OF THE 
 
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 Name of Book and Volume, 
 
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 j University of cdiioi aia. 
 
 THE rvlEDICAL LIBRARY 
 
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 ■ Of San Francisco. 
 
 PRESENTED BY MES. AND MISS FOURGEAUD. 
 ri:intf tiiv. is:.;. 
 
THE 
 
 DISEASES OF THE EAR. 
 
THE 
 
 DISEASES OF THE EAR: 
 
 NATURE, DIAGNOSIS, AND TREATMENT. 
 
 JOSEPH TOYNBEE, F.R.S., 
 
 FELLOW OF THE ROYAL COLLEGE OP SURGEONS OF ENGLAND; AURAL SURGEON Tu, 
 AND LECTURER ON AURAL SURGERY AT, ST. MARY'S HOSPITAL; AURAL SUR- 
 GEON TO THE ASYLUM FOR IDIOTS ; CONSULTING AURAL SURGEON TO 
 THE ASYLUM FOR THE DEAF AND DUMB; AND CONSULTING 
 SURGEON TO THE ST. GEORGE'S AND ST. JAMES'S 
 GENERAL DISPENSARY, LONDON. 
 
 AVITH ONE HUNDEED ENGRAVINGS ON WOOD. 
 
 PHILADELPHIA: 
 
 BLANCHARD AND LEA. 
 
 186 0. 
 
^ 
 
 
 C. SHERMAK A SON, PRINTERS, 
 Corner SerentU and Cherry Streets, Philadelphia. 
 
y- 
 
 I 
 
 THIS VOLUME IS DEDICATED 
 
 TO THE 
 
 (Sobcrnors of St. Ularg's Daspital $011^011, 
 
 WHO, BY ESTABLISHING AURAL SURGERY AS A DISTINCT DEPARTMENT 
 
 OF STUDY IN THEIR HOSPITAL AND MEDICAL SCHOOL, 
 
 EVINCED A DESIRE TO 
 
 ELEVATE THE SUBJECT OF DISEASES OF THE EAR TO ITS DUE POSITION, 
 
 AS A BRANCH OF PROFESSIONAL KNOWLEDGE 
 
 BASED UPON CLINICAL OBSERVATION AND SCIENTIFIC RESEARCH. 
 
PREFACE. 
 
 Ix preparing the i^resent work, it has been my aim to 
 produce a practical treatise on the Diseases of the Ear, 
 having for its foundation the anatomy, physiology, and 
 pathology of the organ. This volume, however, does not 
 profess to give a complete description of the structure and 
 functions of the Ear: it will be perceived that the domains 
 of anatomy and physiology have only been entered upon 
 when requisite for the elucidation of the pathology or treat- 
 ment. 
 
 And now, after twenty years' labor, seeing this volume 
 complete, I cannot but regret that it is not more worthy of 
 its subject, and of the inteUigence of the Medical Profes- 
 sion, to which it is addressed. It only remains for me to 
 continue to devote myself to my labors. And thus, while I 
 sincerely thank the numerous members of the Profession for 
 their generous assistance, in supplying me with the larger 
 part of the means of research which I have enjoyed, I beg 
 stiU further to solicit their aid. Long engaged upon another 
 work, in the shape of " lUustrations of the Pathology of the 
 Ear," for which I possess a large amount of material, I 
 nevertheless require much more. Indeed, even since this 
 
Vlll PREFACE. 
 
 volume has been passing through the press, two recent spe- 
 cimens, received from medical men in the country, have 
 elucidated two entire series of preparations in my Museum.^ 
 
 I need scarcely draw attention to the beautiful illustra- 
 tions in this volume, which, with two or three exceptions, 
 were drawn from nature, on wood, by Mr. Ford. 
 
 Few references having been made in the body of this 
 volume, to the investigations on wliic^i it is founded, I have 
 given, in an Appendix, a list of my published papers, to- 
 gether with their dates, so that the reader may refer to them 
 when he thinks it desirable to do so. 
 
 * It always affords nie much pleasure to show my Museum to medical men. 
 18 Savile Row, January 20, 1S60. 
 
CONTENTS. 
 
 CHAPTER I. 
 
 INTRODUCTION. 
 
 PAGB 
 
 Neglect of the study of the morbid anatomy of the ear, the cause of our igno- 
 rance of aural surgery — Mode of investigating the diseases of the ear 
 — Method of dissecting the ear, ........ 33 
 
 CHAPTER 11. 
 
 THE EXTERNAL EAR. 
 
 Anatomical observations — Use of the external ear — Effect of the removal of 
 the external ear (case) — Pathological observations — Malformations of the 
 external ear, with absence of the external meatus (cases) — Supernu- 
 merary ears — Inflammatory diseases — Chronic erysipelas — Chronic ec- 
 zema — Cysts — Tumors — Deposits — Malignant disease, .... 42 
 
 CHAPTER III. 
 THE EXTERNAL MEATUS. 
 
 ITS EXPLORATION. 
 
 Anatomical observations — Osseous meatus — Membranous meatus — Objects 
 in exploring the meatus — Means of exploration — Lamps — Speculum — 
 Mode of exploration, .......... 57 
 
 CHAPTER IV. 
 THE EXTERNAL MEATUS {continued). 
 
 ON FOREIGN BODIES AND ACCUMULATIONS OF CERUMEN IN THE MEATUS. 
 
 Foreign bodies in the meatus — Mode of removal — Cases — Ceruminous glands 
 — Their diseases — Accumulations of cerumen — Their causes — Table of 
 two hundred cases in which cerumen was removed — Symptoms — Effects 
 — Treatment — Mode of removal — The syringe and its use — Cases, . GS 
 
X CONTENTS. 
 
 CHAPTER V. 
 
 THE EXTERNAL MEATUS {conilnued). 
 
 THE DERMIS AND ITS DISEASES. 
 
 PAGE 
 
 1. Acute inflammation : — a, Acute inflammation confined to the dermis — 
 
 Treatment — Cases. 6, Acute inflammation extending to the brain and 
 its membranes — Treatment — Cases. 
 
 2. Chronic inflammation : a, Chronic inflammation with hypertrophy and ac- 
 
 cumulation of epidermis — Treatment — Cases, b, Chronic catarrhal in- 
 flammation — Treatment — Cases. c, Chronic catarrhal inflammation, 
 extending to the bone and to the brain — Treatment — Cases, d, Ulcera- 
 tion, ............. 88 
 
 CHAPTER VI. 
 
 THE EXTERNAL MEATUS {continned). 
 
 POLYPI. 
 
 Causes of polypus — Symptoms — Three species of polypus : 1. The cellular 
 raspberry polypus — Structure — Treatment with potassa cum calce — 
 Cases — Treatment by removal with the lever-ring forceps — Cases. 2. 
 The fibro-gelatinous polypus — Structure — Treatment — Cases. 3. The 
 globular cellular polypus — Structure — Treatment — Cases, . . .111 
 
 CHAPTER VII. 
 THE EXTERNAL MEATUS {concluded). 
 
 TUMORS. 
 
 Osseous tumors — Structui-e — Two classes — Treatment — Cases — Molluscous 
 tumors — Structure — Effects on the bone — Treatment — Case — Conclusion 
 of the subject of the diseases of the external meatus — Tabular view of 
 the morbid conditions found in the meatus exteruus in 1013 dissections, 13G 
 
 CHAPTER VIII. 
 
 THE MEMBRANA TYMPANL 
 
 STUVCTURE AXD FUXCTIOXS. 
 
 The epidermoid layer — The dermoid layer — The fibrous layers : — The radiate 
 . fibrous lavcr — The circular fibrous layer — The mucous layer — Tensor liga- 
 ment — Functions of the membrana tympani, . . . . .151 
 
CONTENTS. XI 
 
 CHAPTER IX. 
 
 THE MEMBRANA TYMPANI {continued). 
 
 PAGE 
 
 The epidermoid layer — Dermoid layer — a, Acute inflammation — Treatment — 
 Cases, b, Chronic inflammation — Cases, c, Ulceration — Cases. Fibrous 
 laminae : a, Acute inflammation, b, Chronic inflammation, c, Ulceration. 
 d, Calcareous degeneration, e, Relaxation of the membrana tympani — 
 Treatment — Cases, 164 
 
 CHAPTER X. 
 
 THE MEMBRANA TYMPANI {concluded). 
 
 Perforation, causes — Physiological observations — Experiments previous to 
 the formation of an artificial membrana tympani — On the artificial 
 membrana tympani — The mode of applying it — Cases — Rupture of the 
 membrana tympani — Physiological observations — Pathological observa- 
 tions — Cases, . . ^ 18G 
 
 CHAPTER XL 
 
 THE EUSTACHIAN TUBE. 
 
 Anatomical observations — Physiological observations — Pathological observa- 
 tions — Seat of obstruction in the Eustachian tube: — 1, The faucial ori- 
 fice. 2, The tympanic orifice. 3, Middle part. — Causes of obstruction : 
 — 1, Thickened mucous membrane. 2, Relaxed mucous membrane, a, 
 Obstruction of the faucial orifice from thickened mucous membrane — 
 The exploration of the tube — The otoscope — Treatment — Use of the 
 Eustachian catheter and of the explorer — The excision of the tonsils — 
 Cases. &, Obstruction of the Eustachian tube at its faucial orifice from 
 relaxed mucous membrane — Symptoms — Treatment — Cases, c, Obstruc- 
 tion of the Eustachian tube at the tympanic orifice from thickened mucous 
 membrane — Symptoms — Treatment — On the operation of puncturing the 
 membrana tymj^ani. d, Obstruction of the middle part of the Eustachian 
 tube by mucus, by stricture, or by membranous bands, .... 213 
 
 CHAPTER XII. 
 
 THE CAVITY OF THE TYMPANUM. 
 
 Anatomical observations — Pathological observations — Diseases of the mucous 
 membrane : — a, Congestion. b, Acute inflammation — Affecting the 
 portio dura nei've — Extending to the brain — Scrofulous matter in the 
 tympanic cavity, c, Chronic inflammation. J, Chronic catarrhal inflam- 
 mation, e, Chronic catarrhal inflammation extending to the bone, dura 
 mater, or brain, yj Ulceration of the mucous membrane, . . . 248 
 
Ml CONTENTS. 
 
 CHAPTER XIII. 
 THE CAVITY OF THE TYMPANUM {concluded). 
 
 Page 
 a, Rigidity of the mucous membrane — Cause of deafness in advancing years — 
 Treatment — Cases, h, The formation of bands of adhesion, c, Anchy- 
 losis of the stapes to the fenestra ovalis — Pathological observations — 
 Treatment — Cases, d, Disconnection of the incus and stapes — Physiolo- 
 gical observations — Pathological ob.sf:rvations — Cases, .... 288 
 
 CHAPTER XIV. 
 
 THE MASTOID CELLS. 
 
 Anatomical observations — a, Diseases of the mastoid cells in childhoo^l — 
 Cases of the disease advancing to the bone and the cerebrum. 0, Diseases 
 of the mastoid cells in the adult — Acute inflammation of the mucous 
 membrane — Chronic inflammation of the mucous membrane — Purulent 
 infection — Symptoms of remittent fever — Caries of the lateral sulcus — 
 Abscess in the cerebellum, c, Necrosis of the mastoid process — Paralysis 
 of the portio dura nerve — Treatment — Opinion respecting life insurance 
 in cases of discharge from the ear, 321 
 
 CHAPTER XV. 
 
 THE DISEASES OF THE NERVOUS APPARATUS OF THE EAR, 
 PRODUCING WHAT IS USUALLY CALLED "NERVOUS DEAF- 
 NESS." 
 
 a. Diseases in which the ear alone is affected : — 1. From concussion — Three 
 modes — Blows on the ear — Loud sounds — Falls. 2. From the applica- 
 tion of cold — Cold air — Cold water. 3. From the effect of morbid poi- 
 sons — Rheumatic fever — Typhus fever — .Scarlet fever — Mumps — Gout. 
 
 h. Diseases in which the brain, as well as the ear, is affected : — 1. Mental 
 excitement — Over-study — Sorrow. 2. Bodily Debility — Want of sleep 
 — Accouchements — Over-exhaustion in hot climates — Fasting — Nen- 
 ralgia, ............. 367 
 
 CHAPTER XVI. 
 
 THE DISEASES OF THE NERVOUS APPARATUS {concluded). 
 
 Ulceration of the membranous labyrinth — Caries and necrosis of the petrous 
 
 bone, 392 
 
CONTENTS. Xm 
 
 CHAPTER XVII. 
 
 MALIGNANT DISEASE OP THE EAR. 
 
 PAGE 
 
 Origin in the mucous membrane of the tympanum — Destruction of the 
 petrous bone — Sometimes mistaken for polypus — Operations to be avoided 
 — Brain and dura mater involved — Treatment, 404 
 
 CHAPTER XVIII. 
 
 ON THE DEAF AND DUMB. 
 
 Diseases producing deaf-mutism — The condition of the ears in the deaf and 
 dumb, as ascertained by examination during life — The condition of the 
 ear in the deaf and dumb, as revealed by dissection — The mode of exami- 
 ning a child supposed to be deaf and dumb — On the medical treatment of 
 the ears of the deaf and dumb — The amount of hearing possessed by chil- 
 dren usually accounted deaf and dumb — On the education of the deaf and 
 dumb, with cases, 413 
 
 CHAPTER XIX. 
 EAR-TRUMPETS AND THEIR USE, 435 
 
 APPENDIX. 
 
 List of published papers on the Structure, Functions, and Diseases of the 
 Ear, 437 
 
LIST OF ILLUSTRATIONS. 
 
