching briefly upon the question, how in future 
similar cases the fatal issue may be avoided, the omission 
- of the narcosis as the greatest danger would be most im- 
portant in the treatment of diabetic mastoiditis. It is to 





Three Cases of Diabetic Mastoiditts. 151 


be regretted that the results of local anzsthesia are not as 
yet good enough to consider its use except in severe cases. 

Naunyn’s suggestion of the administration of bicarbonate 
of sodium as a prophylactic in operations on diabetics, in ad- 
dition to a regulated diet before and after the narcosis, in 
order to avoid the intoxication with acids and the danger of 
the appearance of coma, is to be commended. 








SHARPLY CIRCUMSCRIBED SOUND- DEFECTS 
IN THE HEARING-FIELDS OF 
CERTAIN DEAF-MUTES. 


By Dr. A. SCHWENDT, 


PRIVAT-DOCENT IN BASEL, 
Translated and Abridged by J. GutTMaAN, M.D. 


CASE I. 


at the age of seven months in consequence of an at- 
tack of meningitis. The right eye is completely blind. 

Both drum membranes are about normal. 

The patient is absolutely deaf in his left ear; on the right 
side, however, there is a fair amount of hearing, especially 
for the middle octaves. The right ear can quite well dis- 
tinguish all vowels. 

The lower limit of his hearing power lies at small c, the 
upper at h*. 

The most peculiar feature in this case is a sharply defined 
deafness for the note f*, whereas c° and g° are clearly heard. 
This tone-defect is best demonstrated with the aid of Koe- 
nig’s high tuning-forks c’-f*, which are accurate instruments 
and produce very high notes. 

We cannot as yet decide whether the note f° could be 
heard or not, if it were produced with greater intensity. 

If these notes are produced with the newly improved 
Edelmann’s Galton whistle, we find that the mark 13.6, 
‘which corresponds to the note f°, can be heard only in the 
immediate vicinity of the ear. It follows that so close by 

152 


i ee seven-year-old deaf-mute, Albert T., became deaf 









Sharply Circumscribed Sound-Defects. 153 





the ear he perceives either the harmonics of f* or only a 
tactile sensation. 

This deaf-mute can hear at a greater distance the notes 
which are produced by the prolongation or shortening of 
the whistle. 








CASE II. 


The nine-year-old deaf-mute, Charles S., became deaf in 
his third year in consequence of influenza. He is absolutely 
deaf for the upper half of the scale. His hearing power is 
about equal in both ears. The lower limit of his hearing 
lies in both ears at contra C, the upper limit right at f’, in 
the left at a’. 

He cannot distinguish vowels but he can hear them if they 
are shouted. 

The only consonant which this deaf-mute can recognize is 
the lingual R. 

His field of hearing, ¢. g., the duration of his perception of 
the note c, as expressed in percentages of the normal, is: 




















Right Ear. Left Ear. 
1) 1) 


° ° 
° ° 
° ° 





















a’ 10 % 10 % 
c 30 % 70 % 
c 33 # 72 % 
C 34 % 80 % 
S 50 & 80 & 





Both cases demonstrate the sharply limited defects of 
hearing power for certain notes or for certain parts of the 
sound scale, which is often met with in cases of deaf-mutes, 
or in persons who have some affection of hearing. 

This second case contrasts sharply with the following case 
of deafmutism. 







CASE “III. 









A twenty-one-year-old girl became deaf in consequence of 
an attack of meningitis and is completely deaf in her right 





154 A. Schwendt. 


ear. In the left, the upper limit lies immediately above ¢’. 
She possesses comparatively good hearing power for the 
notes below g*; for the notes above that point she is com. 
pletely deaf. 

Her duration of hearing as expressed in percentages of the 
normal is as follows: 


Left Ear. 
° 


° 
° 
a high limit 
50 % 
95 % 
65 % 
60 & 
C-1 60 % 


D-2 low limit 


The upper limit varies between b,'a‘ and h’ according to 
her daily disposition; when she becomes tired, the dura- 
tion of tone perception as well as the acuteness of hear- 
ing of speech is diminished. In her ordinary disposition 
she can hear in the immediate vicinity of the ear moder- 
ately loud conversation ; if the conversation is too loud she 
is annoyed by it and says that she cannot understand it as 
well. In contrast to our deaf-mute, Charles S., she has a 
comparatively good hearing power for the octave g’-¢’. 

Charles S., can hear of the consonants only the lingual R ; 
the girl on the other hand can hear all consonants with the 
exception of S. Our deaf-mute Charles S. constitutes a 
contrast also to the two deaf-mutes demonstrated by Bezold 
at the Naturforscher-Versammlung at Munich. These two 
had a good hearing power for low notes, but only a very 
short duration of hearing for the notes g’-g*. In spite of 
this they could hear speech quite well, although for the 
hearing of speech a much longer duration of hearing for g’- 
g’ is required. The perception of the low notes had in this 
case evidently a favorable influence upon the perception of 
speech. 





Sharply Circumscribed Sound-Defects. 155 


Bezold explains this phenomenon by the aid of the Helm- 
holtz-Hensen theory as modified by Ebbinghaus. Accord- 
ing to Ebbinghaus, the fibres of the membrana basilaris 
which are intended for the low notes come into oscillation 
not only by the original note to which they are tuned, but 
also by the harmonics through formation of nodules. In 
this way only can we explain the peculiar phenomenon 
which we observed in the patients demonstrated by Bezold. 





MULTIPLE RAREFACTION, “SPONGIOSIRUNG,” 
OF THE LABYRINTH-CAPSULE FOUND AT 
THE AUTOPSY OF A CASE OF PROGRES. 
SIVE DEAFNESS. 


By Pror. F. SIEBENMANN, BAte. 
(With eight illustrations on Plates 1.-VI, of Vol. XXXIV., No 4, German 
Ldition.) 


Translated by Dr. ARNOLD KNaAppP. 


NE of the two cases described by my pupil, Edward 
Hartmann, in vol. xxx., p. I, of the Zeztschrift fiir 
Ohrenhetlkunde, was of especial interest because v. Tréltsch 
had made the diagnosis of nervous deafness from the func- 
tional examination (markedly diminished bone-conduction). 
At the autopsy and microscopic examination bony ankylosis 
of both stapedii and an extensive rarefaction of the bony 
labyrinth-capsule were found present, and on again looking 
over the specimens, I discovered a considerable exostosis in 
the lower parts of both scale. Nerve bundles and ganglia 
of the auditory nerve and Corti’s organ seemed normal. 
The bony canals of the tractus ganglionaris and of the trac- 
tus foraminulentus were contracted. 

Another case of deafness where I had made a functional 
examination, and later a post-mortem investigation of both 
auditory organs, enables me to conclude that extensive rare- 
faction of the labyrinth-capsule is sufficient, independent of 
an involvement of the bony nerve canals, to produce a de- 
cided diminution of bone-conduction. It shows that the 
same process, according to the localization, may produce 
a bony stapes-ankylosis or progressive nerve deafness with 
correspondingly different functional findings. This micro- 

156 














Multiple Rarefaction of the Labyrinth-Capsule. 157 


scopic condition is interesting from another view point and 
is, in fact, unique, as in both labyrinth-capsules—in the 
cochlea as well as in the semicircular canals—a large num- 
ber of isolated foci existed. These specimens can decide in 
a definite manner the previously unsolved question on the 
origin and further development of these pathological rarefy- 
ing processes. 


K. S., female, fifty-two years old, was admitted to the hospital 
on December 30, 1896. Except for an eczema of the arms, patient 
has always been well. One month ago an attack of sciatica, then 
frequent chills, nausea, and fever. The clinical diagnosis of en- 
docarditis ulcerosa was made. She died on January 5, 1897, and 
at the autopsy the following conditions were found : Endocarditis 
ulcerosa, myocarditis, miliary abscesses of pia and cortex, hemor- 
rhagic infarct of the spleen, infarct and abscesses of the kidneys, 
miliary abscesses in the submucosa of the stomach and intestines, 
abscess of the left thyroid gland, parotitis, embolic hemorrhages 
of the larynx and trachea. 

I was able to examine the patient on December 31st. She 
stated that she had gradually become deaf in the last few years. 
There had been no otorrhoea, but frequent pain in the ears. In 
recent years attacks of vertigo without vomiting occurred, which 
would necessitate lying down. As regards heredity, the father 
had been very deaf; the other relatives, however, had normal 
hearing. 

The examination, on December 31st, revealed normal drum 
membranes. Whisper was heard right at 4 cm, left, 150 cm. 
Fork a’ was lateralized from the vertex to the left (the better) ear, 
and was shortened ten seconds. Rinné a’ positive on both sides, 
right approximately of normal duration (about twenty-five sec- 
onds); left not crossed (not carried over to the right ear); A 
perceived on both sides even on slight impulse. Owing to the 
critical condition of the patient the examination could not be 
prolonged ; the determination of E Rinné left, and the upper and 
lower tone limits had to be given up. The diagnosis of bilateral 
progressive nerve deafness seemed justified. 


Twenty-four hours after death we examined the two tem- 
poral bones, and macroscopically the external and middle 
ears seemed normal. The labyrinths were freed, and the 
superior semicircular canal opened; they were placed in 














158 F. Stebenmann. 


formol, dehydrated, decalcified in hydrochloric acid, im- 
bedded in celloidin, and finally cut into about three hundred 
vertical sections, in the plane of the superior canal. Every 
tenth, and, in the region of the oval window, every fifth 
section were stained with eosin-hematoxylin; later, control 
sections were stained with neutral carmin, picrocarmin, hema- 
toxylin carmin, and according to Weigert-Pal. Very beauti- 
ful pictures were obtained by overstaining with carmin, then 
hematoxylin, and decolorizing with a watery solution of picric 
acid plus a trace of hydrochloric acid (one-half per cent.). 

The following interesting conditions were found and are 
reconstructed into Figs. 1 and 4: 

a. Right labyrinth (the lateral extremity, 2. ¢., the vertex 
of the lateral and posterior canals, is wanting): the nerve 
and membranous labyrinths seemed normal. In each of the 
two bony semicircular canals, partly preserved in the speci. 
men, there was a focus of rarefaction, a third focus was found 
at the oval window, a fourth at the stapes plate, a fifth and 
sixth at the cochlear capsule (see Fig. 1). 

The first focus extends from the canalis subarcuatus to the 
inner (concave) wall of the upper semicircular canal in its 
vertical portion and is adjacent to the endosteum ; it partly 
limits the ampullar extremity in front but does not invade 
the ampulla itself. To the medial side of the superior canal 
the first area terminates abruptly, on the lateral side it ex- 
tends farther than is seen in the specimen. Posteriorly, it con- 
nects by means of prolongations with the second area which 
is situated on the ampullated end of the posterior canal. 

The third area surrounds the oval window above, below, 
and in front so that the posterior half of the lower margin 
and the posterior portion of the window remain free. A 
freely vascularized periosteum is situated beneath the 
mucous membrane of the window niche as far as the bony 
changes extend.’ On the inner side this area extends over 





! The fact first advanced by Schwartze and verified by various authors, that 
the labyrinthine wall of the middle ear especially in peracute cases of sclerosis 
shines reddish through the drum membrane, is probably due to unusually in- 
creased vascularity of these bony parts and to the change of the thin mucosa 
into vascular thick periosteum. I have observed this condition frequently in 
youthful individuals, in purely progressive nervous deafness and not alone in 
stapes-ankylosis, 











Multiple Rarefaction of the Labyrinth-Capsule. 159 


and in front of the window so that it directly forms a portion 
of the facial canal wall, and of the nervous utriculo-ampullaris 
of the pyramid and of the crista vestibuli; a part of the 
bony cochlear wall is involved, especially the wall opposite to 
the vestibule, as well as the vestibular and the tympanic scala 
and the portion corresponding to the area between the basal 
and middle turns. The upper fourth or third only of the 
labyrinth wall situated between the oval and round windows 
shows rarefaction. As to the rarefaction of the window 
margin it is converted into rarefied or osteoid tissue, except 
a part of the lower circumference of the cartilage; the 
annular ligament is decidedly diminished. On the vestibular 
side the window margin is replaced by a rarefied wall which 
above and in front surrounds the edge of the stapes plate on 
both sides; it resembles in thickness and structure true vas- 
cular periosteum. The more recent tissue is found in the 
superficial layers of this osteophyte. It is osteoid in char- 
acter and takes on a deep blue stain. The free surface 
under the periosteum is uneven, rough with coral-like pro- 
jections, and the intervening spaces contain a homogeneous 
pinkish staining mass similar to that in the deeper layers of 
the periosteum. The window niche is somewhat contracted. 

The stapes plate is not thickened, but its vestibular carti- 
laginous covering is converted into bone in the middle 
(fourth area). 

The fifth and sixth areas are in the eochlea. Both are sit- 
uated deep and do not approach the tympanic mucous 
membranes. The fifth has a flat, sausage-like form and is 
situated in the tympanic wall of the tympanic scale at the 
basal turn (at its lower and inner part, see Figs. 2 and 3); it 
forms toward the vestibule the lower and toward the cupola 
the outer cochlear wall and also the lower margin of the 
int. audit. meatus, somewhat altered by osteophytic prolifer- 
ation. The endosteum of the cochlea does not show any 
thickening at this point, but in the places where the spiral 
ligament is covered with rarefied bone there are several 
osteoid homogeneous plates or bone corpuscles intensely 
stained with hematoxylin. The two small extremities of the 
area do not reach the cochlear canal. The bone is normal 

















160 F. Stebenmann. 


in the area of the tractus foraminulentus; the above-de- 
scribed changes in the wall of the meatus are situated to its 
outer side. 

The sixth area (Fig. 3) is likewise situated at the limit be- 
tween the upper and lower part of the basal turn; it covers 
the latter in the vestibular scale, approaches the middle turn, 
and extends for a short space in the direction of the apex 
without invading the cochlear lumen. 

The only connection between the areas is a slight one 
between the first and second. The remaining four are 
isolated. 

A description of the structure of the spongiosa and its 
varying condition at different places will be given later after 
the left temporal bone has been described. 

b. Left temporal bone (all of the semicircular canals are 
well preserved in the specimens); see Fig. 4: 

The nerve and bony labyrinth are normal. The bony 
canals of all three circular canals are surrounded by an area 
of rarefaction (see Fig. 5); the ampullz are free. The lateral 
canal is the least affected where the middle of the crus sim- 
plex shows the above-described changes on the upper sur- 
face. The posterior canal is principally affected, especially 
in its entire length. Of the superior canal (Fig. 6) the 
ampullated extremity is chiefly involved, and especially at 
its inner surface and its concave (inner) edge. 

The fourth focus is situated about the oval window, and 
has about the same shape as area three of the right labyrinth, 
though it is somewhat more extensive. At the posterior 
upper window margin the bone is rarefied but the cartilagin- 
ous margin is unaffected ; the posterior lower part is normal 
both as to bone and to cartilage. Otherwise the cartilage is 
everywhere replaced by spongiosa. At one place (see Fig. 7) 
the ligamentum annulare and the lower stapes margin are 
converted into spongioid bone, which without interruption 
passes over into that of the lower window margin (bony 
stapes-ankylosis). At other places, the stapes presents its 
normal cartilaginous margin. The upper stapes margin is 
dislocated externally, in its anterior part by the osteophytic 
hypertrophies and the consecutive narrowing of the window 





Multiple Rarefaction of the Labyrinth-Capsule. 161 


(see Fig. 7). The pelvis ovalis is deepened and narrowed by 
the proliferation of bone. The focus extends into the depth 
between the vestibule and the middle turn of the cochlea, 
limiting the latter and just touching the apex extending to 
the fundus meatus without involving the endosteum of the 
basal turn or the canal of the modiolus. The walls of the 
facial canal, vestibulum, and of the utriculo-ampullar branch 
are rarefied similar to the right side. Further foci (like five 
and six of the right temporal bone) are wanting. 

The pathological diagnosis is therefore : on both sides, areas 
of rarefaction in the bony capsule of the circular canals, of the 
vestibule and cochlea. Formation of osteophytes on the ves- 
tibula and tympanic surface of the oval window margin. Com- 
mencing osstfication in the cartilaginous covering of the stapes. 
Additionally, on the left side commencing ossification of the 
annular ligament (incomplete stapes-ankylosts ). 

The specimen was well preserved and fixed, and was ex- 
amined in serial sections, so we were able to investigate, Ist, 
the various developmental stages of this ‘‘ spongiosa’”’ for- 
mation, and, 2d, the origin or starting-point of the process. 
As to the first question, we can say that the first stage con- 
sists of a change in the Haversian canals, inasmuch as they 
lose the relation of the innermost layer to hematoxylin and 
carmin, then they enlarge on the labyrinthine side in fun- 
nel-like spaces to large lymph cavities by lacumar resorption ; 
multinuclear giant-cells are often present. The round and 
star-shaped cells of the perivascular lymph spaces multiply, 
and connected by thin processes to form a loose network, 
they fill in the space between the bony wall of the cavities and 
the delicately walled vessels. In a further stage, at those 
places where the resorption process has ceased, the cells of 
the peripheric zone are attached as broad shallow osteoblasts 
to the wall of the cavities, forming a gradually thickening 
concentric area of decalcified tissue which stains deep red 
with carmin, violet, and in places, dark blue with hema- 
toxylin-eosin. An occlusion of the space down to the vas- 
cular lumen does not occur; the stronger refracting cement- 
line (Pommer) between the unchanged original and adjacent 
new bone remains well marked. The two latter areas are 





162 F.. Stebenmann. 


distinctly different at this early period, inasmuch as, apart 
from the staining differences, the new-formed osteoid zone 
is marked by less clearness and by numerous coarse zrreg- 
ular bone corpuscles which are in part enlarged, and often 
possess numerous abnormal distinct prolongations as well 
as one or two very deeply stained nuclei in a light area. 
All the Haversian canals and spaces in this affected area are 
changed by this resorptive and appositional process, and 
tn addition all cartilage containing introglobular spaces (Ma- 
nasse-Gegenbauer) are dissolved and replaced by new-formed 
osseous tissue. The bone about the cartilaginous part of the 
labyrinth window—later also of the stapes—is absorbed by 
large penetrating blood-vessels, and replaced as above de- 
scribed by the spongioid tissue. Bright osteoid plates 
arranged in chains, at first free from bone corpuscles, stained 
blue with hematoxylin, appear isolated in the annular liga- 
ment; after the cartilage of the stapes and window margin 
have almost been brought to touch by proliferation of the 
bony understructure, communicating bridges are formed 
over this narrow cleft. These are arranged radially, more in 
a horizontal than vertical plane, and are attached at the in- 
nermost point of the window margin, and run together, 
changed into spongiosa communicating among each other 
and with the cartilaginous margin or with the bone which 
takes the latter’s place. 

In the later periods, the intervening walls of the medul- 
lary spaces become thicker and the spaces smaller. The 
bone tissue stains with hematoxylin-eosin a bright pale red 
color, and loses, except at the inner zone, its relation for 
carmin. It is an important fact that the new bone gradu- 
ally assumes a lamellar structure; the bone corpuscles are 
arranged concentrically and the nucleus atrophies. The 
medullary spaces become poor in cells and vessels but richer 
in fibrous connective tissue running parallel to the axis of the 
canal. The limiting lines grow gradually less distinct and 
disappear (as Hanau has described in the epiphyses of the 
ribs, see Mader, “‘ On Inflammatory Hyperostosis and Perios- 
tosis of the Ribs in Pleurisy,” Archiv f. Entwickelungs- 
mechantk, vol. vi., No. 4). Abnormally active regeneration 




















Multiple Rarefaction of the Labyrinth-Capsule. 163 


and resorption of bone are seen more distinct at places asso- 
ciated with pale red or pale blue zones outlined by sharp 
lines about the Haversian canals, without the latter under- 
going a distension. 

The characteristics of the two stages correspond exactly 
to the pictures which I have observed (in seven similarly 
diseased temporal bones) either, at the very beginning, as an 
area of pin-head size, or, after thirty years, changes ex- 
tending over the entire labyrinthine capsule. I agree with 
the views of Bezold on the histological conditions. 

There is another reason to show that the decalcified 
carmin zone is new-formed bone, as Pommer and recently 
Hanau have shown. The osteophytic tissue possesses in 
every relation the same microscopic structure, and the same 
in reactions as the carmin zone in the deeper area. In the 
latter the process of resorption and placing together can be 
beautifully followed in those places where the advancing 
resorption line has reached a cartilaginous introglobular 
space, and a fundamentally different structure is deposited. 
Small deviations from this order are occasionally seen; old 
bone may stain a light blue with eosin-hematoxylin instead 
of red; in the younger parts of bone the bone corpuscles 
are frequently not unusually dilated or numerous, etc. 

After we had verified our conclusions on these histologi- 
cal changes by examining other specimens of osseous tissue, 
we went over all of the sections again to investigate the local 
origin of this process. This had the very interesting result 
that this rarefying process does not emanate from the 
periosteum (which Bezold at least does not exclude). Nor 
does it arise originally in the labyrinth capsule (Politzer), 
but that the oldest parts occur at the limit between the endo- 
chondral primartly formed labyrinth-capsules and to the con- 
necttve-tissue bone secondarily deposited from the periosteum 
(probably in the latter itself). For we find the most recent 
richly nucleated areas stained deeply with hematoxylin- 
eosin directly at the endosteum of the labyrinth-capsule ; 
the oldest are situated in the centre of the circular canals, 
about the entering large bony vessels. In the spongioid 
focus occupying the space between the oval window, vesti- 





Na aw eee eee eleeniones sangha romeo aet sf ann nets eaten peat 


164 Ff. Stebenmann. 


bule, cochlea, and facial nerve, the most recent portions are 
situated at the lower window margin in the superficial layer 
of the ring of osteophytes on the vestibular surface of the 
oval window-ledge near the canal for the utriculo-ampullar 
nerve, while the older parts occupy the centre. The latter 
is situated somewhat in front and over the anterior margin 
of the oval window and forms, as other authors have found, 
the place of predilection for this affection. It is without 
doubt due to this condition that the osteophytic wall 
usually is higher in front than in the back, and that the upper 
margin of the window is more extensively affected than the 
lower. A more pronounced development of the wall at the 
posterior margin occurred in Politzer’s fifth case. In 
Bezold’s third case the changes in the bone were pronounced 
posteriorly and below, but no wall was present. 

Area five in the right temporal bone is relatively old ; the 
most recent spongiosa is (as in the area described in 
Bezold’s case two) directed to the cochlea, the oldest is 
situated near the porus acusticus. The entire area six is 
more recent; one part is, however, older; it is pale red, 
lamellated, and poor in nuclei, separated by no limiting 
line from the healthy bone, and situated farthest away from 
the cochlea and directed to the tip of the petrous bone. 
There were no exostoses at the lower part of the promon- 
tory, as Habermann has described, or in the basal turn, as 
Politzer saw projecting into the scala tympani of the basal 
turn (cases five and six), and as were present in the two tem- 
poral bones of my collection published by E. Hartmann. 
No changes were found in the canalis ganglionaris, thus 
differing from the two latter mentioned temporal bones and 
case five of Politzer. 

It is noteworthy that the spongioid spaces are nowhere so 
large that it is permissible to speak of an osteo-porotic 
process. In most of the cases there is an active apposition ; 
though there are numerous places where only resorptive pro- 
cesses are visible, especially in the neighborhood of the nerve 
channels and beneath the endosteum of the labyrinth, so that 
the endolymphatic fluid ts separated only by a connective-tissue 
and frequently very thin septum from the large lymph spaces of 




















Multiple Rarefaction of the Labyrinth-Capsule. 165 


the spongioid area. Broad perivascular spaces connect the 
labyrinth with the porus acusticus and with the tympanic 
cavity. 

An interesting question naturally presents itself: Why 
does the labyrinth-capsule at so late a period show this ten- 
dency to convert its compact, ivory-like bone into loose 
spongiosa? The process is all the more striking as similar 
changes have noi been observed or suspected from the his- 
tory in any other part of the skeleton. An explanation 
for this peculiar process is, according to our idea, to be 
found in the fact that the normal /adyrinth-capsule remains 
throughout life unusually rich in remnants of primary 
cartilage. This occurs in the form of small and large de- 
posits near the labyrinth spaces and is noticeable in sections 
by the deeper staining with eosin-hematoxylin. This stain- 
ing does not affect the cartilaginous remnants alone, but 
the entire inner zone of the labyrinth-capsule and the 
outer zone, especially the area opposed to the perios- 
teum, are stained bright red. The introglobular spaces sur- 
rounded by irregularly shaped walls are most frequent in the 
neighborhood of the posterior half of the oval windows and 
in the basal end of the upper, also of the lower cochlea 
wall—in other words, 7” those regions which serve as places of 
predilection for the spongtose formation. (We have recently 
accidentally encountered an almost hemp-seed-sized piece of 
true hyaline uncalcified cartilage in the labyrinth-capsule of 
an old person. This was situated between the posterior 
edge of the oval window and cochlea, permeated with large 
oval cartilage cells. It lacked the peculiar superficial struc- 
ture of the introglobular spaces, and took on a much deeper 
stain than the latter.) The semicircular canals, the mar- 
gin of the round window, and the modiolus contain less 
cartilage and are consequently less prone to undergo the 
osseous change. 