 1. Cvttiag Foreeie, 49 
 
 2. MalfonMdrigktSxtemlEaroraehiU, 4T 
 
 3. The i»di» ft» iy Memtas Aw dit ot ia a Bxteiwgof » AiM, ia the fiti^rf a fawre 
 
 pMtoior to the Coadjkid Tnxeas, 48 
 
 4. The Tjaqpaaie CkTitj, with the Baalachiaa tabe oprmimg iato its aaterior aad 
 
 jafieriar part, .41 
 
 3. Badtoeataiy Extoaal Eais . M 
 
 C. HcBatoede of the Ezteraal Ear (Wilde . M 
 
 7. TaMoroftheLobafefWlMe), ... 55 
 
 8. ArerticalsectiflBal'thefcft MeatasExtexaos, firABmiihoat iA«aE\i£, 57 
 
 9. The Oiifice of the Meatas Bxtciaas, Bhewiag it> onal ihape, .... 59 
 19. The Obbhms Meatas Bxtcfaas of aa ia&at, M 
 
 11. The Mode of eaaMia ia g the Ear hy aid of gaaligtrt^ 62 
 
 12. Mfliex's l^mp, o|Ma, .... S3 
 
 13. MiDeT's LaaiVk doeed, 63 
 
 14. A get of Spccala feg the pai jw u e rf eT^Miaia g the Bne»aal Meatai^ 65 
 13. The Sargeea >»«»i»i»g the ExteroAl 3Ie«£iij hr means of ICIlier** Lamp aifi 
 
 the Tabalar ^ceala^ 66 
 
 16. Bectaagalar Foreefe, . T2 
 
 17. The Exteiaal Meatas gtcatljr dilated bj a piece of cottoa-voolT 73 
 
 18. CcraMeaiacoatactwiththe oatcr sai&ce of the McadbfaaaTjraqnai, 86 
 
 19. Meatas greatly dilated hjr etxmmtm, 81 
 
 29. Aatcnor wall of the Oaeoas Meatas partlj aheorited, foDowiag the |hi wan of 
 
 aa aecasalatioa of cciaaea, 81 
 
 31. Ccraaea pttf j cctii ^throaghthe Mealmua TrBpam iato the Tjvpaaie Csritj, 82 
 
 23. Syrii^e aad Soxiie, 83 
 
 33. Ear-spoat, tkted oa the head, 8ft 
 
 24. Epidenus firaa the Exteiaal Meatas ia the foim of a tahalar cal de g a c, aad a 
 
 lajer anaagcd cirealaiiy, 9T 
 
 35. The latoaal Sai&ce of the Teapofal Boae, Aaaiag two oiifc.** la the Lateral 
 
 Siaas, filed hj ttramtm : aad also the caiioas Saleas LatenliB, . . 165 
 
 36. The Exteiaal SaiCace of the Temporal Boae, Aorwi^ a caxioai po»tii« cxtead- 
 
 ii^ &oai the Mastoid Procea to the loot of the Zjgoaatie Plroces. 196 
 
 27. Baspheny CeOalar Poljpas, 112 
 
 28. C^alar straetaie of the Ba^heny Peljpasy 113 
 
 29. A large Baspheny Poljpas, Tiable at the oeifiec of the Meatas, 113 
 39. TheSaareofMr. WOde, . 119 
 
 31. The Lerer-riag Forceps, opea, 119 
 
 32. The Lerer-riag Fotccpo holdiag a Polypas, 131 
 
 33. FiW»-gelatiBoas Paijpw, 133 
 
LIST OF ILLUSTRATIONS. 
 
 XV 
 
 FIO. 
 
 34. Structure of the Fibro-gelatinous Polypus, 
 
 35. The Ring Forceps 
 
 36. Globular Cellular Polypus, 
 
 37. Two Osseous Tumors projecting from the walls of the Meatus Externus, . 
 
 38. The vertical section of the External Meatus and Osseous Tumor, 
 
 39. Three Osseous Tumors projecting from the walls of the Meatus, 
 
 40. A large Osseous Tumor and two smaller ones in the Meatus Externus, 
 
 41. Two Osseous Tumors of the External Meatus in contact internally, . 
 
 42. An Osseous Tumor growing from the Upper Wall of the Meatus, 
 
 43. Osseous Matter developed from the walls of the Meatus Externus, 
 
 44. Molluscous Tumor filling the whole of the Meatus Externus, . . . . 
 
 45. Cavity in the Meatus Externus from which a Molluscous tumor has been removed, 
 
 46. Apertures in the upper wall of the Meatus Externus communicating with the 
 
 Cerebral Cavity, produced by a Molluscous Tumor, .... 
 
 47. The Triangular Shining Spot at the anterior and inferior part of the surface o 
 
 the Membrana Tympani, ......... 
 
 ^8. The Dermoid Layer of the Membrana Tympani continuous with the Dermis lining 
 the upper wall of the Meatus Externus, ...... 
 
 49. The Radiate Fibrous Layer of the Membrana Tympani, .... 
 
 50. The Fibres composing the Radiate Fibrous Lamina (magnified), 
 
 51. The Radiate Fibrous Lamina, 
 
 52. The Radiate Fibrous Lamina, after having been treated with Acetic Acid, 
 
 53. The Circular Cartilaginous Band, after having been treated by Acetic Acid, 
 
 54. The External Surface of the Circular Fibrous Lamina (slightly magnified), 
 
 55. The Internal Surface of the Circular Fibrous Lamina (slightly magnified), 
 
 56. The Fibres composing the Circular Fibrous Lamina, ..... 
 
 57. The Fibres of the Circular Fibrous Lamina, treated with Acetic Acid, 
 
 58. The Radiate Fibrous Lamina, the Circular Fibrous Lamina, and the Mucous 
 
 Membrane of the Membrana Tympani (slightly magnified), . 
 
 59. The Attachments of the Tensor Tympani Ligament (slightly magnified), . 
 
 60. Epidermoid Layer of the Membrana Tympani hypertrophied (magnified), . 
 
 61. Granulations on the surface of the Dermoid Layer of the Membrana Tympani 
 
 62. The Membrana Tympani fallen in towards the Promontory (seen in section), 
 
 63. The Membrana Tympani fallen in towards the Promontory (seen from without), 
 
 64. An Orifice in the Membrana Tympani produced by ulceration of the Fibrous 
 
 Laminae, ............. 
 
 65. The Fibrous Layers of the Membrana Tympani ulcerated over a small extent at 
 
 its anterior part, ............ 
 
 66. Calcareous Deposit in the Circular Fibrous Lamina of the Membrana Tympani, 
 
 67. Calcareous Deposit in the Radiate Fibrous Lamina of the Membrana Tympani, 
 
 68. The whole of the Membrana Tympani converted into Calcareous Matter, . 
 
 69. The Artificial Membrana Tympani, ......... 
 
 70. Margin of the circumference of the Membrana Tympani remaining after the 
 
 destruction of the rest of the membrane, ....... 
 
 71. Handle of the Malleus remaining after the destruction of the Membrana Tympani, 
 
 72. Body of Malleus remaining after destruction of Membrana Tympani, 
 
 73. Surgeon introducing the Artificial Membrana Tympani, 
 
 74. An Aperture in the lower part of the left Membrana Tympani, from rupture, 
 
 75. An Aperture in the posterior part of the right Membrana Tympani, from rupture, 
 
 76. An Aperture in the right Membrana Tympani, 
 
 77. The Otoscope, 
 
 78. The Surgeon using the Oto.«cope, ......... 
 
 79. The Explorer, and the Eustachian Catheter into which it fits, . . . . 
 
 PAGE 
 
 124 
 126 
 130 
 136 
 137 
 141 
 141 
 143 
 144 
 145 
 148 
 148 
 
 149 
 
 152 
 
 153 
 155 
 156 
 156 
 157 
 157 
 158 
 159 
 159 
 160 
 
 160 
 161 
 164 
 171 
 175 
 176 
 
 176 
 
 177 
 179 
 179 
 180 
 191 
 
 191 
 192 
 193 
 194 
 208 
 209 
 210 
 221 
 222 
 227 
 
X\n LIST OF ILLUSTRATIONS. 
 
 FIG. PAGE 
 
 80. The Surgeon using the Eustachian Catheter and the Explorer, .... 228 
 
 81. Stricture of the Eustachian Tube 247 
 
 82. An antero-posterior vertical section of the Temporal Bone through the Tympa- 
 
 nic Cavity and Mastoid Cells, 249 
 
 83. The upper Osseous Wall of the Tympanum defective, 250 
 
 84. The Canal for the Portio Dura Nerve at the upper part of the Tympanic Cavity 
 
 incomplete, ............. 260 
 
 85. The Internal Surface of the Temporal Bone, the Tympanic Cavity diseased, . 283 
 
 86. The lower Osseous Wall of the Tympanum incomplete 286 
 
 87. The Orifice seen from the Jugular Fossa 286 
 
 88. Membranous Bands connecting the Ossicles, . ...... 295 
 
 89. Membranous Bands connecting the Ossicles to the Promontory (magnified), • 296 
 
 90. The whole of the Circumference of the base of the Stapes anchylosed to the 
 
 Fenestra Ovalis, the Crura detached, 299 
 
 91 . Base of the Stapes expanded, and osseous matter thrown around it and the Crura, 299 
 
 92. Expansion of the base of the Stapes, and its protrusion into the cavity of the 
 
 Vestibule (magnified), ........... 300 
 
 93. Expansion of the Vestibular Surface of the Articulation (magnified), . . 300 
 
 94. The External Surface of the Temporal Bone of a child, 322 
 
 95. A Vertical Section of the Temporal Bone of a child through the horizontal por- 
 
 tion of the Mastoid Cells, 323 
 
 96. The External Surface of the Temporal Bone, showing the irregular-shaped carious 
 
 portion of bone above the Meatus, ........ 326 
 
 97. A Vertical Section of the Diseased Bone, . . . • . . . . . 327 
 
 98. The right Petrous Bone, showing the carious condition of the Sulcus Lateralis, 346 
 
 99. Caries of the External Semicircular Canal, ....... 398 
 
 ]nn. Carious Temporal Bone, 409 
 
THE DISEASES OF THE EAR. 
 
 CHAPTER I. 
 
 INTRODUCTION. 
 
 NEGLECT OF THE STUDY OP THE MORBID ANATOMY OF THE EAR, THE CAUSE OF OUR 
 IGNORANCE OF AURAL SURGERY — MODE OP INVESTIGATING THE DISEASES OF THE 
 EAR — METHOD OF DISSECTING THE EAR. 
 
 As introductory to this work on the Diseases of the Ear, I may be 
 pardoned the observation, that the subject has hitherto been too 
 much regarded, by the great mass of the profession, as a blank in 
 Medical Science ; indeed, to quote from Mr. Wilde's introduction 
 to his valuable treatise on Aural Surgery, medical men are too 
 ready to affirm that " they know nothing about the diseases of the 
 organ of hearing ;" and many, looking upon the difficulties that 
 surround the investigation as insurmountable, have tacitly aban- 
 doned its pursuit. Yet, if we carefully survey the history of the 
 rise and progress of Aural, as a distinct branch of Scientific Sur- 
 gery, one main cause of the disrepute into which it had fallen may 
 be traced to the neglect of the pathology of the organ of hearing — 
 a neglect that doubtless led also to the ignorance which has pre- 
 vailed as to the structure and functions of some of the most impor- 
 tant of its parts. 
 
 It is a question, however, Avhether the inherent difficulties of 
 Aural Surgery arc of a nature to prevent its being as thoroughly 
 understood as the other branches of surgery. This question has 
 been answered in the affirmative by some, on the ground of the deep 
 and hidden situation of the larger part of the organ, and the extreme 
 
 3 
 
34 THE DISEASES OF THE EAR. 
 
 intricacy of its structure. But surely the organ of hearing is not 
 so much concealed from view as several others (the heart, for in- 
 stance), of whose diseases "we have a very clear knowledge ; nor is 
 its structure more complicated than that of the eye. The result of 
 my own experience, and I think also of those who have carefully 
 attended to my practice at St. Mary's Hospital, is, that the diseases 
 of the ear are not more difficult to diagnose, nor are they on the 
 whole less amenable to treatment, than those of the eye, the joints, 
 or almost any other organ that can be named. 
 
 When my attention was first turned to the study of the diseases of 
 the ear, I resolved to prosecute researches into the pathology of 
 the organ. From that time to the present, I have made nearly 2000 
 dissections ; and although it must be manifest that this number is 
 small, compared to that which is required for the thorough elucida- 
 tion of the subject, still I feel it is a sufficiently solid foundation 
 upon which to build a rational system of Aural Surgery. 
 
 Fully a}vare of the difficulties in the way of procuring specimens 
 from those deaf persons who had been inspected during life, and 
 whose histories had been recorded, I determined at once to dissect 
 every ear that I could obtain, in order to ascertain Avhat arc the 
 most common morbid conditions to which the organ of hearing is 
 subject ; in fact, to secure one step first, by ascertaining something 
 of the morbid anatomy of the ear, before advancing to a consideration 
 of its pathology. The result of my investigations established this 
 general fact, that the existence of some of the most important affec- 
 tions of the ear had not even been imagined. Having advanced 
 thus far with the morbid anatomy of the ear, my next step was to 
 pursue its pathology. This was effected, in the first place, by prose- 
 cuting inc^uiries into the history of the patients whose ears were 
 found to be diseased ; secondly, by dissecting the ears of deaf per- 
 sons supplied to me by medical men, and comparing the morbid 
 appearances observed with the notes accompanying the cases ; and 
 thirdly, by availing myself of the opportunity, during some years, 
 of inspecting all the ;leaf persons in an institution containing more 
 than 2000. individuals, of recording their cases, and then of making 
 dissections of the organ of hearing in those who died. By these 
 means, and by the facilities offered at the public institutions to which 
 I have been attached, of conducting post-mortem inspections of the 
 patients attended by me, I have been able in many cases to compare 
 the symptoms occurring during life, the appearances of the organ. 
 
INTRODUCTION'. 35 
 
 and the history of the case, with the morbid structures found after 
 death. 
 
 3Iode of investigating the Diseases of the Ear. — The following 
 plan for eliciting all the important particulars with which a surgeon 
 ou^ht to be acquainted Avhen endeavering to form a diagnosis of dis- 
 ease of the ear, has been pursued by me during many years. Its 
 use involves no great time or labor ; and as it is desirable that it 
 should be observed by those studying the subject, I will describe it 
 in detail. 
 
 I. The age and occupation of patient. 
 II. State of health, temperament, condition of pulse, &c. 
 
 III. If any relations are deaf, name them. 
 
 IV. History of the affection ; duration ; supposed cause. Former 
 symptoms : if at any time pain in the ears or head. Nature of jyro- 
 gress : whether rapid or slow ; if it has increased by sudden parox- 
 ysms, or by imperceptible degrees. Present symptoms : if pain, 
 noises, or discharge ; amount of hearing power as shown by conver- 
 sation ; whether the patient require to be spoken to distinctly in a 
 room, or within the distance of a yard, or close to the ear : which 
 ear is the worse. Causes aggravating the deafness : a cold, cold or 
 moist weather, bodily fatigue or mental excitement, the act of mas- 
 tication. Causes producing imp)rovement : improved health, dry 
 air, a cold, cold weather, warm weather. 
 