Similar to the cartilage remnants which are situated like 
discs between the epiphysis and diaphysis of the long bones 
and the parts of the skeleton derived from the procarti- 
laginous third and partly second branchial clefts which com- 
mence to ossify in juvenile years, and like many cartilaginous 









166 F. Stebenmann. 


tendon insertions which later change to cancellous bone, we 
observe a process similar, though exceptional, occurring in 
the bony labyrinth, which terminates with the disappearance 
of the cartilage at the window margin and in the intro- 
globular spaces. At the same time, the compact bone 
changes on to the type of connective-tissue bone with the 
formation of a fibrous medulla and periosteal deposits, the 
latter especially about the labyrinth window, in the stapes 
plate, in the oval window niche, and in the lower part of the 
cochlear spiral. 

If I understand Koellicker (Handbuch der Gewebelehre, 
vol. i., p. 346) correctly, a similar process has been observed 
by him and by Strelzoff during the growth of the scapula 
and of the long bones in certain places and considered to be 
normal; except that there the resorptive process has pre- 
dominated over the displacement of bone formed from car- 
tilage by connective tissue. I do not from this fact wish to 
call the rarefaction of the labyrinth-capsule an osteitis, but 
rather to regard it as the final stage of a developmental pro- 
cess which normally does not occur in the petrous bone, 
though it is the rule in other bones, though not in the same 
form and at the same time. 

In all the long and flat bones of the skeleton there is 
a continuous loss and regeneration after birth, so that the 
bone continues to grow without changing its external shape. 
In the labyrinth-capsule, however, there is an exception, as 
the size is attained at birth and a later decrease or increase, 
as far as the examination of the bone shows, takes place only 
in small limits. This probably is the reason that so many 
cartilage remnants are contained in the labyrinth-capsule to 
an old age, while in the other bones which grow, they gener- 
ally disappear early. 

It appears that a compact limitation of the labyrinth-capsule 
ts important for the function of the organ therein contained, 
as this is pronounced in all higher developed animals. An 
active regenerative process as in the other bones would carry 
with it a disturbance in the position of the nutritive vessels 
and also of the cochlear canal; a more extensive blood sup- 
ply from the side of the labyrinth and a closer connection 




















Multiple Rarefaction of the Labyrinth-Capsule. 167 


between the intralabyrinthine vessels with those of the 
bone capsule would be required. We know, however, that 
Hyrtle’s views on the closed-in system of labyrinth vessels 
correspond practically to the actual state (see Siebenmann, 
Die Blutgefisse im Labyrinth des menschlichen Ohres, 
1894) and that the blood-vessels of the endosteum communi- 
cate in only a few places through narrow capillaries with the 
blood current in the bone. The lymph circulating in the 
Haversian canals between the blood-vessels and bony wall 
is shut off from the general labyrinthine lymph space. 
The high importance from a functional standpoint of such a 
separation of the blood and lymph distribution is seen from 
the following condition found at autopsy in connection with 
the vessels of the hearing tests: bilaterally, except a delicate 
osteoid bridge at the left annular ligament, there are no 
changes in the middle ear, but there is an extensive rarefac- 
tion of the cochlea and semicircular canals and bone-conduc- 
tion is very much reduced. 

We were unfortunately unable to make a satisfactory 
functional examination in our case; hence the lower-tone 
limit could not be determined and the not very marked im- 
mobilization of the stapes was not diagnosticated in the liv- 
ing. We have no explanation for the decidedly reduced 
bone-conduction other than the changes just described of 
the labyrinth-capsule. This supposition gains force as there 
were no other anomalies in the labyrinth, and it is made 
almost certain by the fact that the hardness of hearing was 
found not on the side of the stapes-ankylosis but in that ear 
where the spongiosa formation had progressed farthest.’ 

In both cases of Bezold where stapes-ankylosis was found 
at autopsy, the spongiosa also extended to the endosteum. 
The fact that bone-conduction was here not shortened but 
rather prolonged appears to contradict my explanation but 
is due to, first, the thickness and breadth of the spongiose 
bridges in the annular ligament—z. ¢., the bony stapes-an- 
kylosis has reached such a marked degree in both cases, 





' As abnormal rarefaction of bones is observed in the late forms of syphilitic 
disease, it would be well in future to examine more carefully the labyrinth-cap- 
sule at the autopsy of the syphilitic deaf. The well-known observations of Moos 
and Steinbrigge might be explained in this manner. 





168 F.. Stebenmann. 


and, secondly, the rarefaction in one case has extended be- 
yond the oval window and in the other not at all. More. 
over, though bone-conduction was prolonged in both cases, 
it cannot be excluded that, at the time of the functional 
examination, the labyrinth function had already become 
affected. This is even more than probable when we com- 
pare the degree of prolonged bone-conduction in these cases 
with the prolongation observed in cases of stapes fixation 
produced artificially or by depression of the drum. In 
affections of the Eustachian tube’ and in the indirect trau- 
matic ruptures of the drum membrane’ a prolongation of 
fifteen or nineteen seconds (measured with a Bezold-Katsch 
fork) on the affected ear, and ability to hear whisper in 
20-60 cm were present, while in Bezold’s cases of ankylosis 
similar changes in bone-conduction meant only hearing 
whisper in 6 cm. I have several examples, verified by 
Rinné’s test, to show that in a pure middle-ear trouble (total 
closure) of young people the hearing distance for whisper 
may be one metre or more, in cases where Schwabach’s test 
shows a prolongation of eighteen to twenty seconds. These 
two cases of Bezold’s, therefore, support my view that rare- 
faction of the labyrinth capsule, if it extends to the en- 
dosteum, of itself affects the labyrinth function and causes a 
relative diminution of bone-conduction. I should just like 
to mention that I had reached a similar conclusion (Z. £. O., 
xxii., p. 315) by clinical and experimental means, and pro- 
posed the statement that the labyrinth is always implicated 
in progressive bony stapes fixation, even in the supposedly 
pure cases—z. e., even in complete presence of the charac- 
teristic functional symptom-complex. 

It is not necessary here to discuss how, by the overlapping 
of the results of the functional examination of stapes- 
ankylosis and of the nervous progressive deafness, finally 
an atypical picture resembling the latter is produced, as v. 
Tréltsch has intimated. It suffices to say that a large pro- 
portion of such cases belong in this list which Bezold, 





' Siebenmann, ‘‘ Horpriifungsresultate bei reinem Tubencatarrh,” Z. /. O., 


XxX., p. 308. 
? Nother’s ‘‘ Traumatische Perforationen des Trommelfells,” Z. 7. O., xxxiii., 


p. 19. 











Multiple Rarefaction of the Labyrinth-Capsule. 169 


unable to classify among the middle-ear or labyrinth affec- 
tions, placed in a special class under ‘“ Dysacusis.”” I should 
like to emphasize the importance of the determination of 
the lower-tone limit in general as a differential means of 
excluding the pure nervous deafness from the class of such 
combination pictures. 

We have seen that rarefaction of the cochlea capsule, 
wherever it occurs, affects the function of the nervous ter- 
minal organ. In which way does such a disturbance occur 
and how can it be explained? The solution probably deals 
with changes in pressure and density which the labyrinth 
fluid suffers by influence of the spongioid spaces extending 
to the labyrinth fluid. Chemical changes surely take a part 
and assist in increasing the nutritive change in the delicate 
elements of Corti’s organ. The extensive and in part very 
thin diffusion surfaces which in some spaces alone separate 
the enormous lymph spaces of the new-formed spongiosa 
from the perilymph of the labyrinth in the form of very 
thin membranes, increase greatly the number of existing 
lymph passages of the perilymphatic duct and of the peri- 
vascular spaces (however, only indirectly affected). While 
this was the chief communication to the interior of the 
skull or to the posterior cranial cavity, the labyrinth fluid 
now enters upon new relations to the peripheric lymph 
and vessels subjected to other pressure conditions. An al- 
teration in the conditions of diffusion may not be the only 
change; as can be seen at several places in my specimens, 
the septum (reduced to a connective-tissue membrane) be- 
tween the two lymph systems may also be absorbed ; per- 
forations with sudden changes in intralabyrinthine pressure 
and position may occur, and of such a kind that a repro- 
duction of the former condition is not again possible. This 
is the only explanation for the loss of hearing and diminished 
bone-conduction, as the Corti’s cells, stria vascularis, nerve, 
and labyrinth windows showed no marked changes micro- * 
scopically. It can thus also be explained that just in this 
case vertigo with diminished hearing appeared in attacks, 
and that the hearing slowly or incompletely or never was 
brought back to the previous condition. Méniére’s vertigo, 














170 fF. Stebenmann. 


the morbus Méniére in the mild form and in the severe.form 
with vomiting, nystagmus and excessive vertigo in apoplec- 
tic attacks, is not sufficiently explained '; we think, however, 
that thereby a solution has been found, and are further con- 
vinced as we know that these patients usually present the 
other symptoms of so-called sclerosis. The peculiar subjec- 
tive noises, as thunder, thumping, shooting, from which the 
patients suffer terribly, can be without difficulty referred to 
these perforations. 

I will only casually state here that variations of density of 
the labyrinth fluid must be associated with alterations of 
sound-conduction. A diminution of labyrinthine pressure is 
possible in our cases; this would of itself as direct cause ex- 
plain a diminished sound-conduction through the labyrinth 
fluid and the shortening of cranial bone-conduction. We 
must by all means consider all of these factors if we wish to 
explain the remarkable fact that spongiosa formation of the 
labyrinth capsule with stapes-ankylosis produces in one case 
a prolongation, in another a shortening, of bone-conduction. 
In a case since examined at autopsy, a period preceded the 
stage of shortened and finally absent bone-conduction where 
Bezold’s trias of stapes-ankylosis was well developed. 

The question whether we should in future retain the ex- 
pression sclerosis of the ear is to be answered negatively. 
The juvenile form of this symptom-complex is not a con- 
densing process, but, as far as the bone is concerned, just the 
opposite. Progressive nervous deafness of older age depends, 
as we have shown, in most of the cases on quite different 
changes ; a fact important both for the diagnosis and treat- 
ment. In future we will classify such cases of early or late 
appearing progressive deafness with aid of the other fac- 
tors, important for diagnosis, according to the result of func- 
tional examination in nervous deafness or dysacusis (Bezold) 
or stapes-ankylosis with the addition: rarefaction, “ spongio- 
sirung,” of the labyrinth-capsule. 





1 The implication of the canal pro nervo utriculo-ampullaris in the process 
of spongiose formation does not change the nerve or its connective-tissue 
sheath. The changes found in the bony circular canals, as the ampulle are 
unaffected, can only in the above-described manner and way contribute to 
cause the attacks of vertigo. 





Multiple Rarefaction of the Labyrinth-Capsule. 171 


In regard to the treatment, remembering the results of the 
autopsy it can be positively stated that local medication, 
treatment of nose and throat, injections of medicines into 
the tubes, massage of the drum, myringectomy, tenotomy, 
and stapedectomy, excision of oval window, etc., as well as 
the use of potassium iodide, thyroidin, and pilocarpin, are of 
no avail and may aggravate the condition by their irritat- 
ing action. Hence such treatment must be abstained from 
where the diagnosis of rarefaction of the labyrinth capsule is 
made. The fact that catheterization not rarely produces an 
improvement of hearing in progressive nervous deafness, if 
only transient, can be explained because in spongiose for- 
mation of the region of the cochlea tips the lumen of the 
bony tube is somewhat narrowed (only recognized, micro- 
scopically, by thickening of the periosteum). Of the internal 
means, phosphorus alone seems to me to promise anything. 
This, according to recent investigations (Mirwa and Stétzner, 
Fahrbuch fiir Kinderhetlkunde, vol. x\vii.), in rational ad- 
ministration is able, at least in the long bones, to prevent the 
formation of the (normal) spongiosa and to favor the forma- 
tion of compact bone. I usually prescribe an oily solution 
or Kassowitz’s emulsion, 0.01 %, and give 10-20, later 30-40 
ccm daily. If the stomach is very susceptible to fat, the 
phosphorus may be given in glutoid capsules, of which each 
0.5) contains I % phosphorus oil and is dissolved in the in- 
testines. According to the above authors, small and long- 
repeated doses are preferable, as the phosphorus acts only 
when every gastric disturbance isavoided. Our results with 
this treatment are too meagre and not positive enough to 
permit of any conclusions. They have, however, encouraged 
us to continue our experiments on a greater plan. 





CONTRIBUTIONS TO THE KNOWLEDGE OF IN. 
TRACRANIAL COMPLICATIONS OF EAR 
DISEASE. 


By Dr. GEO. LEHR, CLinicat AssISTANT. 


Translated by Dr. RICHARD JORDAN, New York. 


OTWITHSTANDING the gratifying results which 

the surgical treatment of intracranial complications 

of ear diseases has obtained of late, we cannot but confess 
that our diagnostic ability and operative procedures are still in 
need and capable of further improvement. From this point 


of view it seems desirable to record all such cases in detail. 
At the same time such complete and continuous publications 
from the different aural clinics will give us a better insight 
into the relative frequency of cerebral abscess, sinus-throm- 
bosis, meningitis, and their combinations. 

The following report comprises all cases of intracranial 
otogenous suppuration treated in the Rostock Aural Hos- 
pital since Professor Koerner took charge of it, November, 
1896. These publications will be continued from time to 
time. 

All cases not previously reported will be given in full with 
the following two restrictions: 

1. The incurable cases of diffuse leptomeningitis will be 
but briefly mentioned unless they show features of particu- 
lar interest that warrant a full report. 

2. Of the numerous cases of pachymeningitis externa we 
shall include only extradural abscess, 7. ¢., the formation of 





! From the Ear and Throat Clinic of the University of Rostock. 
172 











Intracranial Complications of Ear Disease. 173 


pus and granulations between the bone and dura mater or 
sinus. 

Wherever the bone disease merely reaches the dura or 
sinus, even where they are discolored and granulating, but 
without the formation of pus or causing symptoms of sinus- 
phlebitis or pyemia, neither diagnostic nor therapeutic con- 
siderations would justify the report of such cases, as they 
furnish no particular symptoms and require no other treat- 
ment than the removal of the diseased bone. 

We wish to emphasize this distinction as we find that 
quite a number of cases of simple pachymeningitis externa 
have been reported as extradural abscess —an error which 
might easily confuse our views on the frequency of extra- 
dural abscess. 

Of the intracranial suppurations observed in the period 
referred to, the following have been previously reported : 



















1. Phlebitis of sinus petrosus sup. and meningitis. Death. 
(Koerner, Die otit. Erkrankungen, etc., 2d edit., p. 71.) 
2. Pyemia after acute mastoiditts from measles. Death. 
(Koerner, THESE ARCHIVES, vol. xxvi., p. 294.) 
3. Phlebitis of sinus transversus from cholesteatoma of pet- 
rous bone. Recovery. (Preysing, tbid., xxvii., p. 404.) : 
4. Sinus-phlebitis from cholesteatoma. Operation. Men- 
ingit. serosa ventricularis ac. Death. (Ibid.) 
5. Sinus-phlebitis with pulmonary metastases. Leptomen- 
ingitis. No operation. Death. 
6. Phlebitis of sinus transversus. Sepsis. Operation. 
Death. 
7. Sinus-phlebitis and pulsating pertsinuous abscess from 
cholesteatoma. (TIbid.) 
8. Phlebitis of sinus cavernosus in chronic mastotditis. 
Recovery after mastotd operation. (ILbid.) 
9. Extradural abscess in acute mastotditis. Operation. 
Recovery. (Lbid.) 
10. Acute extradural abscess. Operation. Recovery. (Ibid.) 





















Of the cases of leptomeningitis purulenta which have not yet 
been published, the following will be briefly mentioned: 








































174 Geo. Lehr. 


11, Fritz H., aged forty-one, comes to clinic January 31, 1896, 
with pain in both ears after influenza. 

Treatment. Double paracentesis and evacuation of pus. Pat. 
is lost sight of until March 5, ’96, when he appears again with 
double mastoiditis and cerebral symptoms. 

Operation, which reveals an enormous destruction in both 
mastoid processes, does not stop the progress of the meningeal 
infection. Death, March 9, ’96. 

Post-mortem: Extensive suppurative infiltration in spongiosa 
around hiatus of can. Fallop. On account of this peculiar propa- 
gation in the spongy bone beneath the corticalis, this case to- 
gether with a similar one (No. 19) will be reported in full in a 
separate publication. 

12. Marie N., aged thirty-eight. Rec. Feb. 26,’98. Otor- 
rhoea duplex since early childhood. Mastoid operation. Both 
mastoids represent mere shells filled with pus and granulations. 
Death March 26, ’98, from meningitis. 

Autopsy: Basilar meningitis, probably started from a small 
deep-seated extradural abscess in the posterior fossa. 

13. Emma L., aged twelve. Otorrhcea for two years from diph- 
theria. Acute exacerbation. Family physician opened periosteal 
abscess on left mastoid. Chill. Sent to hospital Aug. 26, ’98. 
Mastoid operation : Mastoid, antrum, and attic full of granulations, 
which are removed. Death on third day after operation with 
meningitis. Transition of inflammation into cranium through 
carious tegmen antri et tympani. 


The following case of leptominingitis deserves a more 
detailed report: 


14. Shotgun injury of temporal bone followed two years later by 
middle-ear suppuration. Operation: removal of ball. Second opera- 
tion ten months later for mastoiditis. Meningitis. Death. 

Gustave D., aged thirteen. Shot himself accidentally in left 
cheek, Dec. 31, ’94 (Flobert rifle, cal. 6 mm). Considerable hem- 
orrhage from wound and ear canal. No other symptoms noticed. 
Wound healed promptly within two weeks. In the fall of ’96 the 
left ear begins to discharge. No pain, but tinnitus and deafness. 
Pat. asks clinical advice April 15, ’97. Muco-purulent discharge 
in left meatus. Ball visible in upper osseous wall imbedded in 
granulations, firmly adherent. Operation the same day: Ball 
chiselled out after temporary displacement of auricle. Tym- 


























Intracranial Complications of Ear Disease. 175 


panum found full of granulations enveloping the dislocated ham- 
mer; incus not found. May 9g, ’97, dismissed from hospital ; 
still slight discharge and granulations in posterior part of tym- 
panum. 

Pat. paid irregular and infrequent visits to clinic until April, 
’98, when he returned complaining of great weakness, frequent 
chills, and dizziness. 

Rec. April 29, ’98. Status: Haggard appearance, slight ver- 
tigo. Profuse discharge from left ear. Canal stenosed through 
bulging of posterior wall. Swelling and fluctuation above and 
behind auricle. Temp. 37.5°—C. 

Apr. 30th.—Mastoid operation. Subperiosteal abscess. Carious 
fistula leading to external canal. Large mastoid cells and antrum 
filled with pus and granulations. Incus found in antrum, small 
piece of metal in upper meatus wall near recessus epitympanicus. 
Wound left open. Plastic operation deferred. 

May 1,’98.—Temp. in early morning 36.8° C., rises rapidly to 
39.6° C. Lumbar pain. Wound of normal appearance. 

May 2¢.—Temp. mrg., 40.4°, P. 150; T. evg., 39.2°, P. 105. 
More backache. Restless. 

May 3d-6th —Temp. varying from 37.7-39.0° in the morning to 
39.6-40° at night. Pulse about 100 p. min., regular. Condition 
stationary. No paralysis, no diplopia. 

May 7th.—T. 38.0°, P. 100. Pain in neck, but no rigidity. Lum- 
bar puncture in two places negative (no fluid obtained) ; diarrhoea. 
T. at night 40.1° C. 

May 8th.—Temp. 37.4-40.1° C. P. 95-140. 

May oth.—Temp. 40.1-37.5° C. Fundus of eye normal. 

May 10th, 4 A.M.—Temp. 37.4.° Pulse 140 and more, very small 
and feeble. Restlessness, slight rigidity of neck. Headache. 

8 a.M. Temp. 39.4°,P.120. At noon slight delirium. Sudden 
convulsions and spasm of respiratory muscles. Pulse 155 p. min., 
felt and counted two to three minutes after respiration stops. 
Artificial respiration without avail. Death. 

Post-mortem: Extensive basilar meningitis, especially about 
chiasma. Dura on petrous bone appear intact and so do the 
facial and acoustic nerves. Removal of petrous bone not allowed. 
Way of suppuration from middle ear to cranium not found. 

All other organs are healthy. 


Remarks: With the ball fixed in the upper wall of the 
meatus outside the middle ear and the suppuration having 




































176 Geo. Lehr. 


followed the injury after nearly two years, there did not seem 
to be any indication to lay bare all the cavities of the middle 
ear after the foreign body was removed. If the patient had 
not been lost sight of, the slight remaining discharge would 
probably have been cured or at least the ensuing mastoiditis 
been recognized and operated for in time. The meningitis 
showed the symptoms of septic infection and could not be 
safely diagnosed before the terminal respiratory convulsions. 

Very gratifying are the surgical results in the following 
cases : 


15. Cerebral abscess in right temporal lobe. Operation. Recovery. 


Sophie S., aged twenty-three, servant ; since her first year the 
right ear has been discharging continually. On December 5, 
1898, she took sick with severe frontal headache, vomiting, drowsi- 
ness, slow pulse; discharge of ear increased and sanguinolent. 
Received December 14, 1898. Status: face very pale. Ques- 
tions answered slowly and with hesitation. No real drowsiness. 
Pulse 60 p. min., small, regular. Temperature 37.1° C. Tongue 
coated, foetor ex ore. No earache but headache on right side 
near vertex. 

Right tympanum full of granulations. Pus not offensive. No 
paralysis. No hemiopia. Pupils equally wide, reaction sluggish, 
beginning neuritis optica. 

Operation (same day): Middle ear full of granulations and 
cheesy purulent material ; hammer carious. Tegmen antri par- 
tially destroyed ; dura covered with granulations. Dura is laid 
bare in the whdle granulating area; it appears dull, discolored, 
is tense but shows pulsation. Incision of dura and exploration of 
temporal lobe with knife in three different directions to a depth 
of 3 cm. No pulse found. Brain substance pale, only slightly 
bulging into the opening. Cross-incision horizontally backward. 
Sinus exposed, appears healthy. Attempt to lay bare cerebellum 
is given up on account of severe hemorrhage from the injured 
emissary vein. 

Wound packed with iodoform gauze. 

December 15th-18th.—General condition fair. No more vomit- 
ing. Reaction to external impressions is sluggish. Temperature 
37.0-37.6° C. Pulse go—100. 

December 19th.—Great apathy. No paresis, no rigidity of neck. 
Temperature 38.0° C. Pulse 70. 














Intracranial Complications of Ear Disease. 177 


December 20th.—Last night very restless, moaning ; increased 
somnolence. Pupils wide, without reaction. Temperature 36.2° 
C. Pulse 64. 

Second attempt to find the abscess, now supposed to be cerebel- 
lar because of the absence of crossed hemiplegia and in view of 
the failure of the previous exploration. 

Cerebellum laid bare in sinus angle. Probing into cerebellar 
substance with scalpel in different directions with no result. 
Temporal lobe is again inspected and found pulsating. Several 
renewed probings are unsuccessful until at last an incision straight 
inward strikes the abscess at a depth of 4cm. Incision of dura is 
enlarged and the finger introduced into the abscess, which is tor- 
tuous, the size of a hen’s egg, and apparently without membrane. 
The purulent matter is offensive, thin, intermixed with numerous 
creamy flakes—quantity about two tablespoonfuls. Cavity drained 
with iodoform gauze. Immediately after the operation the pupils 
are narrow and responsive, the pulse is fuller and more frequent, 
98 p. min. 

December 21st.—Patient feels very buoyant, laughs, and asks 
for food. Pulse varying from 76-100, but strong. Temperature 
normal. 

December 22d.— Dressing changed. About one teaspoonful of 
pus drains out after removal of gauze. 

Eye-fundus : Disc hyperemic on both sides ; the nasal edges 
are blurred. 

December 23d¢.—Rubber drainage tube inserted. 

December 25th.—All\ well. 

December 26th.—At night slightly restless, in the morning 
drowsy. No objective symptoms. 

Two drainage tubes put into abscess cavity, one into anterior, 
the other into posterior part. 

December 27th.—At night much moaning, vomiting ; very rest- 
less. This morning: somnolence, slight rigidity of neck. No 
paralysis. ‘Temperature 38.6.° Pulse too. 

December 28th.—Still drowsy, but no more vomiting or rigidity 
of neck. Strength of left arm seems diminished. 

December 29th—Small prolapse of brain. Anterior drainage 
tube left out, posterior one shortened. In changing the latter 
some pus drains out. 

December 30th.—Much better. Intellect clear. Weakness of 
left arm has disappeared. 











178 Geo. Lehr. 


Thereafter undisturbed recovery. 

Fanuary 10, 1899.—Prolapse much smaller. After-treatment 
and daily dressing through ear canal. 

February 22d.—Wound above and behind ear firmly cicatrized. 
Middle ear epidermized. 

February 28th.—Dismissed as cured. 

March 21st, April 6th, Fuly 12th.——Patient and ear in excellent 
condition. 


Remarks: Thesymptoms were those of increased intra- 
cranial pressure caused by a localized process. The rapidity 
of their appearance, the absence of a distinct choked disc, 
and the presence of a suspicious disease of the correspond- 
ing middle ear tended to exclude an intracranial tumor and 
pointed strongly to the diagnosis: cerebral abscess. As 
localized cerebral symptoms, especially crossed hemiplegia, 
were missing, and as the dura of the temporal lobe showed 
distinct pulsation, we were inclined to suspect the abscess 
in the cerebellum. Nevertheless it was found in the tem- 
poral lobe. Not without interest are the signs of cerebral 
irritation which occurred a week after the evacuation of the 


abscess, caused undoubtedly by the pressure of the drainage 
tubes. After the removal of the latter they disappeared 
promptly. 


16. Enormous extradural abscess in posterior and middle cranial 
fossez. Total destruction of transverse sinus and extensive destruc- 
tion of dura; deep intradural abscess between second and third tem- 
poral convolutions. Operation. Recovery. 

Anna L., aged thirty-six, had otorrheea sin. since childhood, 
after measles. In the fall of 1895, acute exacerbation with pro- 
fuse discharge. 

October, 1898.—Influenza. November roth: Severe earache, 
foetid discharge, dizziness. 

Rec., Mov. 26, 1898.—Ear-bandage soaked with very offensive 
pus. Continuous flow from ear canal of a thin, sanguinolent 
matter intermixed with gas bubbles. Mastoid tender on pressure. 
Gait staggering ; intellect sluggish ; no paresis. Pulse 76 p. min., 
small but regular. Temp. 36.8.° Eyes: pupils equally wide, 
react promptly, horizontal nystagmus ; both discs swollen, edges 
blurred ; veins enlarged and tortuous, hemorrhagic spots in both 
retin, more in the right. 














Intracranial Complications of Ear Disease. 179 





Cranial operation: Corticalis sclerotic, $cm thick. Large 
cavity beneath is lined with cholesteatomatous membranes and 
filled with discolored but not foetid granulations. While opening 
this cavity a large quantity of very offensive pus with gas bubbles 
rushes suddenly out from behind. Incision extended horizontally 
backward. Posterior part of squama temporalis and_post.- 
inferior angle of os parietale removed. Lamina vitrea appears 
rough and is partly detached from diploé. The dura beneath is 
covered with granulations, Occipital lobe and upper cerebellum 
are separated by a deep horizontal furrow caused by the com- 
plete destruction of the outer sinus wall. Near the sinus-knee a 
necrotic piece of sinus is found, 14 cm long, and comprising 
nearly the whole circumference (its anatomical identity is con- 
firmed by microscopical examination). Dura of temporal lobe is 
partially destroyed; the brain convolutions are clearly visible, 
pia mater is covered with granulations. Pus is oozing out from 
between the two lower temporal convolutions, and after separat- 
ing them a small intradural abscess is found containing half a 
teaspoonful of pus. Radical operation of middle ear is postponed. 
Wound packed loosely with iodoform gauze. For two days after 
the operation considerable discharge of liquor cerebro-spinalis, 
which demands frequent renewal of outer dressing. 

November 29th.—Patient in good condition; no headache, no 
vomiting. Pulse 96, regular; temp. 36.0°. Dressing changed on 
operating table. Whole scalp very cedematous except a small 
area around the right (healthy) ear. 

Discharge of pus so copious that counter-incision is made near 
prominentia occip. From the grayish-white bone oozes dis- 
colored blood. The diploé is congested and discolored, tabula 
vitrea partly destroyed, partly detached from diploé. The bound- 
ary line of abscess and granulations is reached near the torcular. 
The removal of all the rotten bone results in an enormous defect 
in the skull, extending from the mastoid up to 1.5 cm from the 
torcular. It is 6 cm wide posteriorly and 4 cm wide farther in 
front. ‘The abscess was bordered all around by an uninterrupted 
wall of granulations and the disintegration of the bone was con- 
fined to the same limits. Of the whole lateral sinus no trace could 
be found. After the operation a severe cedema of the right 
orbital region developed, which disappeared after forty-eight 
hours. 

General condition excellent. Wound is dressed every second 











180 Geo. Lehr. 


day and heals rapidly. Neuritis optica subsiding ; January 14, 
1899, fundus nearly normal. 

January 16th, 1899.—Wound healed, except small fistula on 
mastoid leading into the cholesteatomatous cavity. Radical 
operation: Cholesteatoma, which lines the whole mastoid from 
the tip to the antrum, is thoroughly removed and the cavity 
curetted, enlarged, and polished in the typical way. Plastic; 
large flap is formed of membranous canal (Stacke) and tamponed 
against the roof of the cavity. From the external part of the 
membranous canal and the cymba conche a smaller flap is formed 
which is turned backward and sewed against the cut surface of 
the auricle. 

February 20th.—Retroauricular opening and middle ear dry 
and epidermized. 

February 23d.—Discharge from fistula near the torcular. In- 
cision leads to a deep recess, in which a strip of gauze is found 
and removed. 

February 28th.—Wound completely healed. To cover the 
opening in the skull a cap made of Stent’s mass is fitted to it. 

March 6th.—Patient dismissed as cured. 

Last seen July 13th, in excellent condition. 


Remarks: It could not be doubted that this case repre- 
sented an intracranial suppuration, but whether we had to 
deal with a cerebral or a large extradural abscess was well- 
nigh impossible to decide. The operation unveiled a sup- 
purative process — extensive and complicated beyond expec- 
tation. Besides the enormous destruction of sinus and dura 
the granulations on the pia mater and the abscess between 
the cerebral convolutions are of particular interest. Our 
knowledge of such intradural abscesses is confined to a small 
number of cases (Ceci, Barker, MacEwen). 

Asa rule, the inflammation spreads quickly through the 
meningeal meshes and the formation of a wall of granula- 
tions on the pia mater is of rare occurrence. Remarkable is 
the extensive destruction of the parietal bone apparently 
caused by the long-continued influence of the extradural 
abscess. 

Noticeable for their absence were symptoms of local pres- 
sure, as hemiopia, crossed hemiplegia, and aphasia, which 
have been observed in similar cases. 














Intracranial Complications of Ear Disease. 181 


The healing of the enormous wound took place in a com- 
paratively short time, resulting, as was to be expected, in a 
large defect of the cranium; the latter was sufficiently pro- 
tected by a simple prothesis of Stent’s mass. 


17. Sinus-phlebitis in acute necrosis of mastoid and temporal 
squama after scarlet fever. Operation with ligation of jugular vein. 
Recovery. 

Child, E. B., eight’ years old, developed scarlet fever three 
weeks ago. After two weeks, both ears became affected. The 
family physician made a Wilde’s incision for left mastoiditis and 
sent the child to the clinic. 

Received September 20, 1898; looks very ill. Eyelids and 
ankles oedematous; skin red, desquamating. Temperature 37.8° C. 
Urine contains albumen, epithelium cells, and leucocytes. 

Both ear canals full of pus; behind left auricle, an incision of 
1 cm in length discharging greenish pus, mastoid tender on pres- 
sure. Immediate mastoid operation. Corticalis discolored, pale. 
No fistula ; cells full of offensive greenish pus. Granulations in 
antrum, which is curetted ; mastoid tip removed. 

Dura and sinus laid bare. The latter appears congested and 
thickened ; thereis a small discolored spot near its upper knee. 
Iodoform gauze. Temperature, before operation, 36.0 °, rose two 
hours later to 41.8°, went down to 36.4° during the next twelve 
hours, and then rose again rapidly to 39.8 °. The chart continued 
to show this intermittent type during the following days. There 
were no chills or profuse perspiration. 

Second operation September 23d: Sinus laid bare more exten- 
sively ; emissary vein is torn from it accidentally. Through the 
gap a solid thrombus is visible in the sinus ; a few drops of pus 
ooze out. In the attempt to remove the outer sinus wall a severe 
hemorrhage occurs apparently from behind, which demands im- 
mediate tamponing. A series of enlarged glands alongside the 
sterno-cleido muscle are removed and the jugular vein exposed. 
It is empty and collapsed. At the lowest point it is cut between 
two ligatures. Wound of neck is sewed up. 

On account of the continued intermittent fever, which rages 
from 35.9-41.2° C., an attempt is made on September 27th to 
change the dressing ; it causes a renewed hemorrhage from the 
sinus. Ligation wound on neck healed by first intention. 

Intensity of fever subsides gradually, varying during the fol- 
lowing two weeks from 37.0-38.0° C. 





182 Geo. Lehr. 


October 4th.—First change of dressing. Healthy granulations 
everywhere, Hereafter daily dressing in the usual way. 

October 13th.—Patient complains about pain behind right ear, 
which had been discharging quite freely all the time. Mastoid is 
tender and slightly swollen. At the same time a swelling appeared 
above the left ear, extending over the whole mastoid muscle. No 
fluctuation. Temperature, 398.° C. 

October 14th.—Operation. Leftear: Incision through the infil- 
trated parts. A necrotic piece of bone is found above the linea 
temporalis, covered with sluggish granulations. After its re- 
moval, the dura is exposed and appears normal. No pulsation 
can be felt. Curettement. Iodoform gauze. On the right side 
a Schwartze operation is performed. The whole mastoid from 
the tip to the antrum and the dura is found very pliable, its cells 
partly destroyed and filled with granulations. Dura looks very 
red and congested. After-treatment in the usual way ; healing 
progresses favorably. 

December 7th.—Both mastoid wounds closed. 

February 1st.—A small superficial abscess on the left mastoid 
requires incision and curetting. 

March 29th.—Child dismissed from the hospital in the best of 
health. 


Remarks: Remarkable is the very early development of 
sinus-phlebitis in acute mastoiditis. The necrosis of the tem- 
poral squama is not infrequently seen in infants, but its oc- 
currence in older children is rather rare. The glandular 
swelling on the neck alongside the jugular vein was a 
symptom of the primary disease (scarlatina) and not caused 
by sinus-phlebitis; for the exposed jugular vein showed no 
symptoms whatever of inflammation. More difficult would 
it be to explain the continuance of the fever after the liga- 
tion of jugular vein. It could hardly be that infective mat- 
ter from the sinus was carried into the system. Perhaps the 
nephritis was responsible for it. The glandular swelling also 
and the mastoiditis of the other side have to be taken into 
consideration. 

18, Sinus-phlebitis in acute mastoiditis. Operation. Recovery. 

Mr. K., aged twenty-eight, received March 24, 1898. 

March 16, 1898.—Pain in left ear, discharge three days later ; 
pain behind the ear followed, extending over the whole side of 














Intracranial Complications of Ear Disease. 183 























head, especially at night. He alleges to have been unconscious 
once and to have had several chills. Status: Left meatus filled 
with muco-purulent matter, which pulsates out of a perforation in 
anterior-inferior quadrant of Mt. Upper-posterior part of mem- 
brane bulging, is incised. Soft parts over mastoid are infiltrated 
and very tender on pressure, particularly toward foram. mast. 
Temp. 39.0° C. Pulse 80 p. min. 

March 25,’98. Operation : Corticalis discolored, congested. 
After the first stroke of the chisel, pus pulsates out. Bone be- 
neath corticalis friable. Large cells are filled with granulations ; 
but little pus. Antrum large, full of pus and granulations which 
are curetted. The bone disease extends to the knee of the sinus. 
Here pus wells out from between the bone and the sinus; sinus 
wall is partly destroyed, showing a disintegrated thrombus inside. 
The latter as far as it appears decayed is scraped out in both di- 
rections. Sinus wound and antrum are packed separately. Temp. 
after operation 37.1°, rises to 39.0° in afternoon. 

March 26th.—Temp. 37.7-38.3°. No headache. Uninterrupted 
recovery. 

April 4th—Wound and membrana tympani healed up. 

Remarks.— Here again the rapid development of a sinus- 
thrombosis in an acute mastoiditis is of notable interest. 
19. Extradural (perisinuous) abscess in acute mastoiditis after 
typhoid fever. Operation. Recovery. 

On account of the singularity of the primary bone disease, 
this case, together with the somewhat similar one No. 2, will 
be reported elsewhere. 


It does not seem proper to add general remarks to this 
series of only nineteen cases, but it might be well to point 
out the comparative frequency of severe intracranial compli- 
cations in acute and recent suppurations of the middle ear 
and petrous bone, and it might further be stated that of the 
nineteen cases all but three had intracranial complications 
before they came under our treatment. Two of these, Nos. 
11 and 14, had been in our care previous to the intracranial 
infection, but had stayed away from the clinic until after the 
development of cerebral symptoms. 

Only in one case (No. 12) it is possible, but not certainly 
proved, that the turn for the worse took place under our 












184 Geo. Lehr. 


treatment shortly after the operation for the primary disease 
of the temporal bone. 

Of the nineteen cases, three were recéived with so se. 
vere pyzemia or sepsis that the operation seemed almost 
hopeless. One of them (No. 5) died before anything could 
be done, and two died immediately after the operation per. 
formed as a last resort to save them. Five cases succumbed 
to an inoperable diffuse leptomeningitis purulenta ; one (No. 
4) died from meningitis serosa ventricularis after an opera- 
tion for sinus-phlebitis. 

In the remaining ten cases, the intracranial suppuration 
was cured. These recoveries comprise one cerebral abscess 
(temporal), one intra- and extradural abscess with destruc- 
tion of the transverse sinus, four phlebo-thromboses of the 
sinus transversus, and one phlebitis of the sinus cavernosus. 
The latter case got well after an operation for the primary 
mastoiditis without an intracranial operation. 

The writer is indebted to Prof. Kérner for inviting him 
to prepare the above paper as well as for assisting him in 
doing so. 








EXAMINATION OF THE PUPILS OF THE MUNI. 
CIPAL DEAF-MUTE SCHOOL AT 
DANZIG, GERMANY. 


By Dr. G. KICKHEFEL, Danzic, GERMANY. 









Translated by DAVID GREENE 
(School of Lip-Reading for Deaf and Hard-of-Hearing Adults, New York). 





“JT “HE results of my examinations on the occasion of the 
* introduction of aural teaching in our municipal deaf- 
mute school are hereby made public in the hope that this 
contribution, although it is but small, may promote the 
cause of deaf-mute teaching. So far, but few examinations 
of the ears of deaf-mutes by means of the continuous tone- 
series have been reported. Bezold-Edelmann’s continuous 
tone-series enables us to convey to the ear every tone that 
it is capable of perceiving, and to define the limit of the 
capacity of any ear. My opportunities for literary research 
in this provincial town being limited, I chose Bezold’s 
masterly examinations of deaf-mutes for my guide, and de- 
sire that my efforts in this regard be considered supplemental 
to his. I extended my investigations by using both Bezold’s 
continuous tone-series and Urbantschitsch’s harmonica for 
the purpose of comparing the two scales with each other. 

In our school, which furnishes the material for my exami- 
nations, there were, during the winter term of 1898-99, 
thirty pupils—sixteen being boys and fourteen girls. All 
these pupils were examined, but the following schedule 
comprises the results of the examination of twenty-nine 
pupils or fifty-eight ears only, because in the case ef one 
girl the hearing was but slightly impaired, as the result of 
chronic bilateral suppuration of the middle ear. 

In the following tables the pupils are designated in the 
185 























186 G. Kickhefel. 


order in which they were examined, by the numbers 1 to 29, 
and the ears by r (right) and | (left). 

The investigation was commenced by taking down the 
history of each case, and the hereditary and consanguineous 
conditions as stated by one of the relatives, in most cases by 
the mother. Next followed otoscopic examinations of the 
adjacent organs, tubes, cavities of the nose, and pharynx, 
The otoscopic examinations preceded the functional tests 
for the purpose of ascertaining the presence of obstructions 
to sound-conduction—cerumen, foreign bodies, etc.—and re- 
moving them. Next followed the functional examination 
with the continuous tone-series and Urbantschitsch’s har- 
monica, which I had perfected by extending the scale in 
both directions, so that it comprises the full notes from C, 
to f5. I proceeded with more than ordinary precaution, 
which I considered advisable in the case of deaf-mutes to avoid 
errors. After instructing the pupil to raise his hand every 
time that he feels a sensation of hearing when the tone- 
producing instrument is brought near his ear, he was placed 
before the examiner with his face turned away and his eyes 
covered with a broad bandage, so as to prevent him effectu- 
ally from seeing what is going on. The hair was brushed 
back from the ear which was to be examined, and any hair 
that would not stay back was cut off, so as to avoid any 
possible contact with the tone-producing instrument. The 
other ear was closed tightly with the end of the finger of an 
assistant, which finger had first been dipped into liquid 
paraffin. Care was also taken not to bring the instrument 
to the ear rapidly and suddenly, so as to avoid any move- 
ment of air which might be mistaken for sensation of hear- 
ing. Deaf-mutes are anxious to hear and always ready to 
believe that they do hear. Their sense of touch is very 
acute, as is evidenced by the following incident. One of the 
boys raised his hand regularly every time that the tuning- 
fork was brought near his ear, whether it was vibrating or 
not. The bandage over his eyes was carefully examined 
and properly adjusted, the hair was brushed back of the ear, 
the tuning-fork was brought near his ear slowly and care- 
fully to avoid any motion of the air, and in spite of all, the 











Deaf-Mute School at Danzig, Germany. 187 


boy would raise his hand when the tuning-fork was not 
vibrating. The mystery was solved at last when I warmed 
the tuning-fork in my hand. The cold metal had caused a 
sensation in the boy’s ear, which he mistook for hearing. 

The examination proceeded in this careful way, generally 
beginning with the right ear, and using the deepest tone of 
tuning-fork 6 of the continuous tone-series dis, and thence 
ascending and descending in the scale. Every tone in the 
continuous tone-series that was heard was marked red in 
the schedule, the same as Bezold indicated it in his exami- 
nations of deaf-mutes, whereas every perceived tone of the 
harmonica was marked blue. Those sections of the range of 
hearing which were perceived only when the tuning-forks 
were struck hard, or when the pipes were blown hard, were 
designated by broken lines. Thus each organ of hearing 
received its own schedule, which Bezold justly considers an 
advantage. 

After completing the examination by means of the two 
scales, I tested the acuteness of hearing in each octave with 
c and g of the unweighted tuning-forks of the continuous 
tone-series. The result of this test was put down in two 
decimals for each tone. 

Following the example of Bezold, I finally tested each ear 
with a bell, the tone of which lay between d# and dis‘, and 
recorded the results at the end of the schedule. 

The examination was concluded with a test of the ability 
to hear the speaking voice, which was made during special 
meetings to avoid fatiguing the pupils. In these tests I was 
assisted by the principal of the institution, Herr Ravan. 

The foregoing description shows that my examinations 
required a good deal of time, averaging from two to two and 
a half hours for each pupil. All the pupils were submitted 
to a second test, and to my gratification I found that the 
results agreed with those of the original examination. 

Among the twenty-nine deaf-mutes who were examined, 
there were, according to the statements of their relatives : 


II congenitally deaf, viz.: Nos. 9, 12, 16, 19, 20, 23, 24, 25, 
26, 28, 29Q—or 37-9 % 






188 G. Kickhefel. 


15 had acquired deafness, viz.: Nos. 1, 3, 4, 5, 6, 7, 8, 10, 13, 
14, 15, 17, 18, 22, 27—or 51.7 %. 
3 were doubtful cases, viz.: Nos. 2, 11, 21—or 10.4 %. 

The causes of deafness were: 

In 4 cases, Nos. 7, 13, 18, 22, or 26.7%, cerebro-spinal 
meningitis. 

In 3 cases, Nos. 6, 8, 10, or 20%, inflammation of the 
brain. 

In 3 cases, Nos. I, 14, 15, or 20%, convulsions. 

In 2 cases, Nos. 3, 17, or 13.3 %, scarlatina. 

In 1 case, No. 27, or 6.7 %, chicken-pox. 

In 1 case, No. 4, or 6.7 %, eruption of the scalp. 

In 1 case, No. 5, or 6.7 %, unknown. 

The figures for acquired deafness, 6.7% from unknown 
causes, agree with those of other investigators; thus Wil- 
helmi found 6.3 %, Schmaltz 7.1 %, Barth 6.6%, Bezold 5.8 %; 
Falk only, with 27.8 %, shows different results. 

In three cases, Nos. 2, II, 21, or 10.4 %, the reports of 
the relatives were incomplete, and it had to be left un- 
decided whether deafness was congenital or acquired. In 
this regard also the statements of different investigators do 
not agree: Wilhelmi found .8 %, Falk 2.8 %, Hartman 3.9 
%, Lemke 6.9 %, Bezold 7.6 %, Frankenberger 12.5 %, 
Schmaltz 13.2 %, Roller 15.1 %, and Mygind 21.5 %. My 
figure, 10.4 %, differs by 1 @ only from the average of the 
foregoing percentages, which is 9.4 %. 

Adenoid growths were found during my examination as 
follows: 


Nos. 26, 27, in children, 7 years of age 


“ec sé “ “ 
. 20, 25, 8 
se sé 


2, 6, 15, 9 
1, No. 17, Io 
gs 14, II 
I, 9; 14 
I 
I 


, 


, I, 15 
28, 16 


9 


Depression of the drum-head was found in eighteen ears, 


bilateral in each case, therefore in nine children or 31 %. 


The depression of the drum-head occurring on both sides 














Deaf-Mute School at Danzig, Germany. 189 


proves that the cause was the same on both sides, viz., 
adenoid growths. 

Ten ears, or 17.2 %, showed traces of former deafness on 
the drum-heads—namely, scars in 3 ears, or 5.2 Z—Nos. 15 r, 
21 r, 261; opacity of the drum-head in 7 ears, or 12 4—3 r, 
31,41, 41, 121, 121, 24r. 

In two ears, or 3.4 %, chronic suppuration of the middle 
ear was found, case 24 1 showing perforation of the drum- 
head, and case 15 | polypus with perforation. 

The examination of the nasal passages revealed suppura- 
tion in seven instances, or 12 %—bilateral in 9, 22, 28; 
unilateral in 4 1. 

The tests with the continuous tone-series showed I0 cases 
of total deafness, being 17.2 %, and 48 cases of partial deaf- 
ness, or 82.8 %. 

These results are more favorable than those of Bezold, 
who found 30.4 % of total and 68.4 % of partial deafness. 

The cases of partial hearing are divided into five groups 
only. Bezold gives six groups. Group III. of his scale— 
defective regarding the upper part of the scale—is omitted, 
no cases of that kind having been found in my exami- 
nations. 

Group I. Small areas to the extent of 24 octaves 


WE: cs cnccccvvevccessnsaseees 3 ears, Or 5.2% 
roe Ei, THER... 0. vis ob coe ckisasangs 13 “ 22.4% 
Group IV. Defects at the upper and lower ends 

AES epepeperteien: en 12 “20.7% 
Group V. Defects at the lower end of the scale 

extending over 4 octaves......... Sees 3.4% 
Group VI. Defects at the lower end of the scale, 

ee II 6 ainan scsi wedke's 18 * eee 





48 ears, or 82.8 4 
Taking them individually, 
Bilateral deafness was found in 3 pupils, or 10.3 % 
Unilateral deafnessin . eke i 
Partial hearing in both earsin 22 “ “ 75.9% 
“ in one ear ee eee 
Bilateral total deafness was found in 3 cases only—z, I1, 
20—or 10.3 %; partial hearing in one or both ears in 26 cases, 








190 G. Kickhefel. 


or 89.7-%. These figures approximate those of Bezold, who 
found 
15 totally deaf, or 19 % : 
63 with partial hearing, or 79.7 4 
Special interest attaches to the question of the relation 
between the degree of partial hearing in the different groups 
and the different forms of deafmutism. 
In table I. the degrees of partial hearing are arranged 
according to the forms of deafmutism. 


TABLE I, 





| CONGENITAL ACQUIRED 
Number | DEAFNESS. DEAFNESS, DovstFvt. 
Group. of Ears. a sensi 
Member. | ¢ Number.! ¢ 4 "Number. % 








| 30 | 50 
33-3 | 66.7 


Total Deafness... 10 5 
2 

| 46.2 7 | 53.8 
7 
I 
8 


g<4 
13 | 
12 | | 41.8 | 58.2 


| 


2 
18 


50 | §0 





38.9 | | 44.4 | 16.7 


| 
i — 











It is to be seen from this table that total deafness is to be 
found more frequently among those who acquired deaf. 
mutism than among those who were born with it. That the 
reverse is the case in regard to partial hearing is not at once 
apparent, yet comparing the totals we find for congenital 
deafmutism 145 octaves for 22 ears, against 116} octaves 
for 30 ears in cases of adventitious deafness, or an average 
of 6.6 octaves for each ear of the congenitally deaf and 3.9 
for those whose deafness has been acquired. From this it 
seems probable that the doubtful cases are mostly congenital 
deaf-mutes. 

The presence of analogous defects in both ears furnishes 
interesting points regarding the extent of disease-processes. 


In 10 totally deaf ears I found 6 bilateral, or 60 % 
In Group I. I found among 3 ears ™ —_ 
II. “ 13 46.2 % 
aie Sa ag 12 50 % 
“ Vv. sé “cc 2 at 
eo ” 18 66.7 % 














Deaf-Mute School at Danzig, Germany. IgI 


Compare these figures with those of Bezold, who found: 


Among 48 totally deaf ears ............. 30 bilateral, or 62.5 % 
In Group I. among 28 totally deaf ears... 10 ms “ 30.94 
Se ee ee ee 
* I 6s gamer ee 7 ante 
“ Ty. ‘“ 8 ss ere 4 rT ss 50 4 
és Vv. ‘6 18 66 ‘“ ae ‘“ ‘“ 33-3 P 
sé VI. “ 33 “ ““ oe ‘“ ‘“ 66.7 % 


The fact that my figures are almost the same as Bezold’s 
shows the correctness of his conclusion that “ the percentage 
of bilateral analogous defects of hearing has an important 
bearing on their nosological identity.” 

The results of the tests with the harmonica are not ar- 
ranged in groups but are divided similar to Bezold’s. 