 V. Result of examination. 
 
 Right ear. The distance at which the watch is heard. ^ 
 
 3Ieatus : quantity and condition of the cerumen ; state of the 
 dermis and of the osseous wall. 
 
 Memhrana tympani : surface dull or shining, transparent or 
 opaque, state of the triangular bright spot , if more or less concave 
 than natural. 
 
 Eustachian tube : if air is heard by means of the otoscope to enter 
 the tympanic cavity naturally during deglutition, the nose and mouth 
 being closed ; if the air is heard to enter the tympanic cavity natu- 
 rally during a forcible attempt at expiration with the nose and mouth 
 held closed. 
 
 Left ear : ditto. State of mucous membrane of the fauces. 
 
 ' The medical man should ascertain the distance at which his watch is usually heard by 
 persons whose hearing power is supposed to be perfect. The hearing distance with mj- 
 own watch is about three feet. The wiitch should be gradually brought towards the ear 
 instead of being withdrawn from it. 
 
36 XnEDISEASESOFTHEEAR. 
 
 VI. Previous treatment. 
 
 VII. Diagnosis. 
 
 Although this enumeration of all the points Avhich require filling 
 up, might lead to the idea that the use of this i)laii must be attended 
 ■with considerable trouble in actual practice, it will be found other- 
 wise, as numerous abbreviations may be resorted to. For example, 
 take the following case. 
 
 F. R., set. 43, architect. H. (health) : tolerable, but subject to 
 attacks of sore throat. R. D. (relations who are deaf) : A brother 
 and sister were both deaf when young, but quite recovered before 
 reaching the age of 20. 
 
 H. (history) : "When a boy, suffered from ear-ache, which was 
 often followed by deafness and sometimes by discharge from each 
 ear. Subsequently the attacks of ear-ache ceased; but he has ever 
 since been subject to fits of deafness which have usually come on 
 durin<T an attack of cold, and have lasted for periods varying from 
 two to several weeks. During the attacks, the power of hearing has 
 been so much diminished, that he could only hear a loud voice when 
 within the distance of half a yard. Each attack has usually disap- 
 peared with the occurrence of a sudden crack in the ear. The pre- 
 sent attack came on six months ago, after a bad cold ; it has been 
 slightly relieved on one or two occasions, but the deafness speedily 
 returned. At the present time he requires to be spoken to in a loud 
 voice within a yard of the ears, and there is a constant singing with 
 a sensation of pressure in them, and a feeling as of weight on the 
 head. P. T. (previous treatment) : The application of glycerine to 
 the meatus ; syringing with warm water ; blisters behind the ears ; 
 the use of the Eustachian catheter and a pump over the ears, all 
 without benefit. R. E. (right ear) : M. E. (meatus externus) con- 
 tained cerumen in a normal (juantity and consistence. M. T. (mem- 
 brana tympani) : Outer surface glassy ; the bright spot more elon- 
 gated tlian natural, and somewhat striated ; the membrane of a 
 leaden hue, and much more concave than natural. E. T. (Eusta- 
 chian tube) : No air is heard to enter either during the act of swal- 
 lowing or during a forcible expiration with closed mouth and nose, 
 neither does the patient feel any sensation in the ears, nor is the 
 membrana tympani seen to move during these operations. II. D. 
 (hearing distance): Contact. L. E. (left ear) : the same as the right, 
 except that the membrana tympani is somewhat opaque. The watch 
 is only heard when pressed upon the ear. 
 
INTRODUCTION. 37 
 
 The mucous membrane of the fauces is red and spongy, and much 
 thicker than natural ; and each tonsil is somewhat enlarged. 
 
 D. (diagnosis) : Occlusion of the faucial orifice of each Eustachian 
 tube bj thickened mucous membrane. The grounds for forming this 
 diagnosis are : — 
 
 Firstly. The history of the case, the constitution of the patient, 
 the peculiar similar attacks which had occurred to a brother and 
 sister, and especially the sudden attacks of deafness following a 
 cold, and their sudden disappearance after a crack, the latter being 
 caused by the sudden entrance of the air into the tympanic cavity, 
 and the return of the membrana tympani to its natural position. 
 
 Secondly. The concave condition of the membrana tympani, 
 ■which showed that there was very little air in the tympanic cavity, 
 while there was no history of other disease to cause the concavity. 
 The reason for assuming that the obstruction was at the faucial and 
 not at the tympanic orifice, was the fact that the membrana tym- 
 pani was translucent in one ear, and only slightly opaque in the 
 other ; whereas, an amount of inflammation sufiicient to cause ob- 
 struction at the tympanic orifice of the tube, would necessarily be 
 attended by considerable thickening of the mucous membrane 
 lining the inner surface of the membrana tympani, and produce 
 great opacity. 
 
 Thirdly. The condition of the mucous membrane of the fauces, 
 and the result of the exploration of the tube by means of the oto- 
 scope. 
 
 T. (treatment) : The object is to reduce the mucous membrane 
 covering the orifices of the tubes to a natural condition, so that the 
 muscles may be enabled to open them. For this purpose the solid 
 nitrate of silver was applied to the mucous membrane of the fauces 
 twice a week, and an astringent gargle was also used ; small doses 
 of quinine and colocynth were administered each night. The sur- 
 face of the body was directed to be rubbed daily with a towel dipped 
 in cold water, and abundant exercise on foot was recommended. 
 
 The result of this treatment was to produce some slight improve- 
 ment in the course of the first Aveek ; in the course of the second, a 
 crack took place in the right ear, which was followed by a perfect 
 restoration of the hearing in that organ ; the air Avas then heard to 
 enter, upon slightly forcing it ; but it did not yet find its Avay during 
 the act of deglutition. In the course of a day or two the left ear 
 also improved greatly, though not equally with the right. This may 
 
38 TIIEDISEASESOFTHEEAR. 
 
 be accounted for by the thickened state of the mucous membrane of 
 the tympanum on that side. 
 
 Now the case just cited is ilhistrative of a large proportion of the 
 cases met with in the practice of Aural Surgery. I mean, that in 
 most cases, by a careful attention to the history, aided by an effi- 
 cient examination of the organ, a medical man can form a tolerably 
 accurate diagnosis. It has often been asked, how is it possible to 
 diagnose between anchylosis of the stapes and nervous deafness, two 
 cases in which perhaps no disease of the organ is apparent ? But 
 the history of the origin and progress of the cases, the nature of the 
 patients' constitution, and the symptoms of the diseases, are quite 
 sufficient to remove any difficulty on the subject. Indeed, so much 
 is capable of being learned from the history of a case, that very 
 often a pretty accurate diagnosis may be formed without ocular in- 
 spection. For instance, in the above case my mind was made up as 
 to its nature before making any examination. Again, the condition 
 of the Eustachian tube is to be learnt by the state of the membrana 
 tympani. "When this tube is obstructed, the air that was contained 
 in the tympanic cavity disappears, in part, in the course of a few 
 hours, either from absorption or exosmosis. The effect of this par- 
 tial disappearance of the air from the tympanic cavity is, that the 
 membrana tympani becomes drawn inwards and very concave exter- 
 nally ; and although this peculiar condition of the membrana tym- 
 pani is met with in other diseases of the ear, their history differs 
 from that of simple obstruction of the Eustachian tube. 
 
 My object in citing the foregoing case has been to show that after 
 carefully collecting the history of a case, and making a thorough 
 inspection of the organ, there is generally not much difficidty in 
 forming a tolerablv correct diagnosis. 
 
 Method of dissecting the ear. — In concluding these introductory 
 observations, I will give some directions respecting the mode of re- 
 moving and dissecting the petrous bone. 
 
 The simplest method of removing the ears for the sake of dissec- 
 tion, is, in the first place, to saw off the calvaria in the usual way, 
 and then to take out both the petrous bones together, by means of 
 two transverse vertical sections, one in front of the two petrous 
 bones and tlie other posterior to tliem. The anterior of tliese sec- 
 tions should pass in a line a little anterior to the anterior clinoid 
 processes, and the posterior in a line through the posterior third of 
 each mastoid process. By means of these two sections, the trumpet- 
 
INTRODUCTION. 39 
 
 shaped extremity of each Eustachian tube, a portion of the raucous 
 membrane of the fauces, and the Avhole of each petrous bone, toge- 
 ther with the mastoid processes, can be taken out. The disadvan- 
 tage of this procedure is the disfigurement which is apt to ensue 
 from the falling in of the face. To avoid this disadvantage another 
 mode of removing the cars may be resorted to ; this consists in 
 taking out each petrous bone separately in the following manner: — 
 The calvaria having; been sawn oif, an anterior section is to be made 
 on each side on the same line as in the above plan, but extending 
 only as far as the outer part of the body of the sphenoid bone ; a 
 posterior section on each side is then to be made, as in the first plan, 
 but not extending further inwards than the basilar process of the 
 occipital bone. These two sections are to be made with a saw, or 
 with a chisel and hammer ; the apex of each petrous bone is then to 
 be separated from the sphenoid and occipital bones, and each petrous 
 bone (the outer ear and integument being detached and reflected 
 dowuAvards) is to be drawn outwards, taking care, by inserting the 
 scalpel deeply, to remove as much of the soft parts as possible. 
 With this second plan there is a difiiculty in removing the whole of 
 the guttural portion of the Eustachian tube ; with care, however, this 
 portion may be removed, especially if the final sections separating 
 the petrous bone from the occipital and sphenoid be made to pass 
 obliquely from above, downwards, and inwards. The organ of hear- 
 ing having been removed, the dissection may be conducted in the 
 following manner : — The auditory nerve in its meatus should be first 
 carefully examined, premising that, a previous inspection has been 
 made of the portion of the brain to which the portio mollis and 
 portio dura nerves are attached. The size of the external meatus 
 having been ascertained by allowing a strong light to fall into it, its 
 anterior wall is to be removed by the cutting forceps, made by 
 Messrs. Ash, of Broad Street, Golden Square ; the state of the epi- 
 dermis, the ceruminous glands, and secretion, the dermis, perios- 
 teum, and bone, are to be noticed. The outer surface of the mem- 
 brana tympani is then to be examined ; also the state of its epider- 
 moid and dermoid laminae, its degree of tension, and the amount of 
 motion possessed by the malleus when pressed upon by a fine point. 
 The next step is to ascertain the condition of the guttural portion 
 of the Eustachian tube, to lay open the cartilaginous tube with the 
 scissors, and then to expose the cavity of the osseous portion by 
 means of the cutting forceps. In doing this, the tensor tympani' 
 
40 THE DISEASES OF THE EAR. 
 
 muscle is exposed ; its structure should be examined, and, if it has 
 not a healthy appearance, portions of it should be submitted to mi- 
 croscopic inspection. The upper wall of the tympanum is next to 
 
 Fig. 1. 
 
 Cutting Forceps. 
 
 be cut away, by means of the cutting forceps ; in doing this, great 
 care must be taken not to disturb or disconnect the malleus and 
 incus, which lie immediately beneath it. After the tympanic cavity 
 has been exposed, the first step is to pull the tensor tympani muscle, 
 and to ascertain how far it causes a movement of the membrana 
 tympani and ossicles. The incus and stapes are now to be touched 
 with a fine point, so as to ascertain their degree of mobility ; the 
 tendon of the stapedius muscle is also to be pressed upon. The 
 condition of the mucous membrane of the tympanum, and of the 
 mastoid cells, is then to be ascertained, and any peculiarity of the 
 cavity, the existence of bands of adhesion, &c., to be noted. The 
 most delicate part of the dissection, viz., that of the internal ear, 
 must now be undertaken. The cavities of the vestibule and cochlea 
 are to be exposed, by removing a small portion of the upper wall 
 of each. Before reaching the vestibule, the superior semicircular 
 canal will be cut through and removed; the membranous canal should 
 be drawn out and inspected. As the cavities of the vestibule and 
 cochlea arc laid l)are, it is desirable to see that the (quantity of peri- 
 lymph is natural, as well as its color and consistence. The outer 
 
INTRODUCTION. 41 
 
 surface of the membranous labyrinth having been observed, it should 
 be opened so as to expose the endolymph and otoconia, portions of 
 all which parts should be removed for microscopic inspection. This 
 having been effected, the remaining membranous semicircular canals 
 are to be exposed, and the connection of the base of the stapes to 
 the fenestra ovalis carefully examined. The last stage of the dis- 
 section consists in removing parts of the lamina spiralis, in examin- 
 ing them microscopically, and in exposing from within, by following 
 the course of the scala tympani, the membrane of the fenestra 
 rotunda. The only organ which now remains unexamined, is the 
 stapedius muscle : in order to expose it, the course of the aquse- 
 ductus Fallopii, beginning at the stylo-mastoid foramen, should be 
 followed until the base of the pyramidal eminence, containing the 
 muscle, is reached. 
 
CHAPTER II. 
 
 THE EXTERNAL EAR. 
 
 ANATOMICAL OBSERVATIONS USE OF THE EXTERNAL EAR EFFECT OF THE REMOVAL 
 
 OF THE EXTERNAL EAR (CASE) PATHOLOGICAL OBSERVATIONS — MALFORMATIONS OF 
 
 THE EXTERNAL EAR, WITH ABSENCE OF THE EXTERNAL MEAT0S (CASES) — SUPER- 
 NUMERARY EARS — INFLAMMATORY DISEASES — CHRONIC ERYSIPELAS — CHRONIC EC- 
 ZEMA — CYSTS — TUMORS — DEPOSITS — MALIGNANT DISEASE. 
 