Among 10 ears which appeared totally deaf during the 
tests with the continuous tone-series, there were 6 (20 r, 
13 1,71, 201,71, 10 r), or 60%, which showed small rem- 
nants of hearing, ranging from }$ to 3 octaves, during the 
tests with the harmonica. All remnants of hearing are 
within the small and great octaves. Four ears, or 40%, are 
totally deaf to both the continuous tone-series and the 
harmonica. 

Comparing the tests with the two instruments respectively, 
we find that among the 58 ears there were IO ears, or 17.2 %, 
totally deaf to the tones of the continuous series, but only 
4, or 6.9%, to those of the harmonica. The last named 
figure, viz., 6.9%, does not differ materially from that found 
by Urbantschitsch, who states that only 3 out of 144 ears, 
or 2.1 %, were totally deaf to the tones of the harmonica. 

Of the 3 ears of Group I., one—1o 1—showed a defect at 
the upper end of the scale of the harmonica. One—8 1— 
at the upper and lower ends; and one—28 r—a blank. 
The number in this group is too small to justify conclusions. 

In Group II. there are among 13 ears: 

I ear—17 r—which perceived all the tones of the harmonica. 

4 ears—Ig r, 23 r, 15 r, 19 l—or 30.7%, with defect at the 
upper end of the scale of the harmonica. 

6 ears—16 r, 1 1, 22 r, 4 1, 16 1, 25 r—or 46.2%, with de- 

fects at the upper and lower ends of the scale. 











192 G. Kickhefel. 


2 ears—17 1, 13 r—or 15.4%, with intermissions in the 
scale. 

This group shows the largest number of ears with defects 
in both the upper and lower parts of the scale of the 
harmonica. 

In Group IV. there are among I2 ears: 

I ear—29 1—which perceived all the tones of the harmonica. 

3 ears—22 1, 3 r, 23:l—or 25%, with defects of less than 
two octaves at the lower end of the scale. 

4 ears—12 1,91, 9 r, 4 r—with defects of 34 octaves at the 
upper end. 

3 ears—8 r, 6 r, 3 l—or 25 %, with defects at the upper and 
lower ends. 

1 ear—6 1—with intermissions. 

This group contains the largest number of cases—33.3 7— 
with a defect in the upper portion of the scale of the 
harmonica. 

Of the 2 ears of Group V., 1 ear— 18 1— perceived all 
the tones of the harmonica and 1 — 2 1—showed a slight 
defect in the lower end of the scale of the harmonica. 

Of 18 ears in Group VI.: ° 
15 ears, or 83.3 %, perceived all the tones of the harmonica. 

2 ears, or 11.2%, with defects in the upper portion of the 
scale of the harmonica. 

I ear, or 5.6 %, with a slight defect in the lower portion of 
the scale. 

A comparison of the two scales shows some interesting 
details: 

I. Of the 10 ears which are totally deaf to the continuous 
tone-series, 6 show small areas for the harmonica in the 
smaller and greater octaves, which proves that the tones of 
the greater and smaller octaves of the harmonica have the 
largest amplitude. 

II. In allthe ears of GroupI. the upper limit is higher in the 
continuous tone-series than in the harmonica. This shows 
that the tones of the upper portion of the scale of the con- 
tinuous tone-series have a greater amplitude than those of 
the harmonica. 

III. In most cases the lower limit of the range of hearing 














Deaf-Mute School at Danzig, Germany. 193 


lies deeper in the harmonica than in the continuous tone- 
series. This shows that the tones of the lower portion of 
the scale of the harmonica have greater amplitude than 
those of the continuous tone-series. 

After the tests with the tone-series, the duration of hear- 
ing of each ear was ascertained for the tones of c and gin 
each octave. The figures which I obtained differ from 
those given by Bezold. I found the following: 


G vibrates 258 seconds. According to Bezold, 203 seconds. 


c “ 194 6“ “ ‘“ 169 “6 
g 7 209 " — —_ _ — 
Get ma.” a — _-_ — 
ear 206“ " " 270. =“ 
ear as Ct * ? og: * 
os een ™ » * asa * 
” a ee pee ih 7 ek: > 
g; “ee 132 “ee “ce “ gt “ 
ee es — - - = 
g, ‘ai 24 “ec “ “ec 17 “ 
es ey os -— -_- — 


It was found that the duration of hearing decreases as the 
range of hearing approaches the upper end of the scale. 
This corroborates the supposition that in most cases deaf- 
mutism is caused by lesions in the organ of Corti. 

Next followed tests with a bell, the specific tone of which 
lay between d4 and dis*. The distances at which the bell 
was heard are given in metres. The room in which the ex- 
amination was held did not admit of distances over 8 metres, 
therefore I use the mark > 8 m for those who could hear at 
a greater distance. 

The ten totally deaf ears and the three ears of Group I. 
did not hear the bell. 

Of the 13 ears of Group II., 8 ears, or 61.5 %, did not hear 
the bell; in 5 cases, or 38.5 %, the distance varied between 
05 mand .5 m. 

Of the 12 ears of Group IV.,1 ear, or 8.3%, did not hear 
the bell. With the remaining 11 ears which heard the bell, 
the distance varied between .o1 m and 1.2 m. 

In Group V., the distance ranged from .4 m to 3.25 m. 

















Bais La il insti i “WIS Een a RECLINE TINE Om 









194 G. Kickhefel. 


Of the 18 ears of Group VL., 9 ears, or 50%, heard the 
bell at a distance of > 8 m, and with the remaining 9 the 
distance varied between .15 m and 7.75 m. 

Comparing the distances in the different groups at which 
the largest number of cases heard the bell, we find that in: 


Group I. none heard the bell ; 
“IL. 8 did not hear the bell ; 
** IV. 6 from .05 m and .2 m ; 
- oe”. * awe 345 ws 
* VI.9>8m. 

From this it is to be seen that with the increasing limit 
of audition, the distance also increases, which proves that 
Bezold’s arrangement of the cases into six groups is proper. 

I have now reached the last of my tests, namely, that of 
ascertaining the ability of deaf-mutes to hear speech. It is 
advisable to make separate tests of the ability to hear conso- 
nants, vowels, and words. 

Of the Io totally deaf ears, 4 ears, or 40 %, perceived the 
sound of # correctly, but none of the other consonants was 
heard. 

In Group I., with three cases, was perceived by 2 ears, 
or 66.7 %. 

In Group II., with 13 ears: 


p was perceived by 7 ears, or 58.3 4, 


r? “cc “ “cc 3 “ec 25 %. 
In Group IV., with 12 ears: 
p was perceived by 8 ears, or 72.7 @, 


r “ ““ “ 4 oe 36.4 %. 
In Group V., with 2 ears: 


p was perceived by 1 ear,or 50 %, 
tf “ “ “cc sé 


I 50 %, 
"Sposa ea “2 ears, or 100 . 


In Group VI., with 18 ears: 


p was perceived by 15 ears, or 83.3 %, 


Zz “ ‘“ iT 14 “cc 77.8 %, 
r te ee “ 61.1 4. 





1 It should be borne in mind that the author refers to the rolling 7 in Ger- 
man,—The Translator. 















Deaf-Mute School at Danzig, Germany. 195 


These large percentages do not prove actual auditory per- 
ception of the sounds of /, 7, and 7¢, as correctly remarked 
by Bezold, but simply that these sounds cause tactile sensa- 
tions which may be easily mistaken for hearing, as any one 
will notice if he sounds these consonants while holding the 
back of his hand before his mouth. 

Similar results were found regarding the consonant /. 
This was perceived by, totally deaf ear, by 1 in Group II., 
and by 2 in Group VI. 

m,n, and / were perceived by very few ears only, which, 
as Bezold explains, is accounted for by the fact that the 
special tone of these nasal consonants lies within the limit of 
the lower scale of tones that are not perceived by most deaf- 
mutes. 

n was heard by I ear in Group II., which could distinguish 
all the tones of the scale with a slight intermission from cis? 
to fis?. 

In Group VI., # was heard in 3 instances, # in 2, and / 
in I. 

The consonant & was heard in 2 instances in Group VI. 

The consonant s and the other sibilant sounds were also 
heard in Group VI. only, namely, in 4 instances. 

In testing the ability to hear vowels, the degrees of pitch 
were used which Helmholtz has fixed for this class of 
sounds, viz.: 
for w tone f, 


se o “ b, 
“ a + b’, 
“ t “ d‘. 


The totally deaf ears and those of Group I. did not hear 
any of the vowels. 

In Group II. w was heard by 1 ear, being the only one in 
this group which could perceive the whole lower part of the 
scale; @ and o were heard by 1 ear which had shown only a 
slight defect in the lower part of the scale. 

In Group IV.: 


u was heard by 2 ears, 


“ “ “ 
4 


a 
é 






“ec sé 


I ear. 












196 G. Kickhefel. 


In Group V.: 


wu was heard in 1 ear, 
0 “< é I 66 
“ 2 ears, 


“9 en. 


In Group VI.: 


wu was heard in 17 ears, 


ia “ “ 
0 15 
“ Ty “ 


a 17 
pela vida.» alas 

The results of the vowel tests with deaf-mutes showed that 
when a vowel was perceived the tone corresponding to that 
vowel was also perceived, which proves the correctness of 
Helmholtz’s arrangement of the vowels. 

The results of the tests of the ability to hear words were 
as follows: 

Numbers were not perceived by the totally deaf nor by 
those of Groups I. and IV.—according to Bezold’s state- 
ment only the numbers I-10 and 100 were tried. In Group 
II., 8 and 100 were heard by 15 r. In Group V., 18 1 heard 
all the numbers except 4. 

In Group VI.: 

5 r heard all numbers. 
aaa 7 

sr ”“ 3, 080,500. 
=i Ҥ 2,3, 4, 68,9, 200. 


Now, what are the practical conclusions that may be 
drawn from the foregoing? The tests which have been 
made in the public schools by Richard, Weil, Bezold, 
Schmiegelow, and Ohleman have demonstrated that in a 
considerable number of school children the ears were in a 
sufficiently diseased state to require the treatment of an au- 
rist. There is, therefore, urgent need of the services of 
inspecting physicians who are skilled in the examination of 
the eye and the ear. In the case of deaf-mute children this 
need is still greater, because the ears of all of them are de- 
fective and in many of them the disease which caused deaf- 
mutism is still active. I found adenoid growths in eleven 


except 2. 











Deaf-Mute School at Danzig, Germany. 197 


deaf-mute children. Such growths hinder correct articula- 
tion. Every pupil who articulates badly should therefore 
have his nose and throat examined. 

Chronic suppuration of the nose and of the middle ear 
claims special attention—all that needs to be mentioned in 
this connection is that in some instances tubercle bacilli 
were found in the discharge from the ear. I therefore agree 
with Bezold that it should be one of the first rules of school 
hygiene to place children who are suffering from chronic 
suppuration of the ear under treatment by an aurist. For- 
tunately the constant warnings of this kind have not re- 
mained unheeded, and better attention is now paid to the 
physical conditions of the pupils of the public schools and of 
deaf-mute institutions. 

Of greater importance is the question which was brought 
out by the experiments of Urbantschitsch and Bezold, 
namely, in what way the partial hearing of deaf-mutes can 
be utilized. It is a well-known fact that a considerable 
number of deaf-mutes possess sufficient hearing to receive 
instruction through the ear, and attempts of this sort have 
been made since Itard and Toynbee. The results of Ur- 
bantschitsch in conjunction with the teachers of the deaf- 
mute school in Débling, Austria, have excited universal 
interest, and Urbantschitsch is entitled to great credit. He 
practised his aural exercises with all pupils, even those 
who are totally deaf, and insists that hearing can be de- 
veloped even in apparently totally deaf persons. It remains 
to be seen how far he is correct. I do not believe that the 
results will be of much practical value, because all that can 
be expected is that the deaf-mutes will learn how to make 
use of the partial hearing that they possess. It may be 
safely asserted that if portions of Corti’s organ have been 
destroyed by disease, they cannot be restored through aural 
exercises. 

The results of Urbantschitsch’s agitation was that the 
teachers of deaf-mutes introduced his method in their schools 
before it could be examined by the aurists. No proper 
selection of suitable pupils for aural exercises having been 
made, complaints of failure were soon heard on all sides, 














198 G. Kickhefel. 


and some of the teachers became opposed to aural instruc- 
tion. Urbantschitsch by his experiments has therefore done 
very little to advance the cause of deaf-mute teaching. 

The interest in this question was increased when Bezold 
published the results of his examination of deaf-mutes, show- 
ing that he had succeeded in defining the limit of hearing of 
each ear. Thus a guide was furnished for the instruction 
through the ear. The results obtained at the Central Deaf- 
Mute Institution in Munich prove that Bezold’s method is 
correct. This method was approved by the State Depart- 
ment of Public Instruction, which decreed that “ the semi- 
deaf and semi-mute receive special instruction with a view 
of preserving and improving their ability to hear and to 
speak.”” Since the instruction through the ear was intro- 
duced in the deaf-mute institutions of Bavaria, similar steps 
have been taken in the schools of other States of the Ger- 
man Empire, and it is to be hoped that, in spite of the 
opposition from many quarters, aural teaching will soon be 
carried on in addition to articulation teaching in all the 
German schools. I repeat again that aural teaching is to 
form an integral part only of the general system of deaf- 
mute education without superseding the instruction in and 
by articulation. Only the semi-deaf and semi-mute are to 
be taught aurally in separate hours. I hope that the Joint 
Convention of Aurists and Deaf-Mute Teachers, which is to 
meet next September at Munich, will solve this question 
satisfactorily, and that the time will soon come when aurists 
and deaf-mute teachers will work unitedly for the advance- 
ment of the deaf and dumb. 





dee 





REPORT ON THE TRANSACTIONS OF THE TWENTY- 
THIRD ANNUAL MEETING OF THE AMERICAN 
OTOLOGICAL SOCIETY, HELD AT WASHINGTON, 

D. C., APRIL 13, 1900.’ 








Dr. HERMAN Knapp, New York, after demonstration of some 
anatomical specimens, related a case of extensive acute caries 
of the mastoid and petrous portions of the temporal 
bone, on which he operated successfully with restoration 
of perfect hearing and preservation of the external 
ear canal and the tympanic cavity. 

He sums up the noteworthy features of the case as follows: 

1. In an acute tympano-mastoid suppuration of a healthy man, 
thirty years of age, who never had had ear trouble before, the 
tympanum, drum-head, and hearing power were restored, while 
the destruction went on in the mastoid, and the adjacent third of 
the petrous portion of the temporal bone, under formation of an 
outer fistula of the mastoid. 

2. Headache and the continuance of the mastoid disease de- 
termined the patient to give his consent to an operation which 
he had formerly refused. 

3. The operation, consisting in a total resection of the mastoid, 
exposing the dura in the posterior cranial fossa, scooping away all 
the carious bone in the basal portion of the petrous, and carving 
out with a sharp spoon the bony wall of the facial canal in its 
whole length through the mastoid, and the entire horizontal 
semicircular canal, forming a platform from the latter to the 
frontal semicircular canal, where the caries stopped. 

4. The complete and unusually rapid recovery, with integrity 

































' This being the conjoined triennial Congress of the American Physicians and 
Surgeons, one forenoon only was allotted for the meeting of the Otological 
Society. The abstracts contained in this report have been kindly furnished by 
the speakers, for which the editors of these ARCHIVES, in the name of the 
readers, express their thanks. 







199 











200 Report Trans. Am. Otol. Soc., 1900. 


of the sound-conducting apparatus, and restoration of perfect 
hearing. [Operation January 15, 1900; discharged from hospital 
February rst; wound closed February 16th; March 1st, H 3%", 
V #2] 

Discussion—Dr, DENCH spoke commendingly on the manage- 
ment of Dr. Knapp’s case. It showed what excellent results 
could be obtained if, during the progress of an operation, we 
modified the general plan in its details according to the conditions 
we encountered on our way. Clear exposure and competent 
appreciation of these conditions were the secret of success. 

Dr. GRUENING : I would say that in this connection we should 
not forget that this work has been done by Jansen, of Berlin, who 
has published a large number of cases of caries of the petrous 
portion of the temporal bone, and has successfully operated on a 
large number, so that he certainly opened our eyes to this matter 
many years ago, and those who know the literature of otology are 
aware that these operations have been performed by Jansen. | 
have also performed it in a number of cases knowing that Jansen 
had precedence in the matter. It is a law of surgery to remove 
carious bone wherever we meet it. I must say, though, that I have 
refrained from removing it from around the facial canal. Dr. 
Knapp, in his case, says he cleaned out everything around the 
facial canal. After he had found caries in the canal, I think he 
could probably have opened the bone freely and allowed the ex- 
trusion of the carious substance. In these cases we often see 
that the facial nerve preserves its function. I saw a similar case 
in Berlin in the clinic of Jansen, where he removed everything, 
but avoided carefully just that portion of the bone which included 
the facial nerve. To produce facial paralysis in an operation is 
a very grave thing, especially in cases of the young, and in female 
patients. 

Dr. RANDALL said there was one point in Dr. Knapp’s paper he 
would like to emphasize, the preservation of hearing. In the seri- 
ous danger to life which these cases generally entail, the question 
whether the hearing is saved or not was regarded as of little im- 
portance, but the aurist who sacrifices the hearing is like the ob- 
stetrician who saves only the father. The early as well as the 
radical intervention in these cases was at times extremely import- 
ant if we wanted to retain the function of hearing. In the severer 
cases, the penetration of the carious process to the dura and not 
infrequently to the petrous portion was the rule rather than the 














Report Trans. Am. Otol. Soc., 1900. 201 


exception. In at least half of his last one hundred cases he 
had to lay bare the dura. 

As to the facial, he said that with good light and careful cleans- 
ing of the field with gauze strips, the facial canal could be well 
defined and as a rule scraped clean, and even caries removed, 
without injury to the nerve. 

Dr. C. H. Burnett said that thoroughness in cleaning away 
all that is diseased was the chief object in operation for chronic 
ear disease, and Dr. Knapp, having done that in the case he re- 
ported, could have obtained healing by first intention if he had 
desired it. He illustrated his remarks by a case where he ob- 
tained healing by first intention after a mastoid operation, but a 
relapse followed later, as the tympanic cavity had not been thor- 
oughly cleaned out. When this was done by a radical operation, 
permanent recovery ensued. 

Dr. Bacon said that he could not second all Dr. Randall men- 
tioned. He had had one or two cases of permanent facial paralysis. 
He avoided the facial canal wherever possible. In all the cases he 
had operated on there was considerable hemorrhage and great 
difficulty in seeing what could be removed with absolute safety. 

Dr. Knapp, replying to Dr. Griining’s remarks, said he was 
aware that nothing new had been done in the operation he had 
reported. It was an advanced case of aural disease, but singu- 
larly fortunate. The carious destruction of the whole mastoid 
had extended deeply into the petrous portion, disintegrating the 
cancellous part of the bone, but not yet affecting the compact 
osseous structure of the walls of the facial and semicircular can- 
als. The walls of the facial passed, like an untouched ivory rod, 
from above downward, and as there was no symptom of disease in 
the facial nerve, no indication presented itself to interfere with 
the canal. The disintegration stopped at the superior vertical 
canal, leaving the vestibule and cochlea intact, which accounted 
for the rapid recovery and the excellent auditory result of the case. 
Dr. K. said that he also, in his visits to Berlin, had frequently 
availed himself of the generously given opportunity to witness the 
superior skill of Dr. Jansen, who in dealing with the extensions of 
mastoid disease to the petrous portion and through it into the pos- 
terior cranial fossa, stood at the head of the pioneers in this field. 

Dr. C. H. BuRNETT maintains that chronic ear vertigo of Mé- 
niére’s syndrome is chronologically the latest symptom of chronic 
catarrhal otitis media, being always preceded by profound deaf- 














202 Report Trans. Am. Otol. Soc., 1g00. 


ness and tinnitus. It is due to undue impaction of the stapes 
in the oval window, as well as to stiffening of the round-win- 
dow membrane, from the catarrhal condition of the drum 
cavity. In a normal ear any inward pressure of the stapes upon 
the labyrinth fluid is compensated by a corresponding outward 
movement of the membrane of the round window toward the 
tympanic cavity. Any undue pressure from within the labyrinth 
by influx of perilymph or endolymph from the cranial cavity is 
compensated by a corresponding outward movement of the stapes 
as well as of the round-window membrane towards the drum cay- 
ity. All or any of these compensations being interfered with, in- 
tralabyrinth pressure is increased, the ampullar nerves are unduly 
compressed, and reflex phenomena evoked which are termed ear 
vertigo. As these altered conditions of intralabyrinth pressure are 
not constant, but vary with the health of the patient and the state 
of the drum cavity and internal ear, chronic ear vertigo is parox- 
ysmal in nature. As retraction of the chain of ossicles and con- 
sequent impaction of the stapes in the oval window, in chronic 
catarrh of the middle ear, play the greatest part in the production 
of these vertiginous phenomena by a compromise of the internal 
ear cavity, Burnett proposes to liberate the stapes from the su- 
perposed incus by removal of the latter, through an incision in 
the upper posterior quadrant of the membrana tympani of the 
etherized patient. This he has done in 27 cases, giving entire 
relief from vertigo in every instance. 


Dr. RANDALL spoke of the clinical anatomy of the Eusta- 
chian tube, and the rediscoveries of the Eustachian catheteriza- 
tion as showing need of better appreciation of the known anatomy. 
Among all the variables of aural topography the position of the 
tube-mouths may be counted a constant since it is essentially re- 
lated to bony structures of little varying configuration ; and the 
claims of variation are generally with reference to unrelated nasal 
and pharyngeal points instead of to the back edge of the hard 
palate, which is the true landmark. The lumen of the tube is a 
slit, usually collapsed and at its inner third devoid of the “ safety- 
tube”; while a valve-like fold in its bifurcated lower part serves 
with the drag of the relaxed palate to insure its closure except in 
the act of swallowing. Slight variations are to be expected in all 
points of aural anatomy, but those of the tube having real clinical 
importance will be very rarely found. Sections, casts, and bone- 
preparations were used in illustration of the points insisted on. 












Report Trans. Am. Otol. Soc., 1goo. 203 


Dr. Hiram Woops, Jr., Baltimore, Md., read the clinical 
history of a fatal case of septic sinus thrombosis. 
Patient, a boy thirteen years old. Family history of tuberculosis. 
Measles when he was two years old, followed by right otorrheea, 
which has persisted with occasional intervals ever since. Ap- 
parently he never has had careful treatment. About the 2d Oc- 
tober, ‘99, after a paroxysm of right earache, had a chill, followed 
by fever. This was repeated each day till Oct. 5th, when the fam- 
ily physician was summoned, who sent patient to the reporter. 
On admission the boy was in great pain. T. 1o1.6°, P. 106. 
There was diffuse mastoid tenderness, the aural canal was filled 
with a polyp, while the general appearance of the boy was septic. 
He had a pyemic rigor shortly after admission. Save for these 
constitutional symptoms there were no indications of sinus involve- 
ment. Locally the case presented the picture of internal mastoid- 
itis only. Operation was performed next day. Mastoid process 

was eliminated. The polypus above mentioned sprang from a 
smal] area of necrosed bone. The inner wall of the mastoid cover- 
ing the sinus was soft. Bone was removed, exposing the sinus for 
a space of an inch andahalf. Dura was necrotic, while the exter- 
nal sinus wall was ulcerated, the lumen being plugged above and 
below by a yellowish, fibrinous clot. This was removed with cu- 
rette, and good blood currents obtained in each direction. Sinus 
was closed with plain gauze. On the two succeeding evenings 
there was an elevation of temp. but no chill. Then, without 
characteristic change in the thermal line, there developed in the 
course of ten days a painful swelling in the neck, along the inner 
border of the sterno-mastoid muscle. A large amount of pus was 
evacuated from the jugular canal, the vein being found collapsed. 
After this the T. line became pyemic. Metastatic abscesses de- 
veloped in different parts of the body. Death occurred on Nov. 
1rth. General streptococcus infection was found on autopsy, to- 
gether with a septic thrombus, closing the clavicular end of the 
jugular. The paper discussed the general question of ligation of 
the jugular in cases of septic thrombosis where on operation good 
blood currents are obtained and there are no symptoms of 

jugular involvement. 

Dr. E. B. Dencu, New York, reported a case of sinus 
thrombosis, complicated with cerebellar abscess. 

Discussion.— Dr. GRUENING : I recall at present several cases 
of thrombosis of the lateral sinus in some of which the thrombus 
















204 Report Trans. Am. Otol. Soc., 1900. 


was removed and in some it was not removed ; in some the jugular 
vein was ligated and in others not. 

The FIRST CASE is that of a soldier returning from Porto Rico, 
who had typhoid fever, and who, in the course of the fever, de- 
veloped a thrombosis of the large veins of the leg. He was recov- 
ering from his typhoid fever when he was taken with mastoid 
disease. He had a temperature of 106° and I decided to oper- 
ate. I found a large mastoid of the pneumatic variety and all the 
cells were filled with serous fluid, an examination showing that it 
abounded in streptococci. The lateral sinus was laid bare; the 
inner table was still sound, but on it were a large number of these 
small cells filled with serum. I found that the sinus was abso- 
lutely solid. This patient was very weak and I did not think it 
advisable to proceed any farther. I assumed that it was possible 
for such a man to have a non-infective clot in his sinus, just as in 
the veins of the leg. I found to my joy the next morning an 
almost normal temperature, and he made a rapid recovery with 
the sinus blocked with this thrombus ; so then there are cases, no 
doubt, in which the thrombus is non-infective and can be dealt 
with as in other parts of the body. That is one class of cases. 

A SECOND CASE was that of a child who came into the hospital 
with a history of long-standing otorrheea. It had had several chills 
a few days before admission. I found a thrombus of the lateral 
sinus, not only of the sigmoid portion, but also of the lateral 
sinus proper, and this extended very far back. It was necessary 
to expose two and a half inches of the sinus. It was cleaned out 
completely. The bacteriologist found that the thrombus was non- 
infective and I concluded that it was not necessary to ligate the 
jugular vein. The child recovered. So there is a second class 
of cases where we do actually remove even the non-infected 
thrombus. 

Then a THIRD CASE, that of a young woman, nineteen years old, 
who came to the hospital with a history of chronic otorrhoea. She 
had had a great deal of headache, and for the past week before ad- 
mission several chills. On examination we found caries of the 
ossicles, caries of the walls of the tympanic cavity ; there was no 
tenderness ; the bone was thick and I assumed that perforation 
had occurred into the sinus and that there was probably an abscess. 
On opening I found a perisinuous abscess. After cleansing it 
thoroughly I put a needle into the sinus and drew blood, which 
was found to be non-infective. The patient did not, however, 
improve. She had still chills and high temperature characteristic 














Report Trans. Am. Otol. Soc., 1900. 205 


of sinus thrombosis and I then made a large incision into the 
sinus. There was a free flow of blood from above and below. 
Nevertheless, I ligated the jugular vein, assuming that there was, 
perhaps, an incomplete thrombus at the bulb. The patient recov- 
ered. So that there is a third class of cases where, though we do 
not find a clot in the sinus and no evidence of clot on aspiration, 
still if the temperature continues as the characteristic temper- 
ature of infective thrombosis we should still ligate the jugular. 

A FOURTH CASE is that of a young woman who came to the hos- 
pital four weeks ago with ordinary mastoid disease. I did a com- 
plete operation and she did well for the first two weeks, at the end 
of which time she had very high fever, 104-5°. I put her under 
ether, examined the sinus, and found it was perfectly healthy. 
As there was no indication for any operative interference I con- 
cluded to wait, assuming that there was pyemia without thrombo- 
sis. This patient then developed a swelling in her knee, had a 
fluctuating temperature, then she had an inflammation of all the 
extensor tendons in one hand, and then an inflammation along the 
tendons in the foot. She died, and I thought that if I had in this 
case ligated the jugular the result might have been better. So 
that there is a class of cases where we cannot find the thrombus 
and yet have all the symptoms of infective thrombosis where it is 
well to ligate the jugular. 

There is no hard-and-fast rule. To say that in every case of 
this kind we should ligate is not correct, and to say that in no 
case should we ligate is not correct. 


Dr. EDWARD FRIEDENBERG, New York, read a paper on pneu- 
mococcic perisinuitis. 

Discusston.—Dr. GRUENING : In fifty cases of mastoiditis we 
have had only three cases of pneumococcus infection, and these 
three cases did well. In the other cases were found streptococcus 
and staphylococcus. The bacillus of grippe was not found. 


Dr. GorRHAM Bacon, New York, reported a case of chronic 
purulent otitis media, followed by an abscess in the 
temporo-sphenoidal lobe, and also an abscess in the 
cerebellum; autopsy. 

The patient, Mrs. A. P. , thirty-two years of age, had suffered 
at times from a chronic discharge from the right ear, although of 
late years it had given her no trouble, except that the hearing was 
defective. For one month prior to her admission to the in- 
firmary she complained of severe pain in this ear, and radiating 














206 Report Trans. Am. Otol. Soc., 1900. 


pains on the same side of the head. Three days before ad- 
mission the discharge from the ear reappeared. 

For two weeks she has been confined to her bed, and nine days 
ago she had two chills on the same day. Following the chill 
there was vomiting, and since that time she has had some nausea 
and vomiting. 

As the pain in her head and ear was severe, her family physician 
prescribed opiates, and when she came to the hospital, February 13, 
1900, she was under the influence of morphine and very stupid, 
Temperature 1oo¢° F. Pulse 80. Respiration 20, Right external 
auditory canal full of pus, and very little left of the drum-head. 

Under ether, that same day, the usual mastoid operation was 
performed, and pus,—offensive in character,—granulations, and 
softened bone were removed. No opening could be detected in 
the tympanic roof, and as it was difficult to make a diagnosis of 
intracranial complication owing to the administration of the 
morphine, any further operative interference was postponed. 

February 18th—The pain has continued. To-day she has 
paralysis of left abducens, paralysis of left side of face, slight 
left hemiparesis, moderate left hemianesthesia, left hononymous 
hemianopsia, and choked discs. 

Diagnosis.—Abscess in right temporo-sphenoidal lobe. 

Second operation.—Original wound reopened and the incision 
carried upwards so that the bone could be thoroughly cut away 
for a considerable area above the ext. meatus. Dura found 
thickened, but not adherent to the tympanic roof. A small sinus 
found in the dura with a probe. This was enlarged, and a large 
abscess found on the right temporo-sphenoidal lobe. About two 
ounces of pus evacuated. 

For several days after the operation the patient seemed to im- 
prove, but later the paralysis became worse, the choked discs 
more marked. Patient very restless, and a diagnosis of probable 
leptomeningitis was made. The patient lived till March 3d. 

Autopsy.—The temporo-sphenoidal lobe presented a large ab- 
scess cavity passing well back. It had been well drained. The 
base of brain presented nothing of special interest. Abscess 
found in right lobe of cerebellum. Foul-smelling pus and very 
thick. It appeared to have begun in the dentate body, which it 
destroyed. It then passed across to the opposite lobe, which it 
invaded to the extent of half an inch. The ventricles were found 
normal. No communication could be demonstrated between 


these two abscess cavities. 








REPORT ON THE PROGRESS IN OTOLOGY AND 
RHINOLOGY DURING THE FOURTH QUAR.- 
TER OF THE YEAR 1899. 






By Dr. A. HARTMANN. 







Translated by Dr. ARNOLD KNAPP. 


ANATOMY OF THE EAR. 







272. VARAGLIA,S. On the elastic fibres of the drum mem- 
brane. Arch. ttal. di Otologia, vol. ix., p. 49. 

272. Elastic fibres are abundant in both the tense and the 
flaccid portions of the drum, and can be grouped in three kinds : 
1. Elastic radial fibres of various thickness; these run in the 
radiating layers. 2. Elastic circular fibres are most numerous in 
the periphery and run in the circular layers. 3. Very fine reticu- 
lar fibres which connect the two varieties. GRADENIGO. 

















PHYSIOLOGY OF THE EAR. 






273. ScHArerR, K. The determination of the lower limit of 
hearing. From the psychological seminary of Berlin University. 
Zeitschr. f. Psychologie, etc., 1899, p. 161. 

273. Accordingto SCHAFER, previous experiments on the ab- 
sence of overtones in the production of the lowest tones are not 
convincing. He considers the proof lacking that tones of 16 or 
perhaps of even lower number of vibrations are audible, though the 
possibility is not denied. He shows by experiments that even 16 
stimulations in a second are capable of producing a tone percep- 
tion. The lower limit is not exactly determinable, not a sharply 
defined point, and may show variations with the attention, the 
kind of sound sources, and the condition of other circumstances. 
HARTMANN. 












207 


A. Hartmann. 


GENERAL, 


@.—REPORTS AND GENERAL COMMUNICATIONS, 


274. VILLARET. The increase of ear disease in the German 
army. Deutsche militérdrstliche Zettschrift, 1899. 

275. Laurrs. On the results of aural treatment in deaf- 
mutes. Medic. Correspondensbl. d. Wirt. drst. Landesvereins, Nos, 
40-43, 1899. 

276. VOLCKER. Arrested development of the speech centre. 
Brit. Med. Journal, Dec. 26, 1899. 

274. In the twenty-three years from 1873-96, the number of 
aural affections in the German army which came under treatment 
has steadily increased, and has risen from 6.28 °/,. to 12.12 °/co 
The increase was gradual and equal in all battalions. In addition 
to this increase, a decrease in mortality after ear disease was also 
noted. The number of discharges as unsuitable or invalidated on 
account of ear disease has considerably increased. The author 
is unable to give a cause for this increase, and refutes, according 
to the reviewer, without convincing proofs, the natural conclu- 
sion that the increase of ear disease is only apparent and due to 


the better otological knowledge during the last decade. 
KORNER. 


275. The patients were 59 deaf-mutes and one hearing-mute, 
and varied from 7-22 years in age. Examination revealed naso- 
pharyngeal adenoids to be the most frequent anomaly (61 4) ; also 
atrophic rhinitis and retractions of drum-membrane were frequent, 
and chronic aural suppuration, and simple opacity and perforation 
of the drum-membrane were rarer conditions. In 48.24 of the 
congenitally deaf and in 23.6 % of those becoming deaf later, hear- 
ing of vowel sounds was preserved ; 35 % of the congenitally deaf 
and 81 ¢ of the others were totally deaf for speech. 

In 80 of the 120, various operations were undertaken; _re- 
moval of cerumen, adenectomy, tonsillotomy, etc. After the 
course of a few months, the excellent result was obtained that 49 
were not improved but 37 were more or less improved, and it was 
found that in the congenitally deaf a disease of the sound-con- 
ducting apparatus or of the naso-pharynx was present in greater 
proportion than in those who became deaf, and further treatment 
in the former variety gives much the better hope of improvement. 

In two cases, hearing necessary for ordinary life was obtained 
by removal of adenoid vegetations. The latter operation in four 









Progress of Otology. 209 






other cases was followed by marked improvement. The author 
closes with the plea that children during their first year in a deaf- 
mute institute should be tested for their hearing and an appro- 
priate treatment of the ears, nose, and throat be instituted. 
MULLER. 
276. Ata meeting of the Clinical Society of London held on 
December 8th, VOLCKER showed a girl aged seven and one half 
years, who was unable to speak. She was the elder of two chil- 
dren, her brother being healthy. The father’s sister had a child, 
aged eleven years, who was said to be similarly affected, the fam- 
ily history being otherwise good. The child had been quite 
healthy until the age of six months, when she had a series of gen- 
eral convulsions. These fits recurred occasionally up to the age 
of three years, when they disappeared. She walked at twelve 
months, but had never spoken. She was quite rational and intel- 
ligent. The hearing was normal. Spontaneous speech was lim- 
ited to a few monosyllabic sentences. She could not recognize 
printed or written words, numerals, or letters, but recognized pic- 
tures of objects or objects themselves. She was unable to write 
letters, words, or numerals, or to copy them. She could, how- 
ever, copy straight lines or circles with either hand, preferably 
with the left. When writing with the left hand, she frequently 
made marks from right to left. Accepting the existence of a vis- 
ual and an auditory perceptive centre and a glosso-kinzsthetic 
and cheiro-kinzsthetic centre as maintained by Bastian, Vélcker 
thought that it appeared as if the two former centres were intact, 
but that the latter, or their commissural connections with the first 
two centres, were involved. He thought that the convulsions had 
in some way damaged the region referred to, and produced 
arrested development. The prognosis was thought to be favora- 
ble and the treatment recommended was instruction in writing 
and in lip language. ARTHUR H. CHEATLE., 


























b.—GENERAL SYMPTOMATOLOGY AND PATHOLOGY. 






277. Topp, Frank C. Conveyance of infection through 
the medium of the ear syringe. A remedy. our. of the 
Amer. Med. Assoc., Oct. 14, 1899. 

278. OPPENHEIMER, SeyMourR. The effect of atmospheric 
changes on the hearing in chronic catarrhal otitis media. . Y. 
Med. Four., Oct. 21, 1899. 

279. Masip, J. A. Otitis media in atrophic rhinitis. Revista 
de Ciencias Médicas, Oct. 19, 1899. 


























ep ga ae th amen oe a 
































210 A. Hartmann. 


277. An ear syringe to be aseptic and practicable must meet 
the following requirements: 1. The point which comes in con- 
tact with the ear must be capable of sterilization and so construc- 
ted that it can be easily removed. 2. There must be no suction 
through the point. 

The fountain syringe answers these requirements. Small glass 
points are used and changed after using in a septic case. The 
objection that the current of the fountain syringe cannot be regu- 
lated at will is overcome by a bulb attachment, which has a 
valve at each end. The solution is drawn in at one end and 
through a tube so large that the bulb is quickly filled. The rub- 
ber tube at the other end is smaller and terminates in a joint 
fitted with a shield to protect the operator from the return flow. 
The point can be unscrewed and sterilized. J. B. CLEMENs. 

278. The observations and conclusions drawn are from a study 
of fifty (50) consecutive cases of chronic sclerosis of the middle 
ear, extending over a considerable period of time. The usual 
tests were used to determine the variations in the hearing under 
different atmospheric conditions. 

Conclusions: I. The hearing in at least seventy per cent. (70 4) 
of the cases with chronic catarrhal deafness becomes worse under 
adverse weather conditions. 

II. The degree of impairment of audition, as influenced by 
atmospheric conditions, is determined, to a great extent, by the 
location and the character of the pathological process in the 
tympanic cavity. 

III. The morbid alterations most susceptible to barometric 
variations are those of hyperplasia. 

IV. In purely atrophic changes in the middle ear, weather vari- 
ations have little or no effect upon the auditory function. 

V. Atmospheric influences also impair the hearing by unfavor- 
ably affecting catarrhal processes of the upper respiratory tract 
and Eustachian tube. 

VI. All things being equal, the impaired audition in chronic 
catarrhal otitis is diminished more (under unfavorable conditions) 
in those whose general health is below par than in those other- 
wise healthy. J. B. CLEMENs. 

279. Masip arrives at the following conclusions from a study 
of nineteen reported cases : 

1. Sclerosing otitis media developed in patients with atro- 
phic rhinitis with considerable frequency —in one sixth of the 









Progress of Otology. 211 






cases, presumably in direct connection with the nasal affection. 
The middle-ear inflammation forms a well-characterized group 
in the heterogeneous group of middle-ear scleroses. 

2. These otitides are peculiar on account of the age at 
which they appear in children and young individuals ; they occur 
about the same time in both ears with slight intensity without the 
paracousis of Willis (?), without labyrinthine symptoms or hyper- 
zmia of the malleus or Shrapnell’s membrane. 

3. Some of the scleroses do not appear until at a later age ; 
they are, however, to be regarded as the continuation of pre- 
vious otitides, 

4. Patients with atrophic rhinitis may be affected by other 
kinds of otitis and with greater frequency, independent of the 
nasal atrophy, as with acute or chronic catarrhal or even purulent 
HARTMANN. 


















otitis. 








¢€.—-METHODS OF EXAMINATION AND TREATMENT. 





280. Matruaegt. Athletic respiration, a hygienic therapeutic 
aid in diseases of the nose, throat, and ears. Therap. Monatshefte, 
1899. 

281. StTuRROcK, CHARLES A. A method for the removal of 
foreign bodies from the nose and ear. Brit. Med. Four., Nov. 
25, 1899. 

280. MATTHAEI means by athletic respiration deep respiration 
with closed mouth for an hour to the full limit, with subsequent 
holding of breath for about fifteen seconds. Chronically inflamed 
mucous membranes, especially of the Eustachian tube, are thereby 
diminished. KILLIAN. 

281. STURROCK applies suction by means of a piece of india- 
rubber tubing, rather less in diameter than an ordinary lead-pen- 
cil, and varying in length from one to three inches, according to 
the distance of the foreign body from the surface, attached to the 
nozzle of a brass syringe. He finds it advantageous to dip the 
tubing into glycerine, thereby diminishing the chance of air en- 
tering between the tube and the foreign body. 

ARTHUR H. CHEATLE. 

















EXTERNAL EAR. 






282. LrERMOYEz. A case of menstruation from the right ear. 
Ann. des mal. del or., du lar., 8, 1899. 





212 A. Hartmann. 


283. SCHIMANOWSKI. Paralysis of the abducent nerve follow. 
ing acute diffuse inflammation of the external meatus. Westnik 
oftalmologii, Jan., 1899. 

282. A girl, fourteen years old, otherwise healthy, and who 
had never menstruated, suffered from hemorrhage from the right 
ear in monthly periods, after preceding feeling of malaise, which 
continued for several days. After three years, normal menstrua- 
tion set in, though frequently accompanied by bleeding from the 
right ear and epistaxis. The ear canal was hyperesthetic and 
presented some dilated vessels. ZIMMERMANN. 

283. A few weeks after the aural affection, the paralysis set in 
and slowly disappeared with the healing of the ear canal. 


SACHER. 
MIDDLE EAR. 


@.——ACUTE OTITIS MEDIA. 


284. VocrT. Facial paralysis during acute otitis media. 
Heidelberg, /naug. Dissertation. 

285. Lewis, Rost. A brief history of five cases of mas- 
toiditis.s WV. Y. Med. Rec., Oct. 28, 1899. 

286. TAanstey, J.O. Shall we use cold im acute middle-ear 


or mastoid affections; if so, how long? Laryngoscope, Nov., 
1899. 

284. A complete exposition of the anatomical relations of 
facial nerve canal and description of the causation and clinical 
symptoms of facial paralysis, based on twenty-three cases collect- 
ed from the literature and two observed at the Heidelberg clinic. 

Brou. 

285. The writer’s object in reporting these cases is to demon- 
strate the rapid and insidious development of serious complica- 
tions in acute middle-ear inflammation, and to illustrate that the 
mastoid operation is, fer se, unattended with danger. 

Case 1.—A boy, aged nine, had otitis media acuta following 
scarlet fever and nasal diphtheria. The inflammation first at- 
tacked the right ear. Notwithstanding paracentesis of a bulging 
drum-membrane by Dr. Albert Buck, and douches of bichloride 
solution 1:6000, mastoiditis was well developed two days after. 
Operation showed the mastoid to be much involved, the cells 
filled with a quantity of pus. A few days after the mastoid oper- 
ation the lymphatic glands in the neck of the same side 
suppurated ; they were opened freely and much necrotic tissue 














Progress of Otology. 213 


removed. Still later the left ear became inflamed. Mastoiditis 
followed, for which operation was performed. The patient’s 
condition was poor, but it improved after each operation. Three 
days after the left mastoid was opened pericarditis and endo- 
carditis, with mitral regurgitation and aortic obstruction, were 
discovered. The ears healed, but the patient died later of the 
cardiac involvement. 

CASE 2.—The patient, a male, while apparently convalescent 
for two weeks from an attack of tonsillitis, suddenly developed 
otitis media acuta. Without any known cause, he was found, 
two days after, in a state of marked and alarming collapse. 
Membrana tympani red and bulging, especially in the posterior 
superior quadrant, in which was a small perforation, allowing the 
escape of pus. No tenderness, cedema, or redness over mastoid 
Temperature, 103.2° F.; pulse, compressible, intermittent, 120. 
Patient’s condition critical. The mastoid cells were opened ; 
bony walls were eroded and the large cavity filled with pus. 
Sigmoid sinus was exposed and found covered with granulations. 
A fistulous opening through the tympanic roof was found, though 
the overlying dura was healthy. Shortly after the mastoid opera- 
tion, a phlebitis of the left leg and perihepatitis developed, pro- 
longing the convalescence. The aural lesion finally healed. 

286. TANSLEY, in reviewing the question and reporting a case 
in detail, reaches the conclusion that the use of cold in mastoidi- 
tis is more harmful than beneficial. Its application quiets pain 
and keeps down external swelling, thus masking the condition 
prevailing beneath, in the substance of the mastoid. Thus, as 
cold applied according to the prevailing methods is insufficient to 
destroy the microbes, its use should be discontinued. Early 
operation is urged, particularly if the middle-ear trouble is, or 
has been, an attical one. CLEMENS. 


b.—CHRONIC OTITIS PURULENTA. 


287. Cima, F. Acid bacillus (smegma-bacillus) in the exu- 
date of sucklings’ otitis. Archiv. ital. di Otol., vol. ix., p. 72. 

288. PautTeT. Cholesteatoma of the ear. Gasette hebdom. 
de médic. et de chirurg., No. 99, 1899. 

289. VON zUR MOHLEN. A case of necrosis of the labyrinth. 
St. Petersburg. med. Wochenschr., No. 13, 1899. 

290. HeEssLeER. Middle-ear suppuration and cerebral tumor. 
Arch. f. Ohrenhi., vol. x\viii., p. 36. 




















214 A. Hartmann. 






291. Baratoux. The indication for the exposure of’ the 
middle-ear cavities in the chronic suppurations. Le progrés méd;- 
cal, Nov. 18, 1899. 


292. Lucar. Profuse escape of cerebro-spinal fluid for five 
weeks without cerebral symptoms. er/. klin. Wochenschr., No. 
40, 1899. : 

293. LomMBARD. Essay on the indications of the opening of 
the mastoid process and of the middle-ear cavities in chronic 
purulent otitis, Paris, G. Steinheil, 1899. 


294. TRAUTMANN. The persistent retro-auricular opening 
after the radical operation and the plastic closure of the same. 
Arch. f. Ohrenhlk., vol. x\viii., p. 1. 


295. HAMMERSCHLAG. The operative exposure of the middle- 
ear cavities in chronic otorrhoea at the University clinic of Pro- 
fessor Politzer. Waien. klin. Wochenschr., No. 43, 1899. 


296. KisTerR. Osteoplastic exposure of the mastoid process. 
Centralblatt f. Chir., No. 43, 1899. 


297. Passow. Kiister’s osteoplastic operation on the mastoid. 
Miinch. med. Wochenschr., No. 49, 1899. 


298. Panse. On Professor Kiister’s osteoplastic operation on 
the mastoid. Centralblatt f. Chir., No. 50, 1899. 

299. Ktster. The criticism of Dr. Panse. J/did., No. 52, 
1899. 

287. Based on eight observations, Cima reports that occa- 
sionally a bacillus resistant to acids can be found in the discharge 
of chronic purulent otitis, which resembles the tubercle bacillus 
but is classed among the smegma-bacilli. The tubercle bacillus 
is not so frequently found as is sometimes stated. A certain 
method to decolorize after treatment with carbol fuchsin is the 
use of acidulated alcohol for ten minutes. GRADENIGO. 

288. PautetT describes the clinical and pathological pictures 
of cholesteatoma of the ear. He supports the Bezold-Haber- 
mann theory of the origin of cholesteatoma and agrees with Sie- 
benmann’s views. SCHWARDT. 

289. A poorly nourished child of two and a half years has had 
bilateral otorrhoea for one year after scarlet fever. ‘The right 
canal is filled with polypi. Facial paralysis. Radical operation. 
The mastoid process was normal externally ; the antrum, middle 
ear, and aditus filled with granulations ; no ossicles found, all dis- 
eased parts removed. A regular after-treatment was not possible. 











Progress of Otology. 215 


Four months later there was a fistula behind the ear, gangrene of 
the skin over two square centimetres, very foetid discharge, exu- 
berant granulations on the promontory, with area of white bony 
surface rough to the touch. After detachment of the auricle 
a large piece of bone and an entire circular canal were removed 
with the sharp spoon. This fragment of bone contained all the 
bones of the cochlea and the vestibule and the int. auditory mea- 
tus. Healing by aid of skin grafts. HARTMANN. 

290. HESSLER reports eighteen cases of brain tumor occurring 
with chronic otorrhoea and adjoins a personally observed case. A 
girl, aged eleven, after scarlet fever, left acute otitis media, right 
deafness with no change in drum. The trouble in the left ear was 
complicated by a mastoiditis which necessitated operation. This 
was followed by occasional fever, vomiting, apathy. Considera- 
ble albuminuria. On the eighteenth day two transient convulsive 
seizures of the left, then of the right side, with unconsciousness, 
fever. Trephining, the dura appeared tense and was incised, 
negative puncture of the brain. Some improvement until the 
thirteenth day, severe pains were felt in the left ear, followed by 
coma, continuing to death. The trephine opening was again ex- 
posed ; after release of necrotic brain matter two spoonfuls of 
clear cerebro-spinal fluid were discharged from a fistula which led 
to a cavity as large as an apple. Death four days later. At 
autopsy a sarcoma of the size of a child’s kidney was found in the 
left temporal lobe. 

Uremia, brain abscess, or serous meningitis has previously been 
suspected. The presence of the tumor explains the right-sided, 
total deafness ; this and the distended left lateral ventricle had 
completely flattened the left upper temporal convolutions. 

In the complete discussion on the diagnostic difficulties of 
these rare cases, Hessler says that brain tumor must always be 
suspected and even hysteria. ‘“ The more certain the diagnosis, 
the surer are generally the results of operative treatment.” 

BLOcH. 

291. BARATOUX considers the indications for complete ex- 
posure of the middle-ear spaces under the following headings : 

1. In case of complicated otorrhcea. 

2. To cure chronic purulent otitis media. 

Under 1, it is necessary to make the complete exposure in 
presence of beginning meningeal symptoms. The dura is exposed 
and the wound thoroughly cleansed. The cerebral signs then 











216 A. Hartmann. 


often disappear. If this is not the case after twenty-four hours, 
sinus thrombosis or brain abscess is present, and appropriate 
operative measures must then be undertaken. 

The broad exposure of the ear spaces and the dura is indicated 
also when the brain symptoms appear in the picture of so-called 
“meningisme,” 7. ¢., chronic irritative meningeal symptoms with- 
out any violent outbreaks. 

Baratoux mentions MacEwen’s observation that in acute ex- 
acerbations of a chronic otorrhcea, pneumonic attacks may occur 
which also call for the radical exposure. 