 Anatomical Observations. — The external ear is not unfre- 
 qucntly described as a portion of the external auditory meatus. 
 There arc, however, peculiarities in the structure, functions, and dis- 
 eases of these two divisions of the ear, that render it desirable for 
 them to be considered separately. The external ear, comprising 
 under that name all parts of the organ external to the meatus, is 
 placed between the articulation of the lower jaw and the mastoid 
 process, and consists of a basis of resilient cartilage, covered by 
 common integuments, the two being connected by firm cellular tissue! 
 On the outer surface of the ear, the intciiuments are so firmlv at- 
 tached to the cartilage that it is difficult to draw them apart, or 
 even to move the one upon the other. The skin of the ear is so 
 abundantly supplied with bloodvessels that a dried specimen I pos- 
 sess, injected with size and vermilion, has, at first sight, the appear- 
 ance of a mass of coloring matter, which, upon minute examination, 
 is found to depend upon its vessels, that form a very dense network 
 throughout every part. The lobule of the ear consists of a fold of 
 integuments, Avhich contains cellular tissue and a small quantity of 
 adipose matter. The cartilage presents externally several depres- 
 sions and elevations ; it forms the concha, the large concavity look- 
 ing obli(juely outwards and forwards, and bounded in front by the 
 triangular projection called the tragus, which looks obliquely in- 
 wards and backwards, facing the concha. Posterior, and slightly 
 inferior to the tragus, is the antitragus. Extending upwards from 
 
THE EXTERNAL EAR. 43 
 
 the latter is the antihelix, which forms the rounded curved projec- 
 tion of the outer ear, and divides above and in front into two 
 branches : of which the inferior and more prominent terminates 
 under the helix, by which it is concealed; while the superior branch 
 is very rounded, and seems as if it were the continimtion of the anti- 
 helix. Between the tAvo branches is a fossa, called the fossa inno- 
 minata, or the fossa of the antihelix. The helix is the curved ridge 
 which forms the posterior and superior boundary to the ear : it 
 commences in the cavity of the concha, which it divides into two 
 parts, the inferior being the larger, and passes obliquely forwards 
 and upwards above the tragus ; then curving backwards and down- 
 wards, it is continuous inferiorly with the lobule. Above the tragus, 
 the helix usually consists of a flat band of cartilage, the inner sur- 
 face being applied against the superior branch of the antihelix, and 
 the superior part of the concha. This arrangement of the helix 
 screens a portion of the integuments beneath it from view and from 
 contact with the air. This portion ought to be carefully cleansed 
 and dried, especially in children. In some persons, the helix is 
 absent ; and in certain cases of malformation there is no cartilage 
 in the external ear. 
 
 Use of the External Ear. — Opposite opinions have been 
 entertained respecting the influence of the external ear upon the 
 hearing power, Itard denied that it was of any use, while others 
 have considered that it is of very material service in collecting the 
 sonorous vibrations, and in conducting them to the meatus. Riche- 
 rand says that the external ear may be removed without deafness 
 being the consequence ; " For a few days after the loss, the hearing 
 is rather hard, but the infirmity gradually diminishes, the increased 
 sensibility of the auditory nerve compensating for the imperfection 
 of the organic apparatus." Dr. Hennen cites a case that he met 
 with, in which the external car was completely removed by a cannon- 
 shot, and yet the sense of hearing Avas as acute as ever. Wepfer 
 relates a case in which the outer ear was destroyed by ulceration, 
 but the hearing power was not diminished. Itard says : " Every- 
 thing combines to show that the auricle is absolutely useless in man ; 
 that the hearing is not altered when it is removed, I have had 
 occasion to assure myself most positively." [Traite des Maladies 
 de V Oreille, t. I, 1821.) He owns, however, that this opinion has 
 been opposed by various anatomists, among whom may be cited 
 Valsalva and Haller, who state positively, that although the loss of 
 
44 TIIEDISEASESOFTHEEAR. 
 
 the outer ear does not produce deafness, it is always accompanied 
 by a diminution of the hearing power. Leschevin also states that 
 those who have lost tlie external ear, or have it naturally too flat 
 or ill-shaped, have the hearing less acute. [Cooper s Surgical Diet. 
 7th Ed. p. 4G9.) 
 
 An examination of the details of the cases from which deductions 
 have been drawn respecting the functions of the external ear, shows 
 that experiments sufiiciently careful to decide the question were not 
 performed. In those instances in which a diminished power of 
 hearing was detected, the condition of the other parts of the organ 
 is not recorded ; and where the patients are described as hearing 
 perfectly, no accurate test of the hearing power was employed ; nor 
 does it appear that sufficient care was taken to ascertain whether 
 the supposed perfect hearing depended upon the organ that remained 
 unmutilated. I am, therefore, happy that it is in my power to 
 record a case in which these particulars were carefully noted. 
 
 Case. The right external car removed. — W. B., a sailor, aged 
 33. The whole of the upper portion of the left auricle is absent. 
 The antitragus remains, and also a portion of the tragus, about 
 equal to it in size ; below these the remnant of the lobe slopes 
 gradually down to the side of the neck. He states that his ear was 
 bitten off by another sailor at one of the Navigator Islands ; but 
 the state of the parts rather indicates a removal by a cutting instru- 
 ment. The patient had come from California, Avhere the practice 
 existed of cuttino; off the right ear of a thief. lie was anxious to 
 return to California, but very unwilling to appear there without his 
 right ear, and therefore applied to me to aid him in obtaining an 
 artificial substitute. His very long hair entirely concealed the 
 remaining ear, and prevented any one from detecting the absence 
 of the other. Long hair in men was, however, in California so sus- 
 picious a feature, that wearing the hair short about the cars was not 
 merely fashionable, but absolutely essential to a respectable appear- 
 ance. When examining the patient, I found that each meatus con- 
 tained cerumen, after the removal of which by the syringe, he heard 
 the watch equally well with either ear, at a distance of two feet : 
 nor, after careful experiments, could I detect any difference between 
 the hearing power of the two ears. I sent this patient to the inge- 
 nious Mr. Rein, from whom, I doubt not, lie obtained what he 
 required. 
 
 Pathological Observations. — The two classes of disease of the 
 
THEEXTERNALEAR. 45 
 
 external ear for which the assistance of the surgeon is sought, are, 
 first, malformations, and, secondly, various kinds of inflammation ; 
 to these may be added cases of cysts and tumors, which are, how- 
 ever, comparatively rare. 
 
 I. 3IaIformations of the external ear generally coexist Avith par- 
 tial or entire absence of the external meatus ; but as the state of 
 the outer ear usually attracts attention first, I shall consider the 
 two conditions together in this place. Sometimes the tragus is 
 pressed backwards and inwards so as to close the meatus ; in such 
 a case, the patient must wear habitually a small silver tube, or have 
 a portion of the tragus excised. A much more serious malformation, 
 and unfortunately one that is not uncommon, consists in the absence 
 of the cartilage of the external ear, together with the external mea- 
 tus ; the only representative of these parts being one or more soft 
 and shapeless duplications of the integuments : sometimes, indeed, 
 there is no vestige of either meatus or auricle. 
 
 The attention of the surgeon is called to cases of malformation of 
 the external ear, in order that he may give an opinion, in the case 
 of infants newly born, as to the amount of hearing they are likely 
 to possess ; or when children with this affection grow up with a 
 certain degree of hearing, to decide whether an operation will 
 probably be of any benefit ; and, lastly, to do all in his power to 
 diminish the deformity arising from the partial absence of the ex- 
 ternal ear. 
 
 A case is cited by Mr. S. Cooper (loc. cit. p. 470) of a child he 
 saw, when it was exhibited in London as a curiosity, which was 
 wholly destitute of external ears, and m. Avhom no meatus auditorii 
 were visible. The child, nevertheless, "could hear a great deal, 
 although the sense was certainly dull and imperfect." No careful 
 investigation seems to have been made of this case, nor is it stated 
 Avhether the presence of any meatus auditorii could be detected 
 through the integuments. Judging from somewhat analogous cases 
 which will be cited, it is most probable that the meatus was entirely 
 absent. 
 
 Fritclli and Ovcrteuffer are also quoted by Cooper, as having 
 seen cases in which the outer ear was entirely absent. The former 
 says that the physiognomy of the child resembled that of an ape, 
 and the latter states that his patient heard very well. In some in- 
 stances the auricle is deformed without any abnormal condition of 
 the meatus or tympanum ; but, as a general rule, malformation of 
 
46 THEDISEASESOFTUEEAR. 
 
 the external ear is accompanied by a defective development of the 
 meatus and tympanic cavity. 
 
 This subject has been examined Avith care by Professor Allen 
 Thomson, -who published a notice of several cases of malformation 
 of the external ear, and of ex})eriments on the state of hearing in 
 such persons, in the Edinburgh Journal of Medical Science, for 
 April, 1847, to -wliich is appended an account of the dissection of 
 a similar case of malformation by myself. It appears that there 
 are upon record only three dissections similar to those now under 
 consideration : of these, one is described by Professor Jaeger of 
 Erlangen, one is in the museum of the University of Edinburgh, 
 and tlie third is one made by myself, at the request of the Patholo- 
 gical Society of London, before Avhom it was brought by Dr. Lloyd. 
 In the first two instances, one ear only was affected. " In both 
 (quoting Dr. Thomson), the labyrinth appears to be quite naturally 
 formed ; the cavity of the tympanum and the bony Eustachian tube 
 exist, but are much smaller than usual. The chain of ossicles differs 
 materially from the natural structure, being united, in one of the 
 examples, into one straight and simple piece, and, consequently as- 
 suming very much the form and appearance of the columella of birds 
 or reptiles. The most striking departure from the normal form of 
 the bone consists in the entire obliteration of the meatus externus, 
 wliich seems to be connected with the absence of that portion of the 
 temporal bone which forms the tj^mpanic ring and lower side of the 
 bony canal of the meatus, and the extension backwards of the arti- 
 cular or true glenoid portion of the temporal bone to twice its natu- 
 ral breadth. There is a total deficiency, therefore, of what may be 
 termed the tympanic bone, or of that Avhich forms the posterior non- 
 articular part of the glenoid cavity of the temporal bone, intervening 
 l)etween the fissure of Glasser and tlie vaginal ridge of the spinous 
 process. "Were this part of the bone merely deficient, the cavity of 
 the tympanum would be left freely open below ; but in the two bones 
 now described, it seems to be closed by the unusual extension of the 
 glenoid or articular portion of the bone backwards." In reviewing 
 the cases recorded by him, and comparing them with the results of 
 dissection, Dr. Thomson arrives at the conclusion that the folloAving 
 are the most prominent points of deviation from the natural form 
 and structure : — 1st. An incomplete development of the integu- 
 mental part of the apparatus, viz., the external auricle and outer 
 part of the meatus. 2d. The absence of the membrana tympani 
 
THE EXTERNAL EA 11. 47 
 
 ring and bony part of the meatus, in consequence of the incomplete 
 development of the tympanic bone, or a part of the structure which, 
 in the lower animals, bears that name. 3d. The defective state of 
 the cavity of the tympanum and chain of small bones. 4th. Occa- 
 sional irregularity or deficiency in the development of the malar, 
 palatal, and maxillary portions of the face." My own dissection 
 was laid before the Pathological Society in 1847 ; both ears were 
 equally affected. The external ear consists of a fold of integument 
 of much the same shape and size as the natural lobe, but directed 
 forwards, so that the concave surface which usually looks outwards 
 is directly applied to the surface of the head, and conceals the tra- 
 
 FiG. 2. 
 
 Malformed right External Ear of a chikl. 
 
 gus, which is rather smaller than natural. There are two orifices 
 on the upper part of the interior surface of the appendage, and 
 one at its posterior part : these are the openings of mucous folli- 
 cles. The meatus externus is entirely absent, and a slight depres- 
 sion in the integuments is the only indication of its usual position. 
 Upon removal of the integuments, no meatus or merabrana tym- 
 pani was discovered ; but in their place is a flat surface of bone, 
 which presents two fissures, one very narrow, with a direction for- 
 wards, and a second, three or four lines in length, and from half to 
 three-quarters of a line in breadth, commencing at the anterior and 
 inferior part of the other fissure, with a direction downwards and 
 slightly backwards. This fissure is covered by a membrane. The 
 whole of the tympanic ring is absent, so that the mastoid and squa- 
 mous portions of the temporal bone are only parted by these fissures, 
 the lower of which seems to represent the Glasserian fissure and the 
 external meatus united into one. 
 
 The membrane which covers the fissure appears to be the analogue 
 of the membrana tympani. The zygomatic process of the temporal 
 
48 
 
 THE DISEASES OF THE EAR. 
 
 bone is repvescnted by a small osseous layer developed in tlie middle 
 of a ligament, ■which extends from the external part of the squa- 
 mous portion to the orbit : the malai: bone is absent, the external 
 
 Fig. 3. 
 
 The rudimentary Meatus Auditorium Externus of a child, in the form of a fissure pos- 
 terior to the Condyloid Process. 
 
 part of the orbital circle being formed by a ligament connecting the 
 superior maxillary and frontal bones. 
 
 Upon removing the membrane just described, a cavity was ob- 
 served lined Avith mucous membrane ; this is evidently the cavity of 
 the tympanum, but so very much smaller than natural, as itself to 
 resemble somewhat a fissure in the substance of the bone. It mea- 
 sures two lines in its vertical diameter, two and a half from before 
 backwards, and about half a line from without inwards. This cavity 
 contains two bones which are the analogues of the malleus and the 
 stapes. The former consists of a narrow process directed upwards, 
 and a globular body below, from which another process is directed 
 inwards; but it has no connection with the stapes to which it is 
 superior. The stapes, instead of its two crura, has a process flat- 
 tened above and below, and about three-fourths of a line in length ; 
 to the inner extremity is attached the base, firmly fixed in the 
 fenestra ovalis, while the outer extremity is slightly attenuated and 
 presents no articulating surface. Over the stapes, and having a 
 direction from above downwards and backwards, the portio dura 
 nerve is seen unsurrounded by bone, but in contact with the mucous 
 
THE EXTERNAL EAR. 49 
 
 membrane of the tympanum. The tensor tympani muscle is in a 
 natural state, as is also the Eustachian tube, which opens into the 
 anterior part of the tympanic cavity. The stapedius muscle is ab- 
 sent ; the auditory nerve, cochlea, vestibule, and semicircular canals 
 appear in all respects healthy. 
 
 Fig. 4. 
 
 V 
 
 The Tympanic Cavity, with the Eustachian tube, opening into its anterior and inferior part. 
 The two ossicles, detached from each other, are to the right. 
 
 The healthy state of the labyrinth -would lead the surgeon to ex- 
 pect that sufferers from this deformity might hear some sounds ; but 
 considering the absence of an external meatus and membrana tym- 
 pani, and the imperfect state of the tympanic cavity, the compara- 
 tively large amount of hearing enjoyed must be a source of surprise. 
 In the following case there is every reason to suppose that the con- 
 dition of the ears was similar to that just detailed ; yet the power of 
 hearing was much more acute than in many instances in which the 
 ear is perfectl}'- developed, but in which there exists some thickening 
 of that part of the apparatus essential to hearing. 
 
 Case. Congenital malformation of both ears, and absence of the 
 meatus auditorii. — Miss A. J., aged 22, consulted me in 1851, on 
 the recommendation of Dr. Thoophilus Thompson. On examina- 
 tion, a very small fold of integument, in which was a delicate por- 
 tion of cartilage, represented each external ear. The only vestige 
 of the meatus auditorii was a very slight depression on each side, at 
 the floor of which firm bone was felt. She heard tlie voice perfectly 
 when spoken to loudly within a foot of the head, and best when the 
 voice was directed towards the vertex of the head. She has a slight 
 impediment in her speech, and her face is short and square-shaped ; 
 the zygomatic process appears to be undeveloped. AVhen she at- 
 tempts a forcible expiration with close nostrils, she feels a sensation 
 of pressure in both ears. Does not hear so well during a cold. 
 Three months previously a surgeon liad made a crucial incision over 
 
 4 
 
50 THE DISEASES OF THE EAR. 
 
 the depression in the left ear, but no meatus auditorius Avas found. 
 The patient thought she heard slightly better -while the surface was 
 kept open, but it was found impossible to prevent it from healing. 
 
 Fig. 5. 
 
 RiuHraentary External Ear?. 
 
 I advised that no further operation should be performed, and that 
 she should rest content with the amount of hearing she possessed. 
 She died about two years afterwards, but it was found impracticable 
 to obtain a post-mortem examination. 
 
 In some instances there has evidently been a coexistent abnormal 
 development of the labyrinth, and the patients have been wholly 
 deaf from birth ; it is gratifying, however, for the surgeon to be 
 able to assure the friends of infants respecting whom he may be con- 
 sulted, that, as a general ride, there is a sufficient development of 
 the organ for educational purposes and the ordinary intercourse of 
 life. Thus one of the cases seen by Dr. Allen Thomson was a boy 
 who went on messages for his father, a butcher. lie could join in 
 the conversation of those with wlioui he was intimate ; and even a 
 stranger could communicat* with liiiii liy employing slow, distinct, 
 and rather loud articulation. A girl (»f only moderate intelligence, 
 partly from weakness and partly from imperfect hearing, neverthe- 
 less understood what was said to her, if spoken slowly and distinctly, 
 and always answered by speech. Attempts to improve the hearing 
 in similar cases by means of operations have invariably been unsuc- 
 cessful ; first, because, as a rule, there is an entire absence of meatus 
 and nu'iid>rana tyuiiiani ; and secondly, because it has been found 
 impossible to keep the aperture in the integuments from closing. In 
 most cases of deformity of the external ear and meatus, a peculiar 
 s(|uare shape of the face has been observed, the lower jaw being very 
 
THE EXTERNAL EAR. 51 
 
 short ; and there is also not imfreqiiently imperfect speech and de- 
 glutition. Thus in an infant, a month old, seen in consultation Avith 
 Mr. Roberts, of St. John's "Wood, 1853, the meatus auditorii being 
 entirely absent, and the auricles only partially developed, the chin 
 receded much more than natural, and there was a not unfrequent 
 regurgitation through the nose of the contents of the stomach during 
 eructation. 
 
 Supernumerary ears. — Cases have been recorded in which more 
 than two ears have existed. Mr. Wilde says, that Cassebohm relates 
 the case of a child with four ears ; two placed naturally, and two 
 lower down in the neck : in this instance, there were two petrous 
 portions to each temporal bone. 
 
 II. Inflammations of the external car. 
 
 The two kinds of inflammation to which the auricle is subject are 
 erysipelas and eczema. 
 
 Chronic Erysipelas. — It is unnecessary here to speak of the acute 
 form of erysipelas, since in its nature and treatment it does not 
 differ from the same disease attacking other parts of the bod3^ The 
 chronic form of erysipelas, however, deserves attention on account 
 of its frequency, the discomfort it produces, and its very tedious 
 character. It sometimes originates in the acute form of the disease, 
 and often remains during many years. By degrees the aviricle be- 
 comes hypertrophied and hardened, the meatus not unfrequently 
 closed, and the ear loses its natural form, its surfiice being exceed- 
 ingly tender. This affection generally occurs in females beyond the 
 middle period of life. 
 
 Case. — C. F., aged 49, admitted under my care at the St. 
 George's and St. James's Dispensary, in 1849. She complains of 
 much tenderness in both external ears, which, on examination, are 
 observed to be red and very much thickened ; the integument and 
 subjacent cellular tissue of the right ear are hardened, and the 
 auricle scarcely presents the general form of the natural organ. 
 
 The patient's health was much deranged. A solution of nitrate 
 of silver, two grains to the ounce, was applied to the ear, and mild 
 preparations of steel were administered. Under this treatment the 
 tenderness of the ear greatly diminished. 
 
 Chronic Eczema, like chronic erysipelas, is most frequently found 
 in females beyond forty years of age, in whom there is some consti- 
 tutional debility ; it is, however, often met with in children. It is 
 generally accompanied by extreme irritation of the auricle, which is 
 
52 THE DISEASES OFTHE EAR. 
 
 of a deep-red color, and often very smooth and shining. Scales of 
 epidermis arc seen adhering to some of the parts, and from others a 
 thin discharge exudes. In some cases, especially in adults, the 
 dermis is hypertrophied, and the auricle loses it natural aspect. If 
 necrlected, it is liahle to extend into the meatus, the dermoid layer 
 of which also becomes red and sensitive, and sometimes tumefied, 
 although not unfrequently no tumefaction is apparent ; the dermoid 
 layer of the meatus throws out a discharge very similar to that 
 formed on the external ear ; and sometimes the epidermis collects 
 in quantities so large as to obstruct the canal, and give rise to those 
 symptoms of pressure on the membrana tympani "which Avill be more 
 particularly alluded to under the diseases of the meatus. The treat- 
 ment of chronic eczema is very similar to that of chronic erysipelas. 
 Frequent ablutions with tepid water, combined with emollients, should 
 be practised in the early stages of the affection, when the skin is very 
 sensitive, and the latter should be protected from the air by oiled 
 silk, or very thin vulcanized India-rubber. Afterwards, mild astrin- 
 gents are to be used, and, as Mr. AVildc recommends, a solution of 
 gutta-percha in chloroform may be painted over the surface several 
 times until a complete coat has been formed ; which is to be renewed 
 from day to day, as often as it peels off. The head should be kept 
 cool ; and instead of the ears being studiously covered by layers of 
 warm material, they should be exposed as freely as possible, and 
 very soft pillows avoided. The meatus ought to be frequently 
 syringed Avith tepid Avater, for the purpose not only of removing 
 the dead cuticle and discharge, but also of soothing the irritable 
 dermoid membrane. The introduction into the meatus of ear-picks 
 and other foreign bodies, for the purpose of allaying the itching of 
 tube, must be studiously avoided ; but if the itching becomes ver\' 
 distressing, a vapor-bath and hot injections should be resorted to. 
 In later stages of the affection, when both dermis and epidermis 
 become thicker than natural, the ungucntum zinci or the unguen- 
 tum hydrargyri nitratis may be employed. In addition to local 
 applications, constitutional remedies should be employed. In adults 
 any derangement of the general system should be attended to, alter- 
 ative medicines administered, and great attention to diet enjoined, 
 as well as abundant exercise in the open air. In cliildren, these 
 constitutional remedies require to l)e still more sedulously used, and 
 where there is a tendency to glandular enlargement, sea or country 
 air may be advantageously recommended. 
 
THE EXTERNAL EAR. 53 
 
 In addition to the two kinds of inflammatory disorder just 
 noticed, the auricle is sometimes subject to a chronic inflammation, 
 the seat of which appears to be the cartilage or its immediate invest- 
 ment : it is characterized by slight congestion and by extreme sensi- 
 bility upon pressure. The auricle is also often the seat of chronic 
 inflammation accompanied by excoriations ; but frequent ablution 
 Avitli tepid water and the use of mild astringents generally cflect a 
 cure. 
 
 III. Ci/sts, Tumors, Deposits, and Malignant Diseases. 
 
 Cysts. — The only kind of cyst to which the external ear is sub- 
 ject, is that formed by an efi"usion of blood between the cartilage 
 and the integuments. It has most generally been found in insane 
 persons ; and according to ni}^ friend Dr. Thurnam, of the Wilts 
 County Asylum, who has paid particular attention to the subject, 
 and who has favored me with his experience upon it, it is not now 
 so prevalent as formerly. This he ascribes to the fact that less 
 personal violence is now used. It has been thought by some to be 
 peculiar to the insane ; such, however, is not the case, for a patient 
 with this afiection was admitted under my care, in the year 1852, at 
 St. Mary's Hospital, and one, if not two, other cases of the kind 
 have presented themselves to me. 
 
 This disease, called by Dr. Stifi",^ Hsematoma Auris, is divided by 
 him into four stages. 
 
 1. The stage of hyperemia, and probably chronic inflammation, 
 as shown by the congestion and loss of the elasticity of the carti- 
 lage. 
 
 2. The stage of efi'usion ; an apoplectic layer is suddenly formed, 
 causing obliteration of the ridges and depressions of the ear. 
 
 3. The cystic stage ; in a comparatively short time absorption 
 commences, the ridges reappear, but in altered shape. This stage 
 may last for years. 
 
 4. Permanent induration, complete absorption of the fluid ; and 
 occasionally atrophy of the ear. 
 
 Dr. Thurnam calls this disease " Hsiematocele of the external ear." 
 In a letter to me on the subject, he says: "In the first stage of this 
 affection, I believe an effusion of blood exists between the folds of 
 the integuments and around the fibro-cartilage of the ear : if punc- 
 tured in this stage, there is a discharge of serum of the blood, mixed 
 
 ' Medico-Chirurgical Review, January, 1858. 
 
54 THE DISEASES OF THE EAR. 
 
 with coagulum. I tliink, liowcver, the proper practice is, )iot to 
 puncture in this early stage, but to apply evaporating lotions. Even 
 under this treatment, though still more if left to itself, the tumor 
 
 Fig. 6. 
 
 Hematocele of the External Ear (AVilde). 
 
 often increases so as entirely to disfigure the ear, and produces a 
 large hot swelling of a livid red color. At the end of a week or 
 two, according to circumstances, I have passed, with a common or 
 curved needle, a small seton through the long axis, pressing out the 
 contents, Avhich are now, in addition to their sanguineous nature, 
 more or less purulent, and allowing the rest to escape gradually. At 
 first the diminution of the tumor is trifling ; but under the use of 
 the seton it gradually subsides, and at the end of two or three weeks 
 a certain amount of chronic thickening only remains. Where no 
 such treatment has been adopted, the resulting deformity has been 
 very marked, and has continued through life." 
 
 The patient who came under my notice, at St. Marj^'s Hospital, 
 was a man aged 26, a boxer, who had received a blow on the ear a 
 fortnight previously. The cyst was about the size of a small wal- 
 nut ; it had been punctured, and a transparent fluid was evacuated; 
 it had, however, soon formed again. lie did not return to undergo 
 any treatment. 
 
THE EXTERNAL EAR. 
 
 65 
 
 Tumors. — The lobule of the external ear is subject to hyper- 
 trophy, and to the development of tumors in its substance. Tumors 
 are also developed from the surface of the cartilage, or from the 
 cellular tissue coverino; it. 
 
 Tumor of the Lobule (Wilde) . 
 
 Mr. Wilde relates a case of tumor in the substance of the lobule. 
 " M. S., a female, aged 19, has a hard, firm, ovoid tumor occup3ang 
 the centre of the lobe on each side, but largest on the left. It is 
 of a stony hardness, and is quite distinct both from the cartilage 
 above and the fleshy part of the lobe, which it appears to pass 
 through. The skin covering it is smooth, and of a light pinkish 
 hue, like that of a keloid tumor. It grew gradually from the orifice 
 made for holding the ear-ring, and has been several months attaining 
 its present size. The tumor upon the opposite side, which also 
 surrounds the hole made for the ear-ring is much paler in color, 
 and not larger than a garden pea. The girl states she expe- 
 rienced a great deal of pain and soreness in the wounds made in 
 piercing the ears, and that about three or four months afterwards, 
 she was obliged to remove the ear-rings, on account of the irritation 
 they produced. The large tumor was dissected out, and the ellip- 
 tical aperture left in the lobe brought together with sutures. It 
 healed kindly, and the disease did not return. A section of the 
 
56 THE DISEASES OF THE EAR. 
 
 tumor exhibited a dense yellowish-white fibrous appearance, and was 
 so hard that the nail made no impression upon it." 
 
 Gouty deposits are not unfrequcnt in the external ear. 
 
 Scirrhus. — Kramer, in his work on the Diseases of the Ear, 
 devotes a section to the consideration of a disease which he entitles 
 "scirrhous degeneration of the auricle." In its early stances, he 
 describes its symptoms as analogous to those of erysipelas. As the 
 disease advances, excoriation and ulceration of the auricle takes 
 place, and the cartilage is perforated and destroyed. The auricle 
 becomes nodulated and misshapen ; the nodules ulcerate. I have 
 not met with the disease unless when complicated with disease of 
 the petrous bone. Dr. Kramer cites three cases of supposed scir- 
 rhous degeneration : of these the following occurred in the practice of 
 Dr. Fischer : — A countryman, when eight years of age, perceived 
 an itching, which depended on a scabby eruption of the head. This 
 extended to the right ear, and its irritation being increased by 
 roughly rubbing it Avith the hand, the skin Avas corroded. A redness 
 and swelling of the ear, the certain attendants of inflammation, 
 continued from that time, much encouraged by the plethora and 
 strength of the individual. The disease now remained stationary 
 for some years, but at the time of manhood it broke out afresh, and 
 with increased intensity. During his twentieth year, it had ac- 
 quired so enormous an extent that the whole auricle was converted 
 into a knotty, deformed, and lumpy mass, in which the natural 
 projection could scarcely be detected. At the anterior and inferior 
 extremity of the antihelix the degenerate mass had begun to sup- 
 purate. Dr. Fischer cut away with a knife the whole degenerated 
 ear, and the wound healed in less than six weeks. 
 
CHAPTER III. 
 
 THE EXTERNAL MEATUS— ITS EXPLORATION. 
 
 ANATOMICAL OBSERVATIONS — OSSEOUS MEATUS — MEMBRANOUS MEATUS OBJECTS IN 
 
 EXPLORING THE MEATUS — MEANS OP EXPLORATION — LAMPS — SPECULUJI — MODE OP 
 EXPLORATION. 
 
 The external auditory meatus is a tube formed partly of cartilage 
 and partly of bone. It extends in a transverse direction from the 
 concha of the outer ear to the membrana tympani internally. Its 
 length varies in the adult from an inch and a quarter to an inch and 
 a half. 
 