The radical operation is indicated in well-marked subjective 
symptoms, fistula, facial paralysis, protrusion of the upper part 
of the ear canal, fungous granulations springing from the dura, 
and in local tuberculosis. Ossiculectomy and exposure of the 
attic are indicated in cholesteatoma, granulations, polypi, and 
perforations which have resisted non-operative treatment. In case 
of a relapse, the radical operation is then indicated. 

SCHWENDT. 

292. The seventeen-year-old patient was operated on by 
Luca because of an otorrhcea continuing after opening of the 
mastoid process. After opening the mastoid process a large bony 
defect of the size of a five-cent piece was found at the upper and 
posterior part, where the dura lay bare, and covered by a seques- 
trum measuring a square centimetre. On removing the sequestrum 
an opening was found in the dura and arachnoid which immedi- 
ately discharged so large a quantity of cerebro-spinal fluid with 
blood as to bring the operation to an end. This discharge con- 
tinued for five weeks, and during the first fourteen days necessi- 
tated a twice daily change of dressing. During all this period no 
cerebral symptoms whatever appeared. Lucae thinks this exces- 
sive production of cerebro-spinal fluid was caused by the irritation 
exerted by the sequestrum. MOLLER. 

293. A very thorough monograph (113 pp.) on this subject, 
with thirteen personal observations. HARTMANN. 

294. TRAUTMANN repeatedly advocates the permanent retro- 
auricular opening. Thereby is avoided the deformity in the 
auricle caused by Siebenmann’s plastic. ‘The horizontal incision 
of the canal divides the flaps for the posterior surface into a 
narrow upper and a broad lower one, the vertical incision being 
made at, and not in, the concha. The lower flap is sutured to the 
inferior angle of the wound, while the upper is tamponed. To 














Progress of Otology. 217 


hasten retarded epidermization, occurring, according to Traut- 
mann, in long-standing otorrhoea, swollen and hyperemic mucous 
membrane, chronic naso-pharyngitis, syphilis, tuberculosis, skin 
grafts are employed. To retard hypertrophy of the epidermis in 
healed cavities, a white precipitate salve, one per cent., is used, and 
dry sterile gauze is introduced. Membranes are sometimes formed 
in the situation of a regenerated drum; these, however, do not 
spring from remnants of the drum. 

The retro-auricular wound diminishes with time. A year should 
pass before an attempt be made to close them, never in cholestea- 
toma. The closure of the epidermized fistula is done after 
Passow’s method with some modifications. ‘The auricle is then so 
placed that the scar is invisible. In the twenty-three cases re- 
ported, primary union always took place. The hearing was 
sometimes improved, sometimes made worse ; the former appeared 
to be the case when the epidermis covering was thin. BLOCH. 

295. In addition to the usually accepted indications for ex- 
posing the middle-ear spaces, PoLITzER gives the following: 1. 
In obstinate suppurations from the antrum with fistula in the post- 
upper quadrant, especialiy when adhesions bind the drum rem- 
nants to the inner tympanic wall. 2. The discharge of gritty 
cholesteatomatous masses. 3. Otorrhcea with symptoms of be- 
ginning pulmonary consumption. The statistics embrace sixty 
cases. The indication, duration of after-treatment, and results as 
to healing are given. Finally the origin of endocranial otogenic 
complications is discussed. POLLAK. 

296. KUsTer has practised the so-called osteoplastic operation 
on eight patients. A tongue-shaped flap is made behind the ear, 
commencing above behind the ear down around the mastoid tip, 
and ascends along the posterior border of the mastoid down to 
the bone; the periosteum is elevated along the border and a thin 
bone plate adherent to the skin and periosteum is chiselled free ; 
the flap is turned up and the mastoid is opened according to the 
method described by Kiister in 1889. The flap is replaced and 
sutured except below, where a piece of bone is removed from 
the bony plates to permit gauze drainage. Advantages of the 
operation: No deformity except a thin scar, more rapid healing, 
finally safety of the antiseptic tamponade in injury to the sinus or 
dura, restoration of the bony outline, and in place of the deep 
furrow usually remaining after the ordinary opening there is a 
well-formed bone. The difference is so great that any one com- 











218 A. Hartmann. 


paring the results of the two methods will not have any doubt as 
to the value of the osteoplastic method. Nine case histories and 
one illustration are added. Broa, 

297. The impracticability of Kiister’s method is demonstrated 
step by step in a very lucid and objective manner. The method 
described in 1889 suffers from an incomplete exposure of all the 
middle-ear cavities, and from the impracticable narrowness of the 
newly formed wound canal. The so-called radical method ob- 
viated these difficulties where the cavity was not allowed to fill 
with granulations but was clothed with skin. The new method, 
the osteoplastic, rests on the mistake that a deformity always fol- 
lows the radical operation, while the opposite is the case, as, with 
aid of the plastic procedures, the wound can be sutured at 
once, which leaves only a thin scar. Granted that the osteoplas- 
tic method leads to cure, it would if accepted mean a loss of ten 
years’ labor in otology. In full recognition of Kiister’s merits 
the author concludes as follows, in which he has the support of all 
otologists: “I have well considered the matter before I opposed 
the views of the meritorious Marburg surgeon. I consider it my 
duty, for if Kiister’s suggestions are accepted, completely wrong 
impressions on the value of the radical operation will arise.” 

BrOuHL. 

298. PANSE opposes Kiister’s proposition and says it means 
such a marked step backward that it cannot be too soon warned 
against- because (1) the technic is bad (one facial paralysis, injury 
to the sinus) ; (2) the result is cosmetically inferior to Stacke’s or 
Panse’s plastic. Healing did not take place in one third of the 
cases. 

299.. KisTer’s reply to the preceding, without furnishing any 
new features to the question. BrUHL. 


¢.—CEREBRAL COMPLICATIONS. 


300. GRADENIGO. On the diagnosis and curability of otitic 
leptomeningitis. Arch. f. Ohrenhlk., vol. xlvi., p. 155. 

301. MULLER, R. On the operative treatment of otitic men- 
ingitis. Deutsche med. Wochenschrift, No. 45, 1899. 

302. FERRERI. Severe peri- and endocranial complication after 
acute otitis running a chronic course. Arch. ttal. di Otol., vol. ix., 


P. 49. 
303. Kirmisson. Cerebral abscess. Le progres médical, Nov. 
18, 1899. 














Progress of Otology. 219 


304. Kapjan. Abscess of the temporal lobe of the brain. 
Letopiso russkoi chirurgii, Two autopsies. Yourn. Am. Med. 
Assoc., Nov. 11, 1899. 

305. JURcENs. Streptomycosis of the ear. Monatschr. f. 
Ohrenhlk., 1899, No. 11. 

306. YounGc, ARCHIBALD. Remarks upon the operative 
treatment of infective thrombosis of the sigmoid sinus following 
chronic purulent otitis media. Record of case successfully 
treated. Glasgow Med. Fourn., Oct., 1899. 

307. SCHRAGA. Sinus-phlebitis from chronic otitis ; operation ; 
recovery. Monatschr. f. Ohrenhlk., No. 10, 1899. 

308. Meter, E. Otitic pyemia. Miinchn. med. Wochenschr., 
No. 43, 1899. 

309. RANDALL, B. ALEXx., and ADAMS, JEANNIE S. Lateral 
sinus-phlebitis after otitis media in typhoid fever. Univer- 
sity of Pa. Med. Magazine, Dec., 1899. 

310. RANDALL, B. ALEXANDER. Four cases of cerebellar 
abscess. One success. Two autopsies. fourn. Am. Med. 
Assoc,, Nov. 11, 1899. 

300. GRADENIGO reports four cases. 

I. Chronic bilateral purulent otitis since childhood, right peri- 
sinuous abscess, and beginning thrombosis of transverse sinus ; 
death from basilar meningitis. A girl fourteen years old, jaun- 
diced when admitted to the hospital, hard of hearing for one 
year; the left canal was occluded by a polyp. From the twentieth 
day after the radical operation constant fever, headache, vomiting, 
nystagmus, stiff neck, facial paralysis on the right side, delirium, 
and coma. ‘The autopsy showed the above condition on the 
right side. There was pus in the right int. auditory meatus. 
Gradenigo believes that the concussion of the operation on the 
left ear may have produced the lesion on the other side. 

II. Woman, twenty-seven years old, with left-sided otorrhcea 
since youth, and transient facial paralysis. Recurring polypi, 
meningeal symptoms. Operation: empyema of antrum; the 
sinus was exposed but appeared healthy. On probing in an up- 
ward direction considerable discharge of pus from an extradural 
abscess above the antral roof. After removal of the latter the 
dura of middle fossa was found covered with granulations and a 
purulent membrane. Operation interrupted. High fever, con- 
tinuous meningeal symptoms. Second operation: the dura ex- 











220 A. Hartmann, 


posed to healthy parts and the middle-ear cavities thoroughly 
exposed, removing cholesteatoma and granulations. Recovery. 

III. Boy thirteen years old, acute otitis media in left ear for 
two weeks, high fever, meningeal symptoms. Mastoid process 
was normal. Paracentesis evacuated much pus. No improve. 
ment. Lumbar puncture: in the cloudy cerebro-spinal fluid leu- 
cocytes and very virulent staphylococci. Gradual recovery. 

IV. A woman, thirty-five years old, right cholesteatoma, otor- 
rhoea for nine years, fever during last two weeks and recently 
meningeal symptoms. Bulging of posterior and upper wall. 
Lumbar puncture showed a fluid with many white blood corpus- 
cles and staphylococci. At operation cholesteatomatous masses 
were removed from antrum and middle ear. Dura free. Later 
facial paralysis. Ocular fundus hyperemic. Nine days later fever 
disappeared and gradual recovery set in. Gradenigo believes the 
lumbar puncture to have a curative effect and that packing the 
wound with two per cent. carbolic gauze is very favorable. 

BLocu. 

301. MULLER reports two cases of serous meningitis, of which 
the one is chronic externa and the other ventricular or.acute 
interna. 

I. Mening. serosa ext. chron. An otherwise healthy girl was 
taken ill in April, 1895, with mastoiditis, following ac. otitis me- 
dia. Simple operation, healed at Christmas, 1895. Moderate 
headache and vertigo. In Sept., 1898, sudden aggravation of all 
symptoms, though the ear did not again suppurate. The radical 
operation exposed a large cavity, completely empty, with black, ne- 
crotic, absolutely dry walls in the mastoid process below the scar. 
An abscess in the temporal lobe was suspected and a number of 
punctures were made through the dura; no pus, but some serous 
fluid. Incision with a knife to a depth of 3 cm was also nega- 
tive. A trephine opening was made through the squama. On 
opening the dura, a quantity of serous fluid escaped, but no pus. 
The escape of fluid continued during recovery. Two months 
later the brain wound was healed without any prolapse, and two 
months later the ear wound was also completely healed. A com- 
plete recovery has not, however, taken place, as vertigo, imperfect 
locomotion, reduced sensation of the crossed side, and the recent 
aggravation (increased headache, vomiting, tenderness on percus- 
sion of the left hemisphere, normal eye-ground, pulse, and tem- 
perature) persisted, though the operation on Sept. 15, 1898, can 











Progress of Otology. 221 


be regarded as a life-saving procedure, These symptoms are 
probably due to a chronic inflammatory serous infiltration of the 
brain substance, especially of the temporal lobe, as a result of the 
non-purulent, necrotic disease of the mastoid process. 

II. Mening. seros, interna acuta. Woman thirty-one years 
old, mother of three healthy children, was taken ill with menin- 
geal symptoms suggestive of a brain tumor, though she had had 
otorrhoea for many years. The radical operation was performed 
on account of the otorrhoea and the tenderness of mastoid. The 
antrum contained cholesteatoma, but trephining of the temporal 
lobe proved negative. The general condition did not improve ; 
after a few days the region over the cerebellum was trephined, 
but again no pus was found. No improvement. An enormous 
cerebral prolapse appeared at both openings. Four weeks later, 
a gradual improvement of all symptoms began with a serous 
transudation of the bandage ; complete recovery in three months. 
The diagnosis of meningitis serosa interna, with exudation into 
the ventricles, was made by exclusion, and puncture of the ventri- 
cles is advocated in this and similar cases. No brain symptoms 
remained, notwithstanding the great loss of brain tissue. The 
author believes that the trephine openings should be made away 
from the wound of the radical operation, to guard against infec- 
tion of the brain hernia by the otorrheea, NOLTENIUS. 

302. Report of two cases with severe complications without 
revealing any involvement of the mastoid processes. It is sup- 
posed that in both cases the tubal cells described by Bezold 
were affected and caused the deep abscesses in the neck and 
pharynx. Most of the symptoms were referable to the deep pa- 
rotid region. The operative treatment of analogous cases is 
discussed. 

A case of extradural abscess after acute otitis media without 
mastoid disease is also described. The author is in favor of op- 
eration through the ear. GRADENIGO, 

303. Kirmisson showed a patient before the Paris Surgical 
Society on whom he had operated on account of brain abscess. 
The pus contained streptococci; healing was uneventful, but the 
half-sided paralysis and contracture remained for some time. The 
contracture and paralysis disappeared almost completely with 
massage. SCHWENDT. 
~ 304. Acute suppurative otitis after follicular tonsillitis, One 
month later mastoiditis, and at the same time the characteristic 

















222 A. Hartmann. 


symptoms of an abscess in the temporal lobe. Operation. 
Healing. SACHER. 

305. A soldier who had had a chronic purulent otitis and 
mastoiditis succumbed to a thrombosis of the left transverse 
sinus, meningitis, rapid softening in the temporal lobe, and septi- 
cemia. Pure cultures of streptococci were found in the softened 
areas of the brain, in the antrum and mastoid cells, labyrinth, and 
middle ear. KILLIAN, 

306. Youna’s case was that of a child two and a half years of 
age, the chief interest being that recovery took place without 
ligation of the internal jugular vein, the sinus being incised and 
the septic contents turned out. The thrombosis occurred high 
up, at the knee of the sinus. ARTHUR CHEATLE. 

307. At the operation the sinus was found surrounded with 
pus. It was opened three days later, when distinct pyzemic symp- 
toms had supervened. Ligation of jugular vein. The sinus con- 
tained soft, brownish-red masses of thrombus. Later several 
pyzmic abscesses had to be opened. Recovery. KILLIAN. 

308. Report of eight cases of pyzmia, all due to sinus throm- 
bosis ; of these three had previously been reported. In all cases 
operation was performed ; twice the jugular was ligated. In three 
the otitis was acute ; one of these was fatal. In four the otitis was 
chronic, with a mortality of two. MEIER agrees entirely with 
Leutert’s explanation for the development of pyzmia, 

SCHEIBE. 

309. In this case, after three months of malaise, typhoid fever 
developed which was later complicated by the occurrence of 
middle-ear inflammation. The otitis never became purulent in 
character in the right ear, though reported at times puriform 
in the left ear. During the course of the fever, superficial 
furuncular abscesses formed over the sacrum and shins, but 
no rigors, sweating, or characteristic septic temperature were 
noted. Some ten days after the crisis a relapse occurred, the 
pyrexia beginning with the only approach to a rigor observed. 
Later, while apparently convalescent for a period of two weeks, 
clear signs of an inflammation of the right mastoid and lateral 
sinus developed, which disappeared in three days without opera- 
tion and was followed by an uninterrupted recovery. 

CLEMENS. 

310. Case 1.—The patient, fifteen years of age, had a dis- 

charging ear for three years. A box on the ear three days pre- 














Progress of Otology. 223 


vious to the consultation was followed by nausea, pain, and 
malaise. The mastoid was red, tender, and swollen ; marked fluc- 
tuation, temperature 106° F., appearance anxious and serious. 
Immediate operation refused. Mastoid opened next day. Incis- 
ion through soft parts evacuated two drams of pus, surface of bone 
intact. Mastoid sclerosed, pus found with little caries when antrum 
was reached. No sinus was detected leading to adjoining parts. 
Antrum curetted and packed. Temperature fluctuated, eye- 
ground normal. With a temperature of 103 ° F., pleural friction 
was detected with rapidly following effusion and lung consolida- 
tion. No rigors, no jugular tenderness, no swelling about the 
neck. Patient died six days after operation and thirteen days 
after the injury, 

Autopsy, twenty-four hours after death, showed amazing de- 
struction of both lungs, pleural empyema, dura engorged and 
adherent, pia clouded. Two drams of pus evacuated upon re- 
moving the brain, owing to cerebellar abscess. Dura intact. 
Doubtful evidence of phlebitis. Cerebellar abscess size of pigeon’s 
egg, with thick pyogenic membrane, thinnest in proximity to the 
antrum. Abscess may have antedated the injury. 

Case 2.—Patient fourteen years of age. Had suppuration for 
two months; granulations found over the posterior wall of audi- 
tory canal. Operation showed the posterior osseous wall largely 
destroyed, mastoid one large cavity, sigmoid sinus large and some- 
what forward, bony covering destroyed for one inch and covered 
by granulation. Considerable caries of inner plate. Slight sub- 
dural pus ; two square inches of the dura exposed. Healthy bone 
was reached in all directions during the operation. The patient’s 
general condition was bad, but after ten days was discharged and 
attended the clinic. Two weeks later, an abscess formed at the 
clavicle which was evacuated and a sinus was followed upwards 
for two inches. Healing occurred rapidly below but oozing from 
mastoid sinus continued. The appetite failed, with occasional 
vomiting, other serious symptoms following. With a sub-normal 
pulse of seventy-six (76), temperature of 98° F., cerebellar ab- 
scess was expected and operated for. The operation extended 
deep into the middle and cerebellar fosse. An accident to the 
mastoid vein by rongeur prevented further exploration. Patient 
died. No autopsy. 

Case 3.—Child of six years of age with middle-ear suppura- 
tion. The mastoid was opened, carious bone and granulations 

















224 A. Hartmann. 


removed, At adressing of the wound a rough, overhanging edge 
of the cortex was scraped smooth and a small bone sinus found, 
which led to an abscess cavity about one cm in diameter, in the 
cerebellum. Healing was exceedingly slow, but the patient was 
ultimately discharged cured. 

Case 4.—A child four years of age. Suppuration of the right 
ear followed by mastoid abscess, which had been incised three 
weeks before case came under observation of writer, leaving a 
discharging sinus behind the ear. Much headache on the right 
side. Condition became serious later, with vomiting, convulsive 
twitchings of left arm and leg, without paresis. Little mental 
disturbance. Temperature 98.4° F. Respiration 20, Pulse 88. 
Mastoid was opened, carious bone and granulations removed, and, 
as no defect of the inner table could be detected, further opera- 
tion was delayed. Death. 

Autopsy: An excess of fluid in the arachnoid and ventricles 
was found. Cerebellar abscess about 3x5 cm occupied nearly 
the entire lobe. J. B. CLEMENS. 


a@.—OTHER MIDDLE-EAR AFFECTIONS. 


310@. ARSLAN. Several syphilitic varieties of the cartilage 
of the Eustachian tube. Arch. ital. di Otologia, etc., vol. ix., p. 9. 


311. Stucky, J. A. Fractured base, with deafness, tinnitus, 
exophthalmus, facial paralysis, mastoiditis. Four. Am. Med. 
Assoc., Nov. 11, 1899. 

310a@. ARSLAN presents observations of a clinical picture of 
hyperplasia of the mucous membrane and the cartilage of the 
Eustachian tube in tertiary or hereditary syphilis. The most 
constant symptom is the loss of hearing from tubal stenosis ; this 
does not correspond to increase in volume, which is not recog- 
nizable in the rhinoscopic examination ; it is probably produced 
by the extension of the disease to the walls of the tube. Specific 
treatment gave the best results. GRADENIGO. 

311. Case of a jockey, twenty-one years old, who was thrown 
from a horse and sustained a large contusion of the scalp over 
the vortex, which was rapidly followed by cedema, extending 
down to both ears, though more marked on the right side. Tin- 
nitus and deafness in right ear, no hemorrhage from nose and 
throat. Five weeks after the injury exophthalmus of right eye 
developed, hemorrhagic spots in deep conjunctiva, dimness of 













Progress of Otology. 225 





vision, eye-ground negative. Complete facial paralysis, swelling 
of mastoid integument, tenderness over antrum and tip of the 
bone. Auditory canal red and swollen, bulging posterior superior 
wall, Perforation of the drum, in the superior posterior quad- 
rant, and discharging offensive pus. Constant headache ; vertigo, 
falling toward the left ; aphasia. 

A Stacke-Swartze operation was performed, and the attic, mid- 
dle ear, antrum, and cells found full of firmly adherent clots: no 
pus ; no caries. Malleus was found separated from the drum 
and incus from the stapes. The clots and inflammatory products 
were thoroughly removed, cavities cleaned, and the mastoid 
dressed in the usual way. All symptoms but the facial paralysis 
disappeared after the operation. Recovery was uninterrupted. 
J. B. CLEMENS. 
















NERVOUS APPARATUS. 





312. Lanwnois, E., and Harpour, M. On true hysterical deaf- 
ness. Ann. des mal. de loreille, etc., No. 10, 1899. 

313. ALT. On psychic deafness. Monatschrift f. Ohren- 
heilk., No. 12, 1899. 

314. FEeRA. A case of monolateral multiple progressive par- 
alysis of the cranial nerves. Arch. ital. di Oftol., etc., vol. ix., 
Pp. 34. 

312. LANNots and Harpour endeavor to separate the clinical 
pictures of hysterical deafness from other affections which are 
somewhat similar. The following should not be confounded 
with the true hysterical deafness: (1.) Hysterical deafmutism ; 
(2.) inattention of deaf persons due to psychic depression (déspe- 
rance auditive). The deaf one, discouraged by his unsuccessful 
attempts to hear, gives up all efforts. 

True psychic deafness is complete or nearly complete. It occurs 
without a material change being present in the ear, and forms 
the principal symptom of a general neurosis. Recovery follows 
spontaneously or after a psychic treatment. The author describes 
two cases of male hysteria. The main symptoms are the follow- 
ing: 1. The degree of deafness is greater than that associated 
with middle-ear diseases; the deafness corresponds to laby- 
rinthine or nerve deafness. 2. Bone-conduction is abolished. 
3. The drum membrane appears normal. 4. Insuction of the 
drum membrane is inconstant. 5. The disease is of equal inten- 
sity on both sides. 6. Subjective symptoms are of only short 
























226 A. Hartmann. 


duration. 7. Usually other symptoms of general hysterical neu- 
rosis are present, anzsthesia, contraction of visual field, etc. 8. 


A radical cure follows. SCHWENDT, 
313. An historical and critical discussion on the above theme. 
KILLIAN. 


314. Man fifty years old, with complete left-sided facial par- 
alysis with pains and tactile anzsthesia of the left half of the face. 
Loss of hearing, left, due to the affection of sound-conducting and 
nervous apparatus. Complete paralysis of the left vocal cord. 
Later, necrosis of the left cornea and movements of deglutition. 
Death from inspiration pneumonia. At autopsy a sarcoma of the 
left middle fossa of the skull, extending to the anterior and inner 
part of the posterior fossa, to the left half of the sphenoidal cavity, 
and the posterior end of the middle turbinal. The tympanum 
was free. The left basal nerves are compressed and invaded with 
tumor masses. GRADENIGO. 


NOSE AND NASO-PHARYNX. 
@.—GENERAL PATHOLOGY. 


315. REUTER. Essential anosmia. Arch. f. Laryng., vol. ix. 


316. PxLaczex. Congenital absolute bilateral anosmia. ro/. 
klin. Wochenschr., No 51, 1899. 


317. FRANKEL. Open mouth and short upper lip following 
shortening of frenulum labii superioris. Arch. f. Laryng., vol. ix. 


318. Corpes. Mucoid degeneration of the epithelium of 
glandular ducts in the nasal mucous membrane. Arch. f. Laryng., 
vol. x. 


319. ZUCKERKANDL. On the development of the concha 
bullosa. Monatschr. f. Ohrenheilk., No. 10, 1899. 


315. REUTER divides the essential anosmias with probable 
anatomical causation in three groups after their etiology: 1. The 
anosmia remaining after the complete extirpation of genuine 
nasal polypi; 2. The anosmia in chronic ethmoiditis; 3. The 
anosmia in ozena, In the first class, while in many cases the 
smell returns after the removal of polypi, it may be permanently 
damaged. ZARNIKO. 

316. A woman, sixty years of age, had never possessed the 
faculty of smell. There were no changes in the local condition 
nor in the nervous system. A similar case is described in a man 









Progress of Otology. 227 






forty-four years of age. These two, besides a case of Zwaarde- 
maker’s, are the only ones on record. MULLER. 
317. FRANKEL observes three successive cases of the mouth 
being kept open from abnormal shortness of the frenulum labii 
sup. The maxilla and lips were normal. The deformity was 
permanently cured by simple division of the band with the scissors. 
He suggests the name of mikrocheila. ZARNIKO. 
318. Corpes has studied the bud-like structures, first described 
by the reviewer, then by Birmingham and Okada, which occasional- 
ly occur in hyperplastic epithelium of the nasal mucous membrane. 
These are not independent mucous glands but belong to normal 
mucous glands caused by the mucoid metamorphosis of the cells 
surrounding the excretory duct in the epithelium. ZARNIKO. 
319. The cavities in the middle turbinates may be continua- 
tions of the upper-middle meatuses or of a bulla cell or of an 
anterior frontal cell. There are usually one, and sometimes two 
or three of these cavities. 
The paper of Bergeat (Midinch. medic. Wochenschrift, 1897) 
seems to have escaped ZUCKERKANDL’s attention. KILLIAN. 

















b.—METHODS OF EXAMINATION AND TREATMENT. 