 The Osseous Meatus. — There is a convexity about the middle of 
 the lower wall of the osseous meatus which causes a slight central 
 contraction of the calibre of the tube ; and this convexity, combined 
 Avith a similar one in the anterior wall, often prevents the anterior 
 and inferior fourth or fifth of the membrana tympani being visible 
 
 Fig. 8. 
 
 A vertical section of the left Meatus Externus, from without inwards. 
 
 to the surgeon during his exploration. The superior and posterior 
 walls are slightly concave : the anterior Avail and floor of the meatus 
 extend three or four lines further inwards ; and as the membrana 
 
58 TIIEDISEASESOFTHEEAR. 
 
 tjmpani is attached to the inner extremity of each wall, hence the 
 obli(iuc position of this membrane. The upper wall has intimate 
 relations with the cerebral cavity ; the posterior is separated by a 
 thin lamina of bone only from the mastoid cells ; the anterior wall 
 forms part of the glenoid cavity and the fossa parotidea. The outer 
 orifice of the osseous meatus is of an oval shape, its longer axis 
 being from above downwards, and slightly backwards. The ante- 
 rior and inferior parts of the orifice are rough and scabrous, the 
 fibro-cartilage of the meatus being firmly inserted into them. The 
 posterior and superior parts of the orifice are smooth, and perforated 
 by numerous orifices for the transmission of vessels. The inner ori- 
 fice of the meatus is round, and in the groove of its margin the cir- 
 cumference of the membrana tympani is inserted. 
 
 The diameter of the external meatus varies much. In some adults, 
 it is so large as to admit the introduction into it of the end of the 
 little finger for a considerable distance, and the membrana tympani 
 may be seen by means of tlie ordinary daylight, without the lobe 
 being drawn back. In other persons, the meatus is so small as 
 scarcely to admit a common goose-quill. The large size of the meatus 
 depends generally upon the original conformation of the bony tube, 
 but its contracted state is often the result of osseous development, or 
 a thickened condition of the dermis, or the presence of bony tumors. 
 
 The membranous meatus consists of the following lamina?, begin- 
 ning internally : — 1st, the epidermis ; 2d, the dermis ; 3d, the peri- 
 osteum. Between the dermis and the periosteum of the outer portion 
 of the tube are placed fibro-cartilage, cellular tissue, and ceruminous 
 glands. The c])idermis forms a cul-de-sac, which covers the whole 
 of the outer surface of the dermis, and is prolonged over the outer 
 surface of the membrana tympani, of Avhich it forms the outermost 
 lamina. In the outer part of the tube the epidermis is thick, and 
 is perforated by the ducts of the ceruminous glands. Near to the 
 outlet, it presents orifices for the passage of the hairs which fre- 
 quently protect the entrance of the meatus. At the inner half of 
 the tube, the epidermis is extremely thin, with a shining surface. 
 The scales which compose the epidermis are constantly throAvn off 
 from the free surface of the membrane : they mix with the cerumen, 
 and in the healthy ear are excreted with it. 
 
 The dermis also forms a cul-de-sac by being continuous with the 
 dermoid layer of the membrana tympani. Near to the orifice of the 
 meatus, the dermis differs but little from that covering the cartilage 
 
THE EXTERNAL MEATUS ITS EXPLORATION. 59 
 
 of the concha, Avith the exception that it gives insertion, particularly 
 in elderly persons, to numerous short strong hairs. More internally, 
 the dermis is remarkable for its extreme sensibility, and gives pas- 
 sage to the ducts of the ccruminous glands. The outer half of the 
 dermis is firmly connected, anteriorly and inferiorly, to the fibro- 
 cartilage ; posteriorly and superiorly, where there is no fibro-carti- 
 lage ; the dermis is connected to the superior and posterior parts of 
 the osseous meatus by loose cellular tissue, in which the ceruminous 
 glands are placed. At the inner half of the tube, the dermis is 
 intimately connected with the periosteum, the two membranes being 
 frequently inseparable. 
 
 The outer half of the membranous meatus contains, in addition to 
 the laminte previously noticed, fihro-cartilage, which is continuous 
 externally with that forming the external ear, and, internally, is 
 attached to the rough margin of the osseous meatus by fibrous tissue, 
 which admits of considerable motion taking place between the car- 
 tilage and the bone. The outer part of the fibro-cartilage of the 
 meatus projects and forms the tragus. The fibro-cartilaginous meatus 
 
 Fig. 9. 
 
 The Orifice of the Meatus Externus, showing its oval shape. 
 
 does not form a complete tube, being deficient at its posterior and supe- 
 rior third, where the bloodvessels of the bone freely communicate with 
 those of the meatus. The shape of the orifice of the meatus, consist- 
 ing of fibro-cartilage, is more oval than that of the osseous meatus, 
 and is composed, anteriorly and inferiorly, of the fibro-cartilage, 
 covered by the dermis, posteriorly of the anterior border of the 
 
60 
 
 THE DISEASES OF THE EAR. 
 
 concha, which projects slightly foi'Avards. The superior part of the 
 orifice does not contain any fibro-cartilage ; Init in the remaining 
 portions, the dermis is connected with the fibro-cartilage by very 
 dense cellular tissue. That the orifice of the meatus externus is 
 oval i.s shown by simply introducing the index finger within it in the 
 living subject. It will be found that the finger (itself of an oval 
 shape) enters some slight distance, and that its anterior and posterior 
 surface are in contact with the corresponding surfaces of the orifice ; 
 but if the posterior surface of the finger be directed upwards, and 
 the anterior downwards, its entrance is impossible. The orifice of 
 the external meatus is its narrowest part, and its cavity and the 
 membrana tympani are guarded by the slight projection posteriorly 
 of the tragus, while the posterior margin of the orifice projects 
 slightly forwards. Thus the introduction of a foreign body is pre- 
 vented by the flap of the tragus covering the orifice ; and if that be 
 pushed aside or penetrated, then the projecting posterior border of 
 the orifice directs the body against the anterior wall of the meatus. 
 This condition of the orifice of the meatus is also of great use in 
 preventing the sudden rush of cold air to the surface of the mem- 
 brana tympani, and the passage of water to it, when the head is 
 immersed, or copious ablutions are practised. The projection of the 
 tragus backwards, and of the cartilage forming the posterior margin 
 of the meatus forwards, consequently gives a curved form to the tube, 
 which curvature is increased by the direction of the osseous tube 
 being first slightly forwards, then backwards, and lastly, somewhat 
 forwards again. 
 
 Fig. 10. 
 
 The Osseous Meatus Externus of an infant. 
 
 At birth, only the rudiments of the osseous external meatus are 
 present : these consist of a delicate osseous ring, which, however, is 
 
THE EXTERNAL MEATUS ITS EXPLORATION. 61 
 
 incomplete at tlie upper fourtli, where the surface of the temporal 
 bone is smooth and slightly concave. The upper part of the mem- 
 branous meatus rests on this portion of bone. The inner margin of 
 the remainder is attached to the annulus auditorius ; its outer sur- 
 face is in contact "with the adjacent tissues. As the child grows, 
 the smooth superior surface is gradually developed into the concave 
 upper wall of the meatus, and from the osseous ring spring the ante- 
 rior, posterior, and inferior walls. 
 
 In the exploration of the meatus, the object of the surgeon is 
 threefold. 
 
 I. To render the meatus as straight as is practicable. 
 
 II. To dilate slightly the outer membranous and cartilaginous 
 portion. 
 
 III. To throw as much light as possible on the walls of the meatus. 
 
 To straighten the meatus it is necessary to press the tragus for- 
 wards, and the cartilage forming the posterior wall of the meatus 
 backwards. When the meatus is very large, this may be accom- 
 plished by simply pulling the outer ear backwards by the finger and 
 thumb, at the same time that the tragus is pressed forwards by 
 another finger ; but this is better effected by the aid of the speculum 
 auris, which at the same time dilates the orifice. Some writers have 
 supposed that it is not desirable to use any instrument for this pur- 
 pose ; but the orifice of the meatus is generally so small that it is 
 important to dilate it as Avidely as possible without causing pain, in 
 order to allow the passage of a sufficient volume of the rays of light 
 to permit the inspection of the surface of the meatus, and of that of 
 the membrana tympani. That the orifice of the meatus is suscep- 
 tible of being dilated is shown by placing the end of a finger in it, 
 and then pressing it gently inwards, when the walls will be felt to 
 yield slightly, and to embrace the finger firmly. 
 
 For the proper inspection of the meatus a strong light is required, 
 which can be so thrown as thoroughly to illuminate the visible sur- 
 faces of the meatus externus and the membrana tympani. Sunlight 
 is the best ; but as its presence in om" variable climate can rarely be 
 made available, and as the surgeon must be prepared to make his 
 observations at all times of the day and night, and often on patients 
 lying in bed, it is clear his usual resort must be to artificial light. 
 By a careful use of this light, however, he may, with few exceptions, 
 attain to such a knowledge of the condition of the surfaces illumi- 
 nated as will suffice for his guidance. 
 
62 
 
 THE DISEASES OF THE EAR. 
 
 There are two lamps ■\vliicli throw a good light into the meatus, 
 M. Segalas's and Mr. Miller's. 
 
 iSiyahiif' s lamp is of very simple construction, but can oidy be 
 used with gas. It consists of two vertical iron rods, the anterior 
 
 Fig. 11. 
 
 The mode of examining the Ear by aid of sunlight.' 
 
 of which is about four inches high, and surmounted by a gas-burner 
 whicli tonniiunicates with the vulcanized indiarubber gas-tube. This 
 vertical rod is connected by a horizontal rod, four inches long, with 
 a second vertical rod about three inches high, to the summit of which 
 is fi.xed a circular reflector about four and a half inches in diameter ; 
 and in the centre of which is an orifice for the surgeon to look tlirough, 
 about half an inch in diameter. Attached to the horizontal rod is 
 a ball and socket-joint, and a handle and movable piece by which 
 the lamp may be held in the mouth, and thus l)oth hands left at 
 liberty. 
 
 Miller 8 lamj), called after its manufacturer, was first suggested 
 by Dr. Chowne ; "but it has undergone great improvements in the 
 hands of its maker. It consists of a wax candle, inclosed in a 
 Palmer's spring tube, about six inches in length, standing upon a 
 foot aljout two and a half inches in diameter and three-quarters of 
 
 ' In this figure the head of the patient ought to incline more to the right shoulder. 
 
THE EXTERNAL MEATUS ITS EXPLORATION. 
 
 63 
 
 an inch deep, so as to hold the reflector when not m use. For the 
 top there is a cap -which acts as an extinguisher, and also as a de- 
 fence to the candle when carried about. This lamp will, I think, he 
 
 Fig. 12. 
 
 Fig. 13. 
 
 Miller's Lamp, open. 
 
 Miller's Lamp, closed. 
 
 found efiicient and economical, not merely in cases of disease of the 
 ear, but in all cases where a lamp is required. 
 
 In addition to the lamp, specula are necessary for the examination 
 of the ear. 
 
 Speculum aicris. — Various complicated and somewhat expensive 
 instruments have been invented for the purpose of straightening 
 the outer half of the meatus, for slightly dilating it, and for con- 
 centrating the rays of the sun, or of an artificial light, on the sur- 
 face of the tube and on the membrana tympani. The one in general 
 use previous to the last ten years was the foi'ceps-specuJum: it is 
 made of steel, and consists of two handles or branches crossing each 
 other, but having a strong spring between them ; each of these 
 branches is attached, at the extremity furthest from the handle, to 
 half a metallic funnel, and when the handles are pressed together, 
 the two halves of tlie funnel separate. Is is used by placing the 
 small extremity of the funnel in the outer part of the meatus, and 
 
64 THE DISEASES OFTUE EAR. 
 
 then opening it so as to dilate tlie tube. The objections to the for- 
 ceps-speculum, and indeed to all modifications of it, consist in its 
 being cumbrous, expensive, and not efficient. Thus this instrument 
 is too heavy to remain in the external meatus without being held ; 
 on account of its weight and size it cannot be used "with delicacy, 
 while a sensitive meatus is liable to be pained by it ; further, it re- 
 quires the exclusive use of one hand, so that it cannot be well em- 
 ployed during the performance of an operation, or the use of ajiplica- 
 tions to the meatus or mcmbrana tympani. Another great oly'ection 
 to the forceps-speculum is, that when the tAvo portions of the funnel 
 are st'()arated in the meatus, two spaces are left between them, through 
 which hairs or portions of epidermis and cerumen often project, and 
 obstruct the passage of light. 
 
 To remedy some of the above defects, the tubular ear-speculum 
 was invented by Dr. Gruber, of Vienna, and introduced to the notice 
 of English surgeons by Mr. Wilde, in his paper on Otorrhjea, pub- 
 lished in 1844 in the Dublin Journal of 3Iedieal Science. Mr. 
 Wilde describes it as consisting of " a small conical tube of silver, 
 measurinff about an inch and a half in length, five-eifjliths of an inch 
 in width at the greater aperture, and varying from two to four lines 
 in the clear at the small extremity." The interior and exterior of 
 each extremity is polished, and both openings are circular. Two or 
 three sizes are recommended. There can be no doubt that this 
 speculum was a great improvement over any previously suggested ; 
 but upon comparing its shape with that of the tube it is intended to 
 explore, two grave defects are detected. The first is the coniform 
 shape of its small extremity ; for the widest part of the speculum is 
 introduced into the narrowest part of the tube, and its extremity 
 projects into and obstructs that portion of the meatus which it is 
 desirable should be free. With a speculum of this shape it is, 
 secondly, very difficult to explore the whole of the meatus, and it is 
 not sufficiently embraced by the meatus to retain its position without 
 being held. These disadvantages of the conical speculum were ob- 
 served by the late Mr. Avery, who devoted so much time, and did 
 so much to facilitate the exploration of the various mucous canals. 
 He suggested that the narrower portion of the speculum, for about 
 three-quarters of an inch, should be of the same diameter throughout. 
 There remained, however, tlie other very serious defect in the tubu- 
 lar speculum of the circular form of its small extremity. As has 
 been said, the surgeon can readily assure himself of the oval shape 
 
THE EXTERNAL MEATUS ITS EXPLORATION. 
 
 65 
 
 of the outer meatus, and that the anterior and posterior walls of the 
 tube are flat and only slightly concave ; a form that also partially 
 obtains in the bone. It is clear, therefore, that when a circular tube 
 is introduced into this oval-shaped meatus, it may press against the 
 anterior and posterior walls, and yet leave a considerable space above 
 and below it unoccupied. As a rule, therefore, it is impossible by 
 means of this form of instrument to obtain a view of more than a 
 small portion of the meatus arid membrana tympani at the same 
 time ; and should the meatus be very small, the circular tube does 
 not give passage to a suflficient quantity of luminous rays to enable 
 the surface of the membrana tympani to be discerned. Another 
 disadvantage of the circular speculum is, that the pressure of its 
 convex surface against the anterior and posterior walls of the meatus, 
 
 Fig. 14. 
 