320. Bock. Experiences with electrolysis, especially in nasal 
therapeutics. Berl. klin. Wochenschr., No. 45, 1899. 

321. BAUMGARTEN. Schleich’s procedure in operations of the 
deviations and spurs of the septum. Arch. f. Laryngol., vol. ix. 

322. Breirunc. The importance of the electric internal 
drum massage of the nasal mucous membrane for the general phy- 
sician, and its technic. Deutsche Medizinal-Zeitung, No. 96, 1899. 

323. BAUMGARTEN. The bloody treatment of hypertrophies 
in chronic rhinitis. Wrener med. Presse, No. 46, 1899. 

320. Bocx’s experience with electrolysis in ozna are not en- 
couraging ; the method is, however, of value for cosmetic purposes 
(warts, nevi, calcified atheromata, etc.). It is especially ser- 
viceable in deformities of the septum, and, according to Brock, 
combines all the advantages of other methods and should be em- 
ployed except in especially prominent traumatic deviations or 
where the necessarily prolonged treatment (six to seven weeks) is 
no objection. MULLER. 

321. BAUMGARTEN operates on septum deformities with a 
chisel and painlessly from the use of Schleich’s injections. Hem- 




























Ni NN AA me 







































228 A. Hartmann. 


orrhage is also reduced, though it is more profuse later and re- 
quires careful tamponade. Schleich’s method is also described 
in the division of synechiz and in tracheotomy. ZARNIKO, 
322. BreirunGc has modified the apparatus for vibratory 
massage, by which the action is made more uniform. This mas- 
sage is supposed to correct all disturbances due to increased in- 
tracranial pressure, and to cure nervous coryza. It exerts a 
favorable action on ozzna and not only opens but keeps the 
ostia of the Eustachian tube open. HARTMANN, 
323. BAUMGARTEN recommends removal of hypertrophies 
with the angular scissors without cocaine. POLLAK. 


€.—OZENA., 


324. CozzoLino. A study of the bacteriology and histology 
of ozena. Ann. des mal. de foretlle, etc., No. 7, 1899. 


325. PEWNIZKI. Treatment of ozena with diphtheria anti- 
toxin. Wojenno medizinsky Shurnal, Sept., 1899. 


324. According to CozzoLino, ozzena is due to a primary nu- 
tritive disturbance of the bony turbinals, to which is associated 
secondarily a bacterial infection. The latter is caused by the 
bacillus mucosus, which produces the fever and crusts. 

ZIMMERMANN. 

325. Three cases which received no other treatment than the 
serum injections. The results were absolutely negative. Elec- 
trolysis was also tried. After two or three sittings a complete 
cessation of the foetor occurred. The method is, however, pain- 
ful, and only temporary. SACHER. 


a.—ACCESSORY SINUSES. 


326. WRrROBLUOSKI,. Acute empyema of the antrum of High- 
more. Arch. f. Laryng., vol. x. 


327. Retui. Negative air-douche as diagnostic aid in diseases 
of the accessory cavities. Ween. klin. Rundschau, No. 43, 1899. 

328. Grtnwatp. On the curability of inflammations of the 
maxillary antrum. Arch. f. Laryng., vol. ix. 

329. Licutwitz. Sequestrum developing about the operative 
canal, in the operative treatment of maxillary empyema through 
the alveolus. Arch. internat. de lar., d’ot., xii., 4. 


330. StTRazza. Clinical remarks on the chronic inflammations 


of the frontal sinus, especially as to treatment. Arch. ttal. di 
Otol., etc., vol. viii., p. 361. 





















Progress of Otology. 229 


331. Luc. A case of unusually obstinate frontal empyema. 
Arch. internat. de lar., d’otol., xii., 4. 

332. Causet and DruauLt. Meningitis and orbital abscess 
following a polysinusitis of dental origin. Aan. des mal. del'or., 
du lar., Xxv., p. 8. 

333. KorseLt. Combination of otitis media with rhinogenic 
brain abscess. SBettrdge sur klin. Chirurgie, xxv., 2. 

334. LarRancors. Ethmoid empyema with orbital complica- 
tions. L’année médical de Caen, Sept. 15, 1899. 

335. FERRERI. Fibrosarcoma of sphenoidal sinus. Arch. 
ital. di Otol., vol. viii., p. 445. 

336. GRUNERT. A new plastic method after complete expos- 
ure of the frontal sinus for empyema. JA/dénchen. med. Wochen- 
schr., No. 48, 1899. 

337. Kyte, D. BRapEN. Confined suppuration of the frontal 
sinus with spontaneous rupture. WV. Y. Med. Four., Dec. 16, 
1899. 

327. The use of the negative Politzer’s experiment requires 
only a few seconds and often succeeds. The nose is first cleaned 
and dried, cocainization of middle meatus. Some water is 
held in the mouth, the nozzle of the compressed bag introduced 
in the nostril ; during deglutition the bag is allowed to expand. It 
succeeds almost always in diagnosing accessory sinus disease. If 
no discharge appears, iodide of sodium is administered for two to 
three days to produce a profuse discharge, and the experiment 
is repeated. POLLAK. 

328. GRUNWALD has examined 106 cases with view to 
duration, character of secretion, condition in nose and of the 
teeth, and various complications. In general there is an inverse 
proportion between duration of disease and result of treatment. 
Not the catarrhal but the purulent forms are more favorable for 
healing ; unfavorable are those with the ozzena complex (broad 
nose, crusts). Complications with polypi mean severe disease of 
the mucous membrane and make the prognosis worse. Contig- 
uous diseased teeth make a permanent cure impossible. The 
prognosis is better if the tooth trouble is immediately recognized 
and treated. Some cures are prevented by diseased roots of 
normal-appearing teeth. Other remarks on the complication 
with suppuration of other accessory cavities, bilateral disease, the 
conditions within the cavity (polypi, polypoid excrescences, 











230 A. Hartmann, 


diverticula) follow. Regarding therapeutic measures, the author 
does not think much of simple perforation, and employs it only 
where disease of the teeth or a defect at the corresponding place 
is present, in not too inveterate cases in young rather than old 
individuals, in catarrhal rather than purulent forms. Of opera- 
tions with broad exposure he reserves Bénninghaus’s method for 
the severest cases. Finally he emphasizes that many catarrhal 
diseases will get well by correcting the intranasal changes. 
ZARNIKO. 
329. The antrum of Highmore was opened from an alveolus 
with the electric trephine. Four weeks later, after pain had ex- 
isted since the third day, an annular sequestrum was discharged. 
LicHtwitz believes that the necrosis was due to overheating 
from too rapid moving of the trephine. ZIMMERMANN. 
330. STRAZZA reports 5 cases and discusses the diagnostic 
features and treatment of chronic frontal empyema. Even 
though both sides were affected, the symptoms were only on one; 
the septum was always present, but softened in 2 cases and 
thinned in 1. In acertain number it is impossible to introduce 
a canula in the natural passage ; even if successful, it is painful, 
and the curative action of irrigations is very small, especially as, 
in most cases, the sinus is filled with polypi. For radical treat- 
ment broad external exposure is recommended, so that the soft 
parts may fall back and the cavity be obliterated. No attention 
is paid to cosmetic reasons. It is necessary to remove all fungoid 
masses and the purulent focus. The author is against immedi- 
ate closure of the wound and tampons until a granulating surface 
has formed. It is not necessary to pay any attention to the nasal 
duct. GRADENIGO. 
331. A patient, twenty years old, had been operated on twice 
for frontal empyema with primary suture; the suppuration re- 
turned and extended to the other side. At the third operation 
both sinuses were exposed, the anterior ethmoid cells curetted, 
and the wound was again closed. Six weeks later fluctuation ap- 
peared over the left eye, which was opened and drained. The 
fistula closed after three weeks, though pus still collected. Luc 
put on a pressure bandage, with the result that at the next dress- 
ing the fluctuating had extended to the scalp limits. Several 
periosteal and an extradural abscess were formed, which was op- 
erated on. The patient finally died from meningitis. Luc has 
successfully operated on twelve frontal empyemata, and claims 














Progress of Otology. 231 


that the failure in this case was due to constitutional peculiarities 
of the patient, for which there seem to be no reasons whatever. 
ZIMMERMANN. 
332. The sickness began like influenza, with coryza; then 
fever, vomiting, severe headache, painful cedema of the eyelids 
appeared. The incision of the lower lid evacuated a drop of pus, 
and no carious bone could be detected at depth. Death ensued 
after delirium. Autopsy showed a basal meningitis (right) espe- 
cially in Sylvian fissure, produced by a small destruction of bone 
in the anterior part of the sella turcica. This led into the left 
sphenoidal sinus, which was distended to the right and filled with 
pus. The ethmoid cells and maxillary antrum were likewise af- 
fected, and into the latter projected a carious tooth. The ocular 
symptoms were caused by the transmission of the cavernous sinus 
and the ophthalmic vein. ZIMMERMANN. 
333. A male, thirty-three years old, suffered from right 
chronic otorrhoea and bilateral purulent discharge from the 
nose ; two weeks later 38.4°, vomiting, headache, vertigo, stupor, 
twitches in left arm. No tenderness over mastoid or forehead. 
Suspecting otitic brain abscess, trephine opening in squama, 
brain incised, no pus. Antrum opened, found filled with pus. 
Radical operation. Death after several hours. At autopsy, 
caries of posterior wall of right frontal sinus and abscess in right 
frontal lobes were found. Publication of hitherto reported 
cases (20) of rhinogenic frontal abscess and their symptoms. 
BRUHL. 
334. <A boy, four years old, fell on his nose and had headache 
for three days. Six months later, he was again taken ill with fever 
and became stuporous ; left eyelid oedematous, slight exophthal- 
mos. Examination of nose negative. As an osteoperiostitis of the 
inner orbital wall was suspected, an incision was made at level of 
inner canthus. A probe encountered ethmoid cells filled with pus. 
A broad opening was made between the ethmoid cells and the 
nose. Recovery. SCHWENDT. 
335. FERRERI concludes as follows: a sphenoidal empyema 
should be diagnosticated as early as possible and operated upon, 
lest fatal intracranial complications follow. It is necessary to 
differentiate between a pyogenic inflammation and a neoplasm, as 
the same symptoms may be produced by either for a long time. 
GRADENIGO. 


336. After eradicating the frontal sinus by Kuhnt’s method, 























232 A. Hartmann. 


at both ends of the supraorbital horizontal incision, vertical in. 
cisions are made passing above and below. By undermining, two 
flaps are thus formed. The upper flap is placed in the frontal 
cavity after the epidermic layer has been removed, and the lower 
is pulled over this and sutured to it after being changed toa 
wedge shape. This method has been employed in one case with 
good cosmetic result. GRUNERT recommends his procedure only 
when the cavity is not too deep. SCHEIBE, 
337. A woman, et. sixty, experienced a fulness on the left 
nasal side, thin nasal watery discharge, swelling over the face, 
particularly between the eyes, and soreness at the inner angle of 
the left eye. The swelling increased, the nasal discharge became 
more pus-like, and malaise and general debility ensued. The pa- 
tient had lost over thirty pounds in flesh. The swelling increased 
so much as to hang down over both supraorbital ridges, with 
marked swelling under both eyes. In the median line, an inch 
and a half above the line of the supraorbital ridge, was a tumor- 
like red projection, pitted in the centre with a small spot showing 
some dried secretion. In removing the dried crust an opening 
was found, and upon pressure foul-smelling, thick pus was dis- 
charged. The necrotic area was almost circular, } inch in diam- 
eter. A probe passed easily through the nose. The outer 
opening closed spontaneously after two months. The necrosis 
had involved the outer plate only. M. ToEPLitz, 


€.—OTHER DISEASES OF THE NOSE, 


338. LermMoyez. The treatment of nasal hydrorrhcea with 
atropine and strychnine. <Avn. des mal. de l’or., du lar., xxv., 7. 
339. FREUDENTHAL. Excessive epistaxis controlled by local 
injections of gelatine. Deutsche med. Wochenschr., No. 49, 1899. 
340. Freporow. Forced dilatation of the chest as a means of 
checking epistaxis. Bolnitschnaja gaseta Botkina, No. 29, 1899. 
341. CoTTeLt, A. B. Hemorrhage through the lachrymal 
duct after plugging the nares. Brit. Med. Four., Dec. 16, 1899. 
342. GREEN, W. E. Case of rhinolith. Brit. Med. Four., 
Nov. 4, 1899. 
343. Morr. Contribution to the etiology of the genuine 
fibrinous rhinitis. Correspondenzblatt f. Schweizer Aerzte, 1899. 
344. HEINDL. On the treatment of rhinoscleroma or scleroma. 
Ann. des mal. de lor., du lar., xxv., 7. 











Progress of Otology. 233 


345. Manasse. On multiple amyloid tumors of the upper 
respiratory passages. Virchow's Archiv. 

346. SEIFERT. Tuberculosis of naso-lachrymal canal. Minch. 
med. Wochenschr., No. 52, 1899. 

347. The relation of pathological conditions in the ethmoid 
region of the nose, and asthma. Swain, Henry L., Pathology, 
N.Y. Med. Four., Oct. 28, 1899 ; Rice, CLARENCE C., Clinical 
Phases, V. Y. Med. Four., Nov. 11, 1899; Boswortu, F. H., 
Treatment, V. Y. Med. Four., Nov. 18, 1899. 

338. LeRMoyez has returned to the purely medical treatment of 
vaso-motor coryza ; he recommends strychnine, atropine, 2a 0.005 
to 400 syr., I-3 teaspoons daily. Of 27 patients treated in this 
manner 14 could be re-examined and 11 proved to be cured. 

ZIMMERMANN. 

339. A woman, sixty-eight years old, suddenly was taken with 
profuse epistaxis. Attempts at checking the bleeding with pack- 
ing anteriorly and later posteriorly were only temporarily success- 
ful. The dangerous condition was avoided by an infusion of 
salt solution in the intra-clavicular subcutaneous tissue. The 
hemorrhage did not cease until 20-30 ccm of fluid-warm gelatine 
was injected into the nose with a warmed glass syringe. 

NOLTENIUS, 

340. Feporow has found the following method the best: the 
patient sits upright on a chair, places both arms on his head, and 
takes long, deep breaths with mouth open. SACHER. 

341. <A soldier who was much debilitated had a severe attack 
of epistaxis, necessitating plugging. As a result, blood appeared 
in each lower eyelid and trickled down the cheeks. 

ARTHUR H. CHEATLE. 

342. Ata meeting of the Southern Branch of the British Medi- 
cal Association, Isle of Wight Branch, held October 20th, GREEN 
showed a rhinolith which he had removed from a girl who had 
been troubled with her nose for years. The stone, which occu- 
pied the nose and naso-pharynx as far as the pharynx, was crushed 
with strong polypus forceps and removed in five or six pieces. 
Three months later, the symptoms having recurred, a thin ragged 
plate about 1 inch long, 4 inch wide, and } inch thick, was 
removed from near the back of the nasal cavity. 

ARTHUR H. CHEATLE. 

343. Morr collected all cases of fibrinous rhinitis from the 
literature and added three of his own. These are his conclusions : 
















234 A. Hartmann. 


Genuine fibrinous rhinitis is not to be distinguished etiologically, 
anatomically, or clinically from diphtheria, hence the same pro- 
tective measures are required for either. 

In the author’s cases, virulent Léffler’s bacilli were found in the 
pseudo-membranes. Recovery followed the use of antitoxin., 

In several cases described by others, no Léffler’s bacilli were 
found, but staphylococci and streptococci. According to the 
author, it is possible that the Léffler’s bacilli were overgrown by 
the other cocci so that they no longer were present in the pseudo- 
membranes. SCHWENDT. 

344. Of the eleven cases described, nine concerned the nose 
and naso-pharynx ; in all cases typical rhinoscleroma bacilli were 
found. Treatment consists in restoring the nasal respiration with 
avoidance of destruction. The infiltrates and tumors were 
curetted, bands were divided and kept from reuniting by packing 
with gauze. ZIMMERMANN. 

345. Mawnasse has examined microscopically a case of infil- 
trating amyloid tumors of the larynx and trachea, and a nodular 
tumor in the right palate, tonsil, and larynx. BRUHL. 

346. Fourteen cases, of which thirteen belonged to the eye 
clinic. In five cases the tubercular process was localized to the 
lachrymal canal ; in the other cases the conjunctiva or cornea 
was also affected. In all fourteen cases the nose was also in- 
volved. Secondary tuberculous inflammations of the lachrymal 
canal from the nose are the most frequent. SCHEIBE. 

347. Swain holds that in asthma there must be first an irrita- 
bility of the bronchial structures, secondly some other diseased 
organ, such as the nose, stomach, ovary, etc. And thirdly, the 
neurotic habit. The cause is found outside of the body, in cer- 
tain irritations, as, ¢. g., the pollens of grasses in hay fever, flour in 
baker’s asthma, or in the musty smell of feathers, the last being 
illustrated by a case of a young man, et. twenty-eight, whose 
asthma and even cedematous swelling of the middle turbinate dis- 
appeared after the change of his feather pillow. Swain then gives 
an elaborate theory upon the production of this cedematous tissue 
and how it produces asthma. 

Rice believes that ethmoid diseases are not often associated 
with periodical asthma. The coexistence of asthma and eth- 
moidal disease is due to mechanical obstruction, necessitating 
mouth-breathing, and to the supervening chronic catarrh of the 
entire respiratory tract. Temporary asthma occurs during acute 





















































Progress of Otology. 235 


congestive exacerbations, due to atmospheric changes and to 
derangement of the circulatory and digestive apparatus. 
BosworRTH asserts that a diseased condition of the nasal mu- 
cous membrane tends to produce disease of the bronchial mucous 
membrane. Asthma is due to a vasomotor paresis of the blood- 
vessels of the mucous membrane of the bronchial tubes. Poly- 
poid degeneration, cedematous hypertrophy of the nasal mucous 
membrane, and nasal polypi indicate ethmoiditis. If we remove 
these conditions, we do not cure the asthma, which can only be 
remedied by radical treatment of the ethmoid, viz., to relieve the 
intracellular pressure by breaking down the trabecular walls by 
means of the burr. M. TOEPLITZ. 


f.—NASO-PHARYNX. 


348. Luzzato. On the histology of the hypertrophic pharyn- 
geal tonsil. Arch. ital. di Otol., etc., vol. viii., p. 394. 

349. Lewin, L. Tuberculosis of the pharyngeal tonsil. 
Arch. f. Laryng., vol. 1x. 

350. Der Simoni. Adenoid vegetations according to the new 
views of Hertogue. Solletino delle mal. del’ orecchio, 1899, p. 491. 


351. MICHALKIN, P. Treatment of a fibrous naso-pharyngeal 
polyp with electrolysis. A/edicinskoji obosrnj., No. 5, 1899. 

352. InGaAts, E. FLETCHER. Fibrous tumor of the naso- 
pharynx; sequel. WV. Y. Med. Four., Dec. 16, 1899. 

348. Luzzaro examined the peculiarities of the epithelium - 
and observed emigration of leucocytes in well-preserved ciliated 
epithelium and in squamous epithelium, as opposed to Stéhr’s 
view. The author could not confirm McBride and Turner regard- 
ing the flattening of the epithelium. A simple hypertrophy of 
the adenoid tissue was found in all (fifty) cases. There were no 
sclerotic areas, but numerous hemorrhages and cysts. In two 
tubercular changes were present; one of these caused tubercle 
in the guinea-pig. GRADENIGO. 

349. Lewin places the following questions: 1. With due re- 
gard to all the circumstances which govern the relationship of a 
process to tuberculosis, how often does tuberculosis hide itself 
under hyperplasia of the pharyngeal tonsil? 2. By histological 
examination of pharyngeal tonsils, removed post-mortem from 
phthisical subjects, how often are they tubercular? These are the 
conclusions: 1. In our experience tuberculous foci are present in 




















236 A. Hartmann. 


about 5 per cent. of cases of hyperplastic pharyngeal tonsils, 2, 
The tuberculosis is in the so-called tumor form of mucous mem. 
brane tubercle ; it is characterized by the absence of all externally 
recognizable marks, the so-called latent tuberculosis of the tonsils, 
3. This latent tuberculosis may be the first and only localization 
of tuberculosis in the patient. 4. It is usually associated with 
tuberculosis elsewhere, especially of the lungs, which may not be 
manifest at the time of operation. 5. It is a comparatively fre- 
quent condition in pulmonary tuberculosis. 6, It may attack 
normally large as well as hyperplastictonsils. 7. It is a relatively 
unimportant factor in the etiology of pharyngeal tonsillar hyper- 
trophy. 8. It can be definitely overcome by elimination of the 
tonsil even in simultaneous pulmonary affection. 
This very careful paper was written with the guidance of Pro- 
fessor Brieger. ZARNIKO. 
350. DE Simoni endeavors with theoretic reasonings to connect 
adenoidism and thyroidism. He regards adenoidism and myxe- 
dema as belonging to the same disease, from analogy of clinical 
symptoms of those possessing adenoids and of the weak-minded 
myxomatous, the presence of adenoids in the latter, and the great 
frequency of adenoid vegetations where cretinism is endemic. 
GRADENIGO. 
351. A farmer, thirty years of age, had his nose completely 
filled with grayish-red, soft, bleeding polypi. The buccal and 
pharyngeal cavities were occupied by a hard, fleshy mass starting 
from the base of the sphenoid. The tumor on examination 
proved to be a soft angio-fibroma. The growth was removed by 
electrolysis in a course of treatment lasting seventy-three days. 
No relapse after eight months. SACHER. 
352. A man, now aged twenty-eight, had a fibrous tumor of 
the naso-pharynx as a boy of thirteen years. INGALS had then 
removed the tumor except some part attached to the vertical 
plate of the palate bone. It began afresh to crowd out beneath 
the zygomatic arch. An attempt at radical removal through an 
outer incision in the cheek from mouth to ear had to be abandoned 
owing to profuse hemorrhage. The growth then continued to grow 
for about a year, completely closing the right nasal cavity and de- 
stroying the sight of the right eye. The tumor then remained 
stationary for many months, but the patient began in a couple 
of months to breathe a little through the nose. From now on he 
steadily improved, until after several years the nasal cavity ap- 














Progress of Otology. 237 


peared perfectly free and the right cheek had grown smaller. The 
right eye appears normal, but is blind. The fibrous growth has 
disappeared. The right nasal cavity is an inch wide, the septum 
is pushed aside, and the turbinates are destroyed. There is a 
large opening in the sphenoid cells. M. TOEPLITZ. 


SOFT PALATE, PHARYNX, AND BUCCAL CAVITY. 








352. COUVELAIRE and Crouzon. Movements of the soft 
palate. Transactions of the Biological Society. Le progres 
médical, Dec. 2, 1899. 

353. Masini, G. Have the tonsils an internal secretion? 
Ann. des mal, de l’or., du lar., No. 7, 1899. 

354. MAMLOK, A case of primary malignant lymphoma of 
the tonsil. Arch. f. Laryng., vol. ix. 

355. Lyanz. The treatment of mercurial stomatitis. JMedi- 
cinskoje Obosrenje, Jan., 1899. 

356. GOLDSCHMIDT, The smooth atrophy of the root of the 
tongue in tertiary syphilis. Ber?. klin. Wochenschr., No. 43, 1899. 

357. L.A. The treatment of angina and diphtheria in Celius 
Aurelianus. Miinch. med. Wochenschr., No. 47, 1899. 

358. SIEGERT. On an epidemic of lacunar angina and its 
period of incubation. Minch. med. Wochenschr., No. 47, 1899. 

359. Mayer, Emit. The tonsils as portals of infection. 
Four. Am. Med. Assoc., Dec. 28, 1899. 

360. GoopaLe, J. L. Acute suppurative processes in the 
faucial tonsils. WV. Y. Med. Four., Oct. 7, 1899. 

361. LeLtanp, Geo. A. Tonsillar and circumtonsillar ab- 
scess. WV. Y. Med. Four., Oct. 7, 1899. 

362. HusBBARD, Tuomas. Peritonsillar abscess associated 
with diphtheria. MW. Y. Med. Four., Oct. 14, 1899. 

363. Warp, M. R. Septic thrombo-phlebitis as a complica- 
tion of peritonsillar abscess. MV. Y. Med. Four., Oct. 14, 1899. 

364. Watson, ARTHUR W. Accessory thyroid gland at the 
base of the tongue. WV. Y. Med. Four., Oct. 21, 1899. 

365. InGaAs, E. FLercHer. Fibro-lipomatous tumor of the 
epiglottis and pharynx. JV. Y. Med. Four., Dec. 9, 1899. 

396. McReyNnotps, Joun, Chronic recurring membranous 
pharyngitis, Sour. Am. Med. Assoc., Dec. 2, 1899. 

















a nena te pene 


ct WAl FAA, «aes 





238 A. Hartmann. 


367. Gace, Geo. C. Some of the dangers of acute pharyn- 
geal abscess obviated by the use of a new trocar. WV. Y. Med, 
F our., Dec. 16, 1899. 

368. Hopkins, F. E. Recurrence of the tonsil after excision, 
N.Y. Med. Four., Dec. 2, 1899. 

369. Musson, Emma E. Infective granulomata of the phar- 
ynx; glanders. Four. Am. Med. Assoc., Nov. 25, 1899. 


352a. The movements of the soft palate were observed in a 
man with a large defect in the orbital and nasal regions following 
an operation for carcinoma. 1. During inspiration with closed 
mouth the velum is slightly raised. 2. The palate also moves 
conjointly with the pharyngeal wall, whereby the naso-pharynx is 
shut off. This consists of (a) a raising of the soft palate to not quite 
the horizontal, or beyond the horizontal (incomplete or complete 
closure) ; (4) an advancing of the posterior pharyngeal wall which 
approaches the soft palate; the posterior median line and the 
upper wall of the pharynx remain immovable ; (c) a protrusion of 
the salpingo-pharyngeal plica, forming upper and posterior sup- 
porting columns forthe velum. The closure of the naso-pharynx 
is complete during swallowing, sucking, expiratory pressure in 
blowing and whistling ; an incomplete closure takes place during 
coughing. During phonation, the degree of closure varies : (a) in 
pronouncing vowels, the closure increases from a to ¢, from ¢ to 0 
and to a, and from w to; (4) in pronouncing the consonants, the 
closure varies according to the accompanying vowels ; (c) for the 


consonants m and z the closure is very incomplete. 
SCHWENDT. 


353. The tonsils of dogs and calves were removed and ex- 
tracts made with water or glycerine which was injected into the 
auricular vein of the rabbit. The exposed heart and the femoral 
vein then showed for some time a distinct slowing and strengthen- 
ing of the heart activity. This action did not take place when 
the tonsils had been chronically or congenitally hypertrophied. 
Masini regards the tonsils as internal secreting organs. 


ZIMMERMANN. 
354. A very careful analysis of a typical case of this rare 
condition. ZARNIKO. 


355. LJANz discusses the prevention of mercurial stomatitis 
and speaks of a number of tooth pastes and soaps. The best 
remedy for stomatitis is hydrogen peroxide (8-10 per cent) ; it 
is non-toxic, non-irritating, and very germicidal. The author 











Progress of Otology. 239 





prescribes a 2 per cent. gargle. In large and many ulcers he 
employs iodoform in powder or ethereal solution. SACHER. 
356. After an examination of two hundred cases of syphilis, 
GOLDSCHMIDT concludes that the smooth atrophy of the base of 
the tongue is not clinically a pathognomonic sign of tertiary syphi- 
lis, as it may be present in other conditions, either combined with 
a poor development of the tongue in general or when the rest of 
the tongue is well developed. MOLLER. 
357. An interesting historical paper by an anonymous writer. 
AURELIANUS possessed a long list of therapeutic measures, in- 
cluding intubation, of which he personally was not in favor. 
SCHEIBE. 
358. The period of incubation is four days. The patient 
should be isolated, and the brothers and sisters should not be 
allowed to attend school until the fifth day has passed without 
infection. SCHEIBE. 
359. After an elaborate review of the published cases, in 
which an angina was followed by articular rheumatism, severe 
general infections, metastatic abscesses, angina pectoris, broncho- 
pneumonia, and other affections, MAYER narrates a case of his 
own observation in a young man et. nineteen, who twenty-four 
days after an attack of acute follicular tonsillitis was seized with 
syncope and vomiting. After the endocarditic murmur had be- 
come fainter, symptoms of hemichorea of the right side, and finally 
also of the laryngeal muscles, developed, from which the patient 
completely recovered. M. TOEPLITZ. 
360. Eight cases of. acute amygdalitis with intrafollicular foci 
of suppuration showed : 1, the streptococcus more abundant than 
the staphylococcus, where the foci were numerous; 2, the foci 
in two cases with, in six cases without circumtonsillar inflamma- 
tion ; 3, the foci clinically to represent a severe infection ; 4, no 
clinical signs by which the abscesses could be diagnosticated ; 5, 
histologically : a, the foci to vary in size, number, and location ; 
6, the fibrinous exudate in the crypts quite marked; ¢, in the 
cases with peritonsillar abscess, the connective-tissue spaces 
crowded with polynuclear neutrophiles. The conclusion may 
hypothetically be arrived at, that the pyogenic infection of the 
follicles is secondary to a previous infection of the crypts by the 
staphylococcus pyogenes. M. TOEPLITZ. 
361. LeLanp used for opening tonsillar and circumtonsillar 
abscesses the sickle knife, cutting lengthwise through the tonsil, 














240 A. Hartmann. 


and introduces his sterilized index finger into the incision, thereby 
breaking up the diseased tissue in and around the tonsil. The 
abscess is thus found much quicker than by other methods, and the 
duration of the affection is much shortened, as is well illustrated 
by the reported cases. In some instances the deep-seated abscess 
had to be opened on the following day with the probe-pointed 
knife. M. ToEPLitz. 
362. Case 1: a farmer, et. thirty, had, after an acute amygda- 
litis, his right tonsil incised and pus evacuated. The next day 
both tonsils and pharynx were found to be covered with false mem- 
branes. Thirty-five hundred units of antitoxine did not prevent 
the membranes from invading the naso-pharynx, nares, and larynx, 
On the sixth day laryngeal stridor and extreme dyspncea, puru- 
lent discharge from the throat, and ichorous flow from the nares 
ensued, associated with extreme swelling of the anterior cervical 
region suggestive of phlegmon. Tracheotomy was performed. 
The patient died after eighteen hours. The wife and two chil- 
dren also had diphtheria, but recovered. Case 2: the eldest son 
of a large family had sore throat, two young children mild amyg- 
dalitis, a younger daughter typical diphtheria; another had 
quinsy. About four days later the one was moribund from diph- 
theritic toxemia and the other had a large peritonsillar abscess 
with pseudo-membrane. ‘The abscess was incised and much pus 
evacuated. M. TOEPLITZz. 
363. Warp adds to three cases collected from literature two 
of his own observation. Case 1: a woman, et. thirty, felt at first 
pain in the left tonsil, and after three days presented a swelling 
of the right tonsil and marked tumefaction of the right side of the 
neck with chilly sensation. The tumefaction extended from the 
angle of the jaw down to the clavicle. Then pain in the right side 
of the chest, cough, expectoration tinged with blood, diarrhcea, 
vomiting, enlargement of spleen, and severe chills appeared. 
Incisions of the tumefaction and tonsils evacuated pus. Death 
ensued on the ninth day. The autopsy revealed thrombosis and 
thrombo-phlebitis of the internal jugular and the veins leading 
upward to the tonsillar plexus, a metastatic abscess in the middle 
lobe of the right lung, other foci in the apex and base, and great 
enlargement of the spleen. Case 27 a man, zt. forty-two, had, 
after opening of a left peritonsillar abscess, increased swelling of 
the left tonsillar region and the tissues of the neck resembling a 
cellulitis, Death followed soon. The autopsy showed a thrombo- 














Progress of Otology. 241 


sis and thrombo-phlebitis of the internal jugular and multiple 
small abscesses of the kidneys. M. ToeEpuirz. 

364. WATSON reports two cases of accessory thyroid glands at 
the base of the tongue. The first occurred in a woman, aged 
fifty, and occupied the lingual base from the epiglottis to the 
papille circumvallate, being an inch and a half long, an inch 
wide, and an inch thick ; the second case was seen in a colored 
girl, et. sixteen, who had felt the lumps for five years in her 
throat. It looked like the first case except for its ulceration. 
The diagnosis was made in both cases by the microscope. 

M. TOEPLITZ. 

365. INGALS’s patient, zt. twenty-eight, had difficulty in speak- 
ing, swallowing, and breathing, particularly in a recumbent pos- 
ture. A smooth tumor filled the laryngo-pharynx, leaving only a 
small chink about a quarter of an inch wide at the left side. 
Stout steel wire, passed through a uterine ecraseur, succeeded in 
cutting it off in four pieces of 14: 1, $: 4, 1}: § and $ inches re- 
spectively. The tumor had been attached to the upper portion 
of the right side of the epiglottis, to the right pharyngo-epiglottic 
fold, to a part of the base of the tongue, and to the right side of 
the pharynx. The first removed mass was a typical fibroma, an- 
other a fibro-lipoma, and the last large mass a lipoma. The 
right side of the epiglottis became adherent to the pharynx and to 
the base of the tongue without preventing deglutition. 

M. TOEPLITZ. 

366. The patient, a female, et. nineteen, presented a mem- 
brane remaining one or two days when it spontaneously disap- 
pears, leaving the throat in apparently healthy condition, always 
covering the soft palate, sometimes also the centre pharynx, being 
pearly-white, with pin-hole perforations, recurring two or three 
times a week when not treated. It contained no diphtheria bacilli 
and no fungi. ' M. ToeEptitz. 

367. The point of the trocar is cone-shaped and a guard fer- 
rule is placed half an inch from the point. The curve of the 
trocar adapts itself to the shape of the tongue. A Y-shaped tube 
is connected with the trocar through one limb, the other ending 
in a rubber bulb, while to the stem a glass bulb is attached, which 
also ends in a rubber tube closed with a clamp. If the flow of 
the pus is too thick, the clamp is closed and the rubber bulb when 
squeezed produces suction. If the flow is thin, the trocar can be 
used without the tubing. M. TOEPLITZ. 














242 A. Hartmann. 


368. Hopkins adds to one case of his own observation occur- 
ring in a girl zt. thirteen, in whom one tonsil had recurred four 
months after excision, the views of many authors widely differing 
as to the cause and frequency of recurrence, the smallest number 
being observed by laryngologists. M. Toep.itz. 

369. A woman, et. fifty-six, presented rapid enlargement of 
the tonsils; she lost flesh, but had extreme fulness of the neck, 
beginning at each side of the angle of the jaw, giving it a pouched 
appearance. Apart from the large tonsillar masses, a soft growth 
of the size of a black walnut filled the left half of the naso-phar- 
ynx, and lingual masses were seen in the glosso-epiglottic space. 
Removed portion of the left soft and friable tonsil was supposed 
to be a sarcoma. After radical removal of the masses improve- 
ment took place. In April, 1895, a year and a half after the 
operation, the lingual masses had increased, the faucial ones 
had also returned, and the vault had filled up again, also on the 
right side. In December, 1895, the diagnosis of glanders was 
made with the microscope. On March 17, 1896, the fauces and 
naso-pharynx were thoroughly cleared from the masses, where- 
upon the patient improved. Inoculations of six guinea-pigs pro- 
duced orchitis and intestinal lesions covered with bacilli mallei. 


On March 27, 1896, intestinal disorders took place. The phar- 
ynx appeared well in June, but the patient died in September. 
No autopsy was held. M. TOEPLITZ. 














BOOK REVIEWS. 


VII. Lecons sur les suppurations de!’ oreille moyenne 
et des cavités accessoires des fosses nasales et leurs 
complications intra craniennes. By Dr. Henry Luc, ancien 
interne des hépitaux de Paris. Octavo-volume of 500 pages, 
with 28 figures in the text. Paris: J.-B. Bailliére et fils, rg00. 

The author publishes, in 26 lecons, the lectures he delivered at 
his clinique in Paris. 

The first lecture gives a general view of the topography 
of the accessory cavities, their connections with the naso- 
pharynx, and their contiguity to the cranial cavity to which their 
suppurations frequently extend. He mentions the unique case 
of Westermayer, where even an empyema of the maxillary antrum, 
the latter alone being at some distance from the skull, after per- 
foration of the upper posterior wall entered the skull through the 
upper part of the pterygo-maxillary fossa. He speaks of the 
transmission of the infection from one sinus to the other, of 
the lining membranes, the pyogenic microbes, and the diagnosis 
of the empyemas where the old objective signs (swelling, redness 
of the integument, pressure sensibility, escape of pus) had been 
essentially supplemented by the electric illumination through 
mouth, nose, and upper-inner corner of the orbit. 

The next two lectures are devoted to acute middle-ear suppuration, 
of which the author gives an excellent description. We mention 
some points. He says: “I cannot well imagine that an 
acute suppurative otitis exists without a certain degree of con- 
comitant antritis, but we should not speak of mastoiditis before 
the suppuration has spread into the mastoid ce//s” (p. 16). He 
emphasizes the grave signs otitis produces in small children, 
which fact, “ perhaps, is explained by the more intimate circula- 
tory connection between the ear and brain in the child ” (p. 20). 
As to the terminations, he distinguishes six kinds : recovery ; re- 


243 



















































244 Book Reviews. 


covery with diminution of hearing ; recovery with persistent per- 

foration of the drum membrane; with mastoid complication ; 
with intracranial infection; transition into the chronic state 
(p. 25). 

The variations of this, the typical clinical picture, may be 
designated by prominent symptoms, and their etiology, as the 
grippe form, by its tendency to mastoid and intracranial complica- 
tions ; the acute mecrosing form in the infectious diseases, scarlet 
fever, diphtheria, typhoid fever, measles ; further, the peculiar 
course when erysipelas develops in an ear with ordinary otitis 
purulenta, during the regular course of which at once are noticed 
long and marked chills, temperature 105° F., later falling to the 
normal, these attacks repeating themselves for the next days, until 
the characteristic elevated border of the erysipelas ambulans shows 
that pyzmia is not the cause of these rapid changes. Zwuderculosis 
(lack of pain), syphz/is (inordinate degree of deafness by labyrinth 
complications), and diabetes (tendency to extensive destruction of 
bone in mastoid and surroundings) are discussed. 

The treatment does not contain anything new. Early large 
paracentesis, removal of the pus by inflation (catheter or Politzer), 
drainage by the introduction of thin, round, long wicks of 
absorbent cotton or gauze, touching or even a little entering the 
perforation in the drum-head (Loewe). The wound should be 
dressed or cleansed at least once daily, the ear inflated, the 
meatus mopped out with absorbent cotton, then a few drops of 
carbolic acid 1 part, to glycerine 15 parts, instilled, and a drainage 
wick of gauze introduced again. The glycerine-carbolic-acid 
wash acting as an antiseptic and analgesic, favors the escape of the 
secretion by mixing with and diluting the pus. When the period 
of pain is over, this treatment is replaced by peroxide of hydro- 
gen and insufflation of boric acid powder. The cleansing with a 
syringe is to be substituted for the above dressing, if the patient 
cannot be dressed by the physician every day. He recommends 

caution in its use. We would say that the chief remedy in a case 
of acute otitis media is rest in bed. This disease is important 
and requires care and nursing. Forcible inflation of the ear 
before or after the paracentesis should be omitted, just as in- 
jections, for we have seen aggravation of the disease follow their 
use immediately. The inflations are proper when the active in- 
flammation is passed. We have no experience with the carbolic- 
acid glycerine drops; we depend chiefly on paracentesis, dry 














Book Reviews. 245 


treatment, rest in bed, and patience until the full recovery is 
obtained, for relapses and dangerous complications are rife. 

The next subject which the author takes up and describes in 
full detail is acute and chronic mastoiditis (55 pages). He empha- 
sizes the variations of the structure of the mastoid as determining 
to a great degree the clinical picture. The etiology, symptoma- 
tology, and treatment are well presented, particularly the opening 
of the mastoid. He devotes a full lecture to the Bezold mas- 
toiditis, which the peculiar features and the gravity of this variety 
fully deserve. 

Lectures VII.-X. treat of chronic suppurative middle-ear inflam- 
mation (70 pages). The first lecture consists in general remarks 
on the disease, its causes, otoscopic condition (perforations of 
membr. tymp., small or large, the importance of their location, 
the aspect of the “ fundus of the ear,” the mucous membrane, con- 
gestive swelling, thickening, fungosities, granulations, and polypi, 
and their histology), epidermization, cicatrices, changes in the 
ossicles, etc. In the symptomatology he describes also the manner 
of examining the ear, its cleansing (Hartmann’s tympanum 
syringe), and the significance of the substances which are re- 
moved, for instance those from the attic by the variable prognosis 
of facial paralysis and the acuteness of hearing, and the value of 
the exploration with the straight and bent probes. To judge how 
much importance as to prognosis and indications is to be laid on 
the different conditions found by a thorough examination, he 
describes them in five progressive types. 

Lecture X., the suppuration of “Shrapnell’s cavity.” The 
author describes the attic, adopting the views of Schmiegelow as 
published in the Zeitschrift fur Ohrhke., 1891, and the English 
edition, these ARCHIVES, xx., p. 228-256. The various important 
conditions, caries, necrosis, granulations, polypi, and cholestea- 
toma, found in this small and intricate cavity are well set forth, and 
their treatment, up to ossiculectomy and removal of all carious 
and necrosed portions of the osseous walls, is dwelt upon. 

The next three lectures are devoted to the consideration of 
chronic mastoiditis, 36 pages. The cases known as latent mas- 
toiditis (no fistula, etc.) require careful examination of the tym- 
panic cavity and its recesses, and judicious appreciation of the 
subjective and objective symptoms in the course of the affection, 
facial paralysis, etc. Deep, intense, constant pain, varying in in- 
tensity, and mostly pressure sensibility in a particular point, 











246 Book Reviews. 


mostly at the base, are the only signs preliminary to an intra- 
cranial complication. 

The so-called radical operation, the opening of all the cavities 
of the ear, is described ; first Stacke’s, then Zaufal’s method. The 
descriptions are very clear, and the propositions well considered. 

Cholesteatoma occupies a full lecture. ‘The diversity of opinion 
on this remarkable formation is set forth at great length. The 
subject is practically very important. 

Lectures XIV.-XIX. treat of the empyemas of the accessory 
sinuses (141 pages). 

The maxillary sinus receives 47 pages ; the descriptions are very 
elaborate. He says an exact diagnosis begins with the cultivation 
of rhinology in modern times. ‘The sign of Heryng (of Warsaw), 
shown first at the congress of Paris in 1889, namely, the trans- 
lumination,’ has assisted materially in the diagnosis of all the 
sinuses. It has been extended by Vohsen, Davidson, and others. 
Luc describes in full detail, and with a certain degree of enthu- 
siasm, his way of curing chronic maxillary empyema; he calls it 
La méthode opératoire Caldwell-Luc, because Dr. Geo. W. Cald- 
well, of New York, has published essentially the same operation 
before him (Mew York Med. Jour., Nov. 4, 1893), of which the 
author heard only a year ago. The technique is as follows: 
1. Incision of the mucous membrane of the mouth in the canine 
fossa in a horizontal line. 2. Chiselling through the bone hori- 
zontally at the level of the molar teeth as far as the angle between 
the lower and nasal walls. 3. Cleaning out the sinus with bent 
spoons. 4. Formation of an artificial hiatus in the nasal wall. 
5. Establishing drainage into the nose. 6. Suturing the wound 
in the mouth. He has done this operation many times, and his 
colleagues in Paris have adopted it. The results have been rapid 
and permanent, exceedingly satisfactory recoveries. We cannot 
enter into further details, but have received the best impression 
from reading the description of the method and the accounts of 
recovery given by the author. 

The frontal-sinus empyema is discussed at length, its simulta- 
neous existence with ethmoidal and maxillary empyemas is em- 
phasized, and, in chronic cases, the operation by removal of the 
anterior osseous wall recommended. He considers critically the 





1 We leave the French word ‘‘translumination” (Durchleuchtung in Ger- 
man), which is, perhaps, as good or better than the customary word, ‘*‘ trans- 
illumination,” of English writers. 














Book Reviews. 247 


different methods. In rebellious cases, he says, a German sur- 
geon, G. Diint,’ has proposed the total resection of the anterior 
wall. The author might have mentioned the osteoplastic opera- 
tion of Czerny (Heidelberg) and Golovin (Moscow), and the bold 
and very excellent method of Jansen (Berlin). Jansen detaches 
the skin and periosteum along the inner corner and upper margin 
of the eyelid, together with the uncut pulley of the tendon of the 
superior oblique muscle of the eye, removes the lower bony wall 
of the sinus and all diseased bone, not only in the walls of the 
frontal sinus, but of the adjacent ethmoidal cells. The reviewer 
has seen the most surprisingly good results of this operation done 
in New York, and has adopted it himself. 

The reviewer, greatly interested in Dr. Luc’s monograph, has 
given his pen more scope than is usual in book reviews. He has 
to be brief with the remainder of the work. The empyemas of 
the ethmoidal and sphenoidal sinuses are described with the same 
care and judgment as the preceding subjects, which shows that 
the author is less of an “ autodidacte”’ than he alleges to be in the 
preface of his book. He shows that he is fairly familiar with the 
literature of his subject, in particular the German, less perhaps 
than he should be with the English, but he is fully at home among 
the host of important diseases which form the subject-matter of 
his lectures. This can particularly be said of the last part of 
the work : the intracranial complications of the suppurative 
diseases of the middle ear and the accessory cavities of the nose. 

The subjects of the remaining seven lectures are as follows: 
Mechanism and propagation of intracranial infection. Extra- 
dural abscess. Sinus thrombosis. Pyzmia without sinus-throm- 
bosis. Brain abscess. Leptomeningitis. Further, a supplementary 
lecture on the ophthalmoscopic diagnosis of the cerebral compli- 
cations of the sinusites, by Dr. Valude, of Paris. 

The presentation of this last part of the book is in keeping with 
the preceding. ‘The style of the book is clear and easy. It will 
introduce the student thoroughly into this important and essen- 
tially modern branch of medicine and surgery, and delight the 
adept by walking pleasantly over a familiar field in which the 
author points out to him many view-points the beauty and signifi- 
cance of which he probably did not appreciate before. H. K. 





' The reviewer does not know this name: perhaps it is a typographical error 
for Kuhnt, Professor of Ophthalmology in Koenigsberg, who published, about 
three years ago, an excellent monograph on Frontal-Sinus Empyema. 











248 Appointments. 


VIII. A Treatise on Nasal Suppuration. By Dr: L. 
GRUNWALD (Munich). ‘Translated from the second German 
edition by Wi.t1aAM Lamp, M.D., etc., Birmingham. Published 
by William Wood & Co., New York. Pp. 335. Price, $3. 

The importance of affections of the accessory sinuses has of 
late years been more and more appreciated. The knowledge of 
this chapter of rhinology received its foundation by more exact 
and careful anatomical and pathological investigations. The 
clinical aspect has been furthered especially by Griinwald. Die 
Naseneiterungen of this author was the first—and until recently 
the only—book giving a detailed description of these affections. 
Its excellence and deserved popularity are well known. Its inac- 
cessibility to those not conversant with German has now been 
removed by the appearance of Dr. Lamb’s translation. 

The localized or focal suppurations of the nose and its acces- 
sory cavities are treated in a general and ina special part. In 
the former, the etiology, morbid anatomy, symptomatology, 
methods of examination, therapeutics, and prognosis are discussed 
in general. In the second part, the suppurations are taken up sep- 
arately, and the special features in each variety are dwelt upon. 
The subject-matter is illustrated by case histories from the author's 
practice, and frequently by a critical review of the cases published 
by others bearing on the subject in question. The methods of 
treatment are described in an especially lucid and practical man- 
ner. The relation of syphilis to nasal suppuration and a very 
brief chapter on tuberculosis are added in an appendix. A com- 
plete bibliography up to the year 1896 (the date of the last 
German edition) concludes the volume. 

The work of the translator has been extremely well done. Dr. 
Griinwald’s very vigorous and interesting style seems not to have 
lost force in the translation. As far as the book itself is con- 
cerned, it is excellently gotten up and quite surpasses the German 
original. We are sure that in its enlarged field of activity this 
book will continue to instruct, and stimulate investigation, in 
this very interesting field of nasal surgery. A. K. 





APPOINTMENTS. 


New York Potycuinic: Drs. Francis J. Quinlan and R. C. 
Myles have been elected Professors of Laryngology and Rhinol- 
ogy at the New York Polyclinic. 














Society Meetings. 249 


SOCIETY MEETINGS. 


The Western Ophthalmological and Oto-Laryngological Society 
elected, at their last meeting, April 5-7, 1900, at St. Louis, Mo. : 
Dr. M. A. Goldstein, of St. Louis, President; Dr. H. V. Wuerde- 
mann, of Milwaukee, First Vice-President ; Dr. C. R. Holmes, of 
Cincinnati, Second Vice-President; Dr. Fayette C. Ewing, of St. 
Louis, Third Vice-President ; Dr. W. L. Ballenger, of 100 State 
Street, Chicago, Secretary. The place and time of the next meet- 
ing will be Cincinnati, O., April 11-12, rgor. 


We are glad to publish the following notice in compliance with 
the request of the editors of the fournal of Laryngology, Rhinol- 
ogy, and Otology : 

“An Appendix to the /nternational Directory of Laryngologists 
and Otologists, compiled by Mr. Richard Lake, is in course of prep- 
aration. In it will be found corrections of names and addresses 
already given, an additional list of names and addresses received 
since publication, and an obituary list. 

“ , . Considerable additions have been obtained for the 
foreign list, which will materially add to its value and complete- 
ness. The decision of the editors of the fournal of Laryngology, 
Rhinology, and Otology, under whose auspices the Directory is pub- 
lished, to allow no name to be inserted in the British list for 
which sanction has not been given in writing, at once explains 
some omissions and criticisms. The editors, whilst desirous of 
making the Directory as complete as possible, consider it best to 
adhere to this course. It is therefore hoped that all engaged in 
the practice of Laryngology, Rhinology, and Otology will assist 
as far as possible in making this useful work complete,” by send- 
ing in their names and addresses to the editor, /nternational Di- 
rectory of Laryngologists and Otologtists, 129 Shaftesbury Avenue, 
W. C., London. 








Leitschrift fur Ohrenheilhunde XXX 


Die Tonstrecken der Taubstummen 1893 und 1896. 
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