 A set of Specula for the purpose of examining the External Meatus 
 
 which are nearly flat, is liable to produce pain, especially where the 
 tube is small. It is therefore evident that the part of the speculum 
 inserted into the meatus should be of an oval shape. This modifica- 
 tion of the tubular ear-speculum Avas suggested by me in a paper in 
 the Lancet, published in August, 1850 ; since which time most of 
 these instruments have, I believe, been made of this shape, and have 
 been found to answer every purpose for which a speculum auris can 
 be required. In order to hold the speculum more firmly, it is desira- 
 ble that the expanded portion should bo somewhat flattened ; and this 
 flattening should be at right angles with that of the smaller extremity, 
 A set of three or four specula should be in possession of the surgeon. 
 It has been suggested that the tubular ear-speculum should be made 
 
 5 
 
66 
 
 THE DISEASES OF THE EAR. 
 
 of glass silvered ; but the thickness of the material would, occupy too 
 large a portion of the cavity of tlie meatus. 
 
 Mode of examination. — After the preliminary investigation has 
 been conducted, the patient being as nearly as possible on a level 
 with the surgeon, the latter, taking the lamp in one hand, sliould 
 feel and inspect the external ear and the orifice of the meatus, Avith- 
 out the use of the speculum. Having done this, a speculum adapted 
 to the size of the meatus is to be taken in hand, and introduced into 
 the orifice of the meatus, care being taken that the long diameter of 
 each coincides. If the speculum enters very easily, and there ap- 
 pears to be room for a larger one, the next size should be selected, 
 and the orifice fully dilated ; for in all cases, the larger the speculum 
 used the greater will be the quantity of luminous rays entering the 
 tube, and the more complete the view of the meatus and membrana 
 tympani. The speculum, having been introduced, is to be pressed 
 slightly backwards, for the reasons I have mentioned, and then, by 
 
 Fig. 15. 
 
 The Surgeon examining the External Meatuf: by means of Miller's Lamp and the 
 Tubular Speculum. 
 
 means of the lamp in the other hand, the rays of light are to be di- 
 rected successively on the several walls of the meatus and on the 
 membrana tympani. The size of the different parts of tlie tube, the 
 
THE EXTERNAL MEATUS ITS EXPLORATION. 67 
 
 quantity, color, and position of the cerumen, if present, should be 
 noted ; if absent, the state of the part of the tube in which it natu- 
 rally exists, and the degree of vascularity of the dermis lining the 
 inner half of the meatus. 
 
 A considerable degree of care is required in the examination of 
 the meatus in the infant and child. The total absence of the osseous 
 meatus in the former, and its very limited size in the latter, should 
 always be borne in mind, or the surgeon, when he introduces the 
 speculum, is apt to press upon the membrana tympani. In many 
 cases it is necessary only to open the orifice of the meatus, when the 
 membrana tympani is at once seen Avithout the introduction of the 
 speculum any further. 
 
CHAPTER IV. 
 
 THE EXTERNAL MEATUS {coniinued). 
 
 OX FOREIGN BODIES AND ACCUMULATIONS OF CERUMEN IN 
 THE MEATUS. 
 
 FOREIGN BODIES IN THE MEATUS — MODE OF REMOVAL — CASES CERCMINOrS GLANDS — 
 
 THEIR DISEASES — ACCCMtJLATIONS OF CERUMEN — THEIR CAUSES — TABLE OP TWO 
 HUNDRED CASES IN WHICH THE CERUMEN WAS REMOVED — SYMPTOMS — EFFECTS — 
 TREATMENT — MODE OF REMOVAL — THE SYRINGE AND ITS USE — CASES. 
 
 FOREIGN BODIES IN THE MBATUS. 
 
 Foreign bodies are frequently introduced into the outer meatus. 
 Among those which have fallen under my own notice may be named 
 beads, slate-pencil, leaves, a shell, a pea, sealipg-wax, a percussion- 
 cap, a pin, a piece of paper, seeds of grass, tobacco, wool, cotton- 
 wool, human hairs, bacon, lint, camel's-hair pencil, and camel's hair. 
 When a body is put into the meatus by design, it is either done by 
 a child in play, or by an adult for the purpose of medical treatment, 
 or an alleviation of the itching of the tube. "When a patient is sus- 
 pected of having a foreign body in the ear, the first step of the sur- 
 geon is to make a careful inspection of the tube in suidight or with 
 the speculum and the lamp, with the view of ascertaining whether 
 there really is anything present. In a great number of cases, having 
 explored the whole of the meatus, and seen the membrana tympani, 
 he will be able to assure the patient or the friends that no foreign 
 substance is there. For want of this pre-inspection, lives have been 
 destroyed in attempting to extract from the ear imaginary bodies 
 which had never lodged there. Medical men are not generally aware 
 of the impunity with which a foreign substance may continue for a 
 time in the meatus. It is not uncommon to find a mass of hard 
 cerumen in contact with the whole of the meatus and with the outer 
 
THE EXTERNAL MEATUS. 69 
 
 surface of the membrana tympani, without causing any pain or inflam- 
 mation ; and I have frequently removed other substances, as beads, 
 pebbles, &c., which had been either in contact with the membrana 
 tympani or in its immediate vicinity, Avithout causing any painful 
 irritation. Nor is this remarkable when it is remembered that the 
 meatus and outer surface of the membrana tympani are a continua- 
 tion of the outer skin, and, like it, covered with a layer of epidermis. 
 The meatus and membrana tympani are extremely sensitive when 
 pressed upon by hard or rough substances ; but soft, smooth bodies 
 may be gently pressed against them without exciting pain. Thus 
 the artificial membrana tympani, made of vulcanized india-rubber, 
 is placed against the outer surface of a perforated membrana tympani 
 without producing any unpleasant sensation. 
 
 When a foreign body has been detected in the external meatus, it 
 should be removed as soon as possible. The syringe and warm water 
 are, as a general rule, quite sufficient to remove all rounded solid 
 bodies. I have succeeded in extracting beads and other hard sub- 
 stances which appeared to be impacted in the meatus, by means of 
 the syringe only, though a good deal of time is occasionally required. 
 It may at times be useful to move the body slightly by means of a 
 probe a little bent downwards, so as to facilitate the passage of the 
 water to the back of it ; for the mode by which the syringe acts, is 
 in forcing the warm water inwards behind the foreign body, and thus 
 gradually expelling the latter outwards. Mr. Wilde and other 
 writers recommend the use of the curette, spatula, or forceps, in the 
 extraction of extraneous substances from the meatus : but I have 
 rarely been obliged to use any of these instruments, and resort to 
 them should be avoided if possible. Dieifenbach, who advocated the 
 use of a curved director, or curette, must have met with cases show- 
 ing the practice to be dangerous ; for he says, " Should violent 
 bleeding supervene, and there be no likelihood of completing the 
 operation at one sitting, cold and afterwards warm applications are 
 to be resorted to, to prevent suppuration." It is also almost impos- 
 sible to pass a curette between the extraneous substance and the 
 meatus without impelling that substance inwards, in which case it is 
 very apt to be pressed /orc?^/?/ against the membrana tympani, and 
 cause inflammation. Cases are sometimes met with in which the 
 most lamentable results have followed attempts at removing foreign 
 bodies by instruments. Death itself has not unfrequently happened ; 
 
70 THE DISEASES OF THE EAR. 
 
 and -vvliei-o tlie life of the patient has been spared, the car has some- 
 times been destroyed and the ]>o)'tio dura nerve paralyzed. 
 
 Should a patient apply for relief "who has much inflammation and 
 tumefaction of the meatus, consequent perhaps upon attempts pre- 
 viously made to remove the body by instruments, the best course is 
 to apply leeches and fomentations to subdue the inflammatory 
 symptoms, before attempting the extraction by the syringe. 
 
 In certain cases the presence of a foreign body in the meatus 
 cives rise to coufrhiu'r, and even to vomitiiij: ; svmptoms ■which seem 
 traceable to irritation of the auricular branch of the pneumo-gastric 
 nerve. A patient under my care, "with a portion of dead bone in 
 the meatus, suffered under a cough, -which no treatment subdued, 
 but -which disappeared as soon as the bone -was removed. In a 
 notice of Professor Romberg's work, in the British and Foreign 
 Medical Hevieic, \o\. XVII, it is stated tliat Arnold met -with a 
 case of chronic vomiting in a child, -which long resisted all medical 
 means, but -which -was cured by removing a bean from each of the 
 child's ears. 
 
 There are substances of a different character from those already 
 alluded to -which arc not so easily removable by the syringe. These 
 are -wool, cotton--wool, tobacco, leaves, paper, and similar soft mate- 
 rials, -which expand in the tube and perfectly fill it. If the syringe 
 fails to remove these bodies, they can be seized Avith the lever-ring 
 forceps, ^vitll ^v]lie]l they can be easily -witlidra-wn.* Insects some- 
 times enter the meatus, and arc apt to cause more irritation than 
 the presence of solid bodies. If they touch the membrana tympani, 
 they cause extreme sensitiveness of it, and spasmodic contraction of 
 the tensor tympani muscle. The use of the syringe, or, if that be 
 not at hand, the pouring of a little -warm -water into the ear, affords 
 instant relief. Foreign bodies Avhich press upon the outer surface 
 of the membrana tympani are apt to force the chain of bones inwards, 
 and thus press the stapes towards the vestibule, causing the peculiarly 
 distressing symptoms of giddiness and confusion in the head which 
 not unfrequently attend upon an accumulation of cerumen. These 
 cease as soon as the foreign body is extracted. 
 
 There is little known as to the effect of narcotics introduced into 
 the external auditory meatus : but I have every reason to believe 
 that the narcotic property of a piece of tobacco in the meatus was 
 the cause, in one instance, of very serious cerebral derangement. 
 
 ' See a description of this instrument in Chapter YI. 
 
I 
 
 THE EXTERNAL MEATUS. 71 
 
 It is probable that, in the following case, the foreign body escaped 
 spontaneously. 
 
 M. S., aged 9, was brought to me by a medical man, in January, 
 1852. He stated that, on the previous evening, the mother of the 
 child had seen her put a bead into the right ear ; that he himself 
 had seen what he supposed to be the bead, but he had been unable 
 to extract it by the forceps. By means of the lamp the surfaces of 
 the meatus and membrana tympani were seen, and the dermis 
 throughout was much congested, especially near the orifice where 
 the forceps had been applied, but no foreign substance could be de- 
 tected. 
 
 CASES OF FOREIGN BODIES REMOVED FROM THE EXTERNAL MEATUS. 
 
 Case I. Slate-pencil in the ear of a cJiild. — J. S., aged 7, Avas 
 brought to me at the St. George's and St. James's Dispensary, on 
 November 28th, 1849, her mother stating that she had pushed a 
 piece of slate-pencil into the right ear. She had not complained of 
 pain, and had slept well. Upon examination, by means of the 
 speculum and lamp, a rough piece of slate-pencil was observed lying 
 on the floor of the meatus, one end being apparently in contact with 
 the membrana tympani, while the other looked towards the orifice 
 of the meatus. It was easily removed by the syringe and warm 
 water, and found to be nearly half an inch long, and a quarter of 
 an inch broad. The membrana tympani was red, the bloodvessels 
 of its dermoid layer being distended. The patient did not complain 
 of pain, and in a few days the membrana tympani was healthy. 
 
 Case II. A percussion-cap in the ear for fifteen years. — C. E.. 
 aged 26, was admitted at St. Mary's Hospital in November, 1852. 
 She said that lately she had felt somewhat deaf in both ears. 
 Upon examination, a mass, like hardened wax, was observed near 
 the orifice of the left meatus. It Avas removed by the syringe, and 
 proved to be a percussion-cap surrounded by Avax. The patient 
 said that she remembered, when about 11 years of age, she put a 
 cap into her ear, but she believed it had been taken out, and had 
 never thought of it since. The membrana tympani was concave, the 
 Eustachian tube natural, and the power of hearing was nearly gone. 
 Right ear : hearing distance seven inches, membrana tympani dull. 
 concave ; Eustachian tube natural. It appears that the thickening 
 
72 THEDISEASESOFTIIEEAR. 
 
 of the right incmbrana tynipani had recently caused a dulness of 
 hearing in that ear : the left ear had doubtless been useless for some 
 time ; but so long as the right ear remained perfect, the defect in 
 the left was not observed. 
 
 Hairs are apt to collect in the meatus ; they either enter in small 
 pieces while the hair is being cut, or those growing at the orifice fall 
 inwards : great iritation is caused by them. 
 
 Case III. A coUeetion of hairs in the external meatus. — W. S., 
 aged 09, complained of an extremely unpleasant crackling in the 
 right ear whenever he moved the head or ear. It came on two 
 months before seeing me, after bathing in the sea; and he had had 
 a similar attack some years previously, which had subsided sponta- 
 neously. The hearing distance was three inches. A large mass of 
 short liairs was syringed out of the ear ; the symptom of crackling 
 at once disappeared, and the hearing distance became two feet. 
 Another gentleman, from the same cause, was troubled with excessive 
 itching. 
 
 Fig. 16. 
 
 Rectangular Forceps. 
 
 Case IV. A pin iiiipaeted in the rneafus. — A. R., a servant, aged 
 35, came in great fear and in some pain, complaining that wliile 
 picking the left ear with a pin she had dropped it into the ear, and 
 was unable to remove it. The head of the pin was seen to lie close 
 on the membrana tympani at its lower part, and the point seemed to 
 be inserted in the membranous meatus. The syringe proved ineffec- 
 tual, and I therefore had to remove it with the rectangular forceps, 
 an instrument of great utility wliere the extraneous substance cannot 
 be otherwise removed. On attcni])ting to withdraw the pin, I dis- 
 coverctl that its point was firmly fixed in tlie dermis, and that the 
 only way to extricate it was to seize it by the middle, jiush it gently 
 
THE EXTERNAL MEATUS. 
 
 73 
 
 inwards against the raembrana tympani, and then suddenly draw it 
 out. 
 
 Cotton-wooL — In one case a portion of cotton-wool had been in 
 the right ear for ten years without producing any other symptom 
 than a feeling of fulness. In the following case, where it rested on 
 the membrana tympani, symptoms similar to those of pressure on 
 the brain were very decided. 
 
 Case V. Cotton-wool in the meatus. — The Rev. 0. M., aged 55, 
 consulted me in 1840. Since an attack of measles when a child, 
 has had a discharge from the left ear ; and has been accustomed to 
 push a portion of cotton- wool into the meatus. Has lately suffered 
 from giddiness and a sensation of Aveight on the head ; which symp- 
 toms his medical advisers thought were produced by derangement of 
 
 Fig. 17. 
 
 The External Meatus greatly dilated by a piece of Cotton-wool ; the latter is seen 
 below, and to the left. 
 
 the Stomach, as during attacks of dyspepsia he was decidedly worse. 
 Upon examination a large quantity of cotton-wool Avas observed in 
 the meatus in contact Avith the membrana tympani : it had evidently 
 been pushed in by other portions which had been thrust upon it. 
 The cotton was removed by means of the syringe, and was found to 
 have closed an orifice in the membrana tympani. After the removal 
 of the cotton, the attacks of giddiness wholly subsided. 
 
 In a dissection, of which a drawing is subjoined, I found a piece 
 of cotton-wool in the meatus, where it had probably remained for 
 many years; and it had so largely dilated the bony meatus, that the 
 index finger could be passed in as far as the membrana tympani. 
 
 Case VI. A shell in the meatus ; removal by instruments ; para- 
 
74 THE DISEASES OF THE EAR. 
 
 lysis of the jjortio dura nerve. — Miss A., aged 14, consulted me, in 
 May, 1853, on account of complete deafness of the right ear and 
 paralysis of the right side of tlie face. Iler father stated that eight 
 years previously she had, in play, put a small shell into the ear ; 
 that the surgeon, in endeavoring to remove it, forced it deeper into 
 the ear, breaking the shell, and causing intense pain. After its re- 
 moval there was much discharge from the ear, and in a few days the 
 muscles of the right side of the face lost their power, Avhich they 
 have not regained. Upon examination there was no vestige of the 
 memhrana tympani ; the mucous membrane of the tympanum was 
 very thick and red, and there was not the slightest power of hearing. 
 Case VII. Tobacco in the meatus; i^ain and numbness in the 
 head; ^mrtial stupefaction, inability to walk straight. — M. B. S., 
 aged 50, applied for relief in 1843. He stated that for four months 
 he has had pain and a sensation of numbness in the right side of the 
 head, which feelinn;s are much ago-ravated at times. He also com- 
 plains of giddiness, and sometimes reels across a room ; at otliers he 
 is obliged to sit down, feeling quite oppressed and stupefied. He 
 has also suffered from indigestion. Upon consulting a medical man, 
 he was treated by cupping, purgatives, &c., but without relief. Upon 
 examination of the right external meatus, a considerable quantity 
 of black matter was seen, which was easily removed, and was found 
 to consist of tobacco in a moist state, mixed Avith cerumen and wool. 
 The next day the head-symptoms were much diminished ; in a few 
 days they wholly disappeared, and the patient remained free from 
 them. Tiie tobacco had been introduced into the meatus a short 
 time before the attack, on account of toothache. The mass was soft, 
 and so loosely packed that it appears probable the symptoms were 
 caused by the narcotic principles of the tobacco, rather than by its 
 pressure on the membrana tympani. In cases of pressure, too, the 
 symptoms disappear at once on the removal of the cause ; whereas, 
 in the present instance, they subsided slowly. 
 
 THE CERUMINOUS GLANDS AND THEIR DISEASES. 
 
 The ceruminous glands surround the outer half of the membra- 
 nous meatus, Avith the exception of the portion situated within a line 
 or two of the orifice. They are contained in the cellular tissue be- 
 neath the dermis, on the surface of which the ducts open. Kolliker 
 
THE EXTERNAL MEATUS. 75 
 
 has recently shown them to bo modifications of the sudoriferous and 
 not of the sebaceous glands, as was previously supposed. The ceru- 
 men secreted by these glands forms, in the perfectly healthy ear, a 
 band about half an inch in length, and half a line thick. This band 
 should be of a consistence just sufficient to enable it to retain its 
 position, at the same time that it can collect the small particles of 
 dust, &c., which float in the atmosphere, and prevent their accumu- 
 lation on the surface, or in the vicinity of the membrana tympani. 
 Two other functions ascribed to the cerumen are, that by its bitter 
 taste it prevents the ingress of insects ; and that in some peculiar 
 manner it assists the poAver of hearing. Its principal use is unques- 
 tionably to arrest and collect the particles of dust. Its bitterness 
 may possibly deter the entrance of insects ; but the idea that it me- 
 chanically assists in collecting or conducting the sonorous vibrations 
 to the labyrinth, or that it is of any use, in fact, in the actual pro- 
 cess of hearing, is, in my opinion, quite erroneous. No doubt its 
 absence is very frequently accompanied by a diminution of the hear- 
 ing power ; but this absence appears rather to result from the sym- 
 pathy which exists between these glands and the deeper structures 
 of the ear. Very often, when these return to their normal state, 
 the ceruminous glands again pour out a healthy secretion. The most 
 convincing proof that the cerumen does not mechanically assist in 
 the function of hearing is, that in many cases, when the ceruminous 
 glands alone are affected, and their secretion consequently arrested, 
 no diminution in the heai'ing power can be detected even by the use 
 of the most delicate tests ; and cases must frequently occur to medi- 
 cal men, where there has been a long-continued discharge from the 
 surface of the dermis, no cerumen being secreted, without perceptible 
 diminution of the hearing power. It is also well known that the 
 entire removal of the ceruminous secretion does not impair the hear- 
 ing power ; and in no case of deafness has it been shown that the 
 introduction of cerumen or of any substance to supply its place, or 
 even the promotion of its healthy secretion under the influence of 
 stimulants, has in the least degree improved the hearing. Indeed, 
 if the peculiar properties of soft cerumen be considered, it must be 
 manifest that its function would be rather to absorb superabundant 
 sonorous undulations than to increase their intensity. The natural 
 method whereby the cerumen when it has performed its duties is 
 expelled from the ear, is the action upon the external meatus of the 
 condyloid process of the lower jaw, during the movement of masti- 
 
76 THE DISEASES OF THE EAR. 
 
 cation .iiul articulation. By these movements, the cerumen is brought 
 quitf to the orifice of the meatus, whence it either falls out in small 
 particles, or is removed by the towel. 
 
 Diseases of the Cerumhious Glands. — The ceruminous glands 
 sometimes pour out a too abundant secretion, which is either of a 
 light brown color and softer than natural, or hard and dark colored ; 
 it may also be entirely absent. When soft and semi-liquid, it is 
 generally found in young patients having a tendency to glandular 
 enlargements, and in whom the dermis of the meatus is hypertro- 
 \)]\\vt\ ; thus, without any accumulation beyond that which adheres 
 to tlie walls of the meatus, the cavity is nearly filled with cerumen. 
 It is, however, generally found in a state harder than natural ; and 
 this condition, by preventing its free escape from the ear, gives rise 
 to that very common affection, accumulation of cerumen in the ex- 
 ternal meatus. 
 
 CoUectiuns of Cerumen. — Cerumen accumulates in the external 
 meatus from two different causes : one, a primary affection of the 
 ceruminous glands ; the other, a secondary and sympathetic derange- 
 ment of the deeper-seated cavities. Thus, while in a large number of 
 cases the removal of the accumulated cerumen is productive of im- 
 mediate relief to the deafness ; in others, the hearing is only par- 
 tially or not at all benefited by the operation. In order to ascertain 
 the ninuerical relation between the cases of accumulation that are 
 cured, and those that are only relieved, by the use of the syringe, I 
 have arranged in a tabular form the results of one hundred consecu- 
 tive cases that have occurred in my private practice. 
 
THE EXTERNAL MEATUS. 
 
 77 
 
 TABLE SHOWING THE EFFECT ON THE POWER OF HEARING OF THE RE- 
 MOVAL OF AN ACCUMULATION OF CERUMEN IN ONE HUNDRED CASES J 
 THE NORMAL DISTANCE OF TESTING-WATCH BEING THREE FEET. 
 
 
 HEARING DISTANCE BEFOllE 
 
 HEARING DISTANCE AFTER 
 
 O 
 
 REMOVAL. 
 
 REMOVAL. 
 
 
 Right Ear. 
 
 Left Ear. 
 
 Right Ear. 
 
 Left Ear. 
 
 22 
 
 1 inch 
 
 8 inches 
 
 18 inches 
 
 18 inches 
 
 22 
 
 normal : no cerumen 
 
 half an inch 
 
 normal 
 
 normal 
 
 32 
 
 7 inches 
 
 crack of nails 
 
 12 inches 
 
 7 inches 
 
 70 
 
 contact 
 
 contact 
 
 contact 
 
 contact 
 
 33 
 
 half an inch 
 
 half an inch 
 
 normal 
 
 normal 
 
 35 
 
 2 feet 
 
 half an inch 
 
 normal 
 
 normal 
 
 45 
 
 contact 
 
 half an inch 
 
 2 inches 
 
 2 inches 
 
 15 
 
 half an inch 
 
 3 inches 
 
 normal 
 
 normal 
 
 44 
 
 normal : no cerumen 
 
 half an inch 
 
 normal 
 
 normal 
 
 59 
 
 1 inch : no cerumen 
 
 crack of nails 
 
 1 inch 
 
 crack of nails 
 
 25 
 
 crack of nails 
 
 3 in. : no cerumen 
 
 1 inch 
 
 3 inches 
 
 18 
 
 4 inches 
 
 half an inch 
 
 normal 
 
 normal 
 
 29 
 
 5 inches 
 
 normal : no cerumen 
 
 normal 
 
 normal 
 
 8 
 
 contact 
 
 contact 
 
 3 inches 
 
 contact 
 
 U 
 
 half an inch 
 
 half an inch 
 
 half an inch 
 
 half an inch 
 
 49 
 
 G inches 
 
 6 inches 
 
 6 inches 
 
 6 inches 
 
 53 
 
 crack of nails 
 
 2 in.: no cerumen 
 
 4 inches 
 
 2 inches 
 
 28 
 
 half an inch 
 
 normal: no cerumen 
 
 normal 
 
 normal 
 
 26 
 
 1 inch 
 
 half an inch 
 
 8 inches 
 
 7 inches 
 
 26 
 
 half an inch 
 
 2 inches 
 
 normal 
 
 12 inches 
 
 49 
 
 9 inches 
 
 1 inch 
 
 9 inches 
 
 1 inch 
 
 19 
 
 7 inches 
 
 1 inch 
 
 7 inches 
 
 24 inches 
 
 32 
 
 quarter of an inch 
 
 half an inch 
 
 normal 
 
 normal 
 
 53 
 
 normal 
 
 half an inch 
 
 normal 
 
 normal 
 
 30 
 
 half an inch 
 
 10 inches 
 
 6 inches 
 
 normal 
 
 — 
 
 2 inches 
 
 I2 inch 
 
 2 inches 
 
 half an inch 
 
 41 
 
 18 inches 
 
 5 inches 
 
 18 inches 
 
 8 inches 
 
 65 
 
 contact 
 
 contact 
 
 2 inches 
 
 2 inches 
 
 27 
 
 pressure 
 
 pressure 
 
 half an inch 
 
 3 inches 
 
 44 
 
 4 inches 
 
 pressure 
 
 6 inches 
 
 3 inches 
 
 25 
 
 24 inches 
 
 1 inch 
 
 normal 
 
 3 inches 
 
 40 
 
 pressure 
 
 normal 
 
 normal 
 
 normal 
 
 65 
 
 crack of nails 
 
 crack of nails 
 
 2 inches 
 
 contact 
 
 27 
 
 12 inches 
 
 contact 
 
 normal 
 
 normal 
 
 27 
 
 18 in.: no cerumen 
 
 pressure 
 
 18 inches 
 
 18 inches 
 
 70 
 
 pressure 
 
 pressure 
 
 1 inch 
 
 1 inch 
 
 56 
 
 normal 
 
 pressure 
 
 normal 
 
 7 inches 
 
 
 
 2 inches 
 
 2 feet 
 
 normal 
 
 normal 
 
 20 
 
 2 inches 
 
 2 in.: no cerumen 
 
 2 inches 
 
 2 inches 
 
 53 
 
 24 in.: no cerumen 
 
 contact 
 
 24 inches 
 
 12 inches 
 
 38 
 
 contact 
 
 half an inch 
 
 normal 
 
 normal 
 
 7 
 
 2 inches 
 
 normal : no cerumen 
 
 24 inches 
 
 normal 
 
 14 
 
 2 inches 
 
 5 inches 
 
 24 inches 
 
 24 inches 
 
 29 
 
 2 inches 
 
 6 inches 
 
 normal 
 
 12 inches 
 
 40 
 
 4 inches 
 
 pressure 
 
 8 inches 
 
 5 inches 
 
 14 
 
 contact 
 
 normal: no cerumen 
 
 6 inches 
 
 normal 
 
 35 
 
 7 inches 
 
 half an inch 
 
 normal 
 
 normal 
 
 22 
 
 2 inches 
 
 contact 
 
 24 inches 
 
 normal 
 
78 
 
 THE DISEASES OF TUE EAR. 
 
 
 BEARING DISTANCE BEFORE 
 
 UEARINO DISTANCE AFTER 
 
 H 
 
 REMOVAL. 
 
 REMOVAL. 
 
 
 Rigla Ear. 
 
 Left Ear. 
 
 RigJu ESt. 
 
 Left Ear. 
 
 45 
 
 IG inches 
 
 3 inches 
 
 24 inches 
 
 8 inches 
 
 19 
 
 normal : no cerumen 
 
 contact 
 
 normal 
 
 normal 
 
 28 
 
 normal : no cerumen 
 
 pressure 
 
 normal 
 
 normal 
 
 — 
 
 normal : no cerumen 
 
 half an inch 
 
 normal 
 
 normal 
 
 46 
 
 quarter of an inch 
 
 pressure 
 
 half an inch 
 
 half an inch 
 
 23 
 
 4 inches 
 
 5 inches 
 
 normal 
 
 normal 
 
 44 
 
 pressure 
 
 pressure 
 
 normal 
 
 normal 
 
 25 
 
 normal : no cerumen 
 
 1 inch 
 
 normal 
 
 normal 
 
 14 
 
 2 inches 
 
 2 inches 
 
 normal 
 
 normal 
 
 60 
 
 1 inch 
 
 1 inch 
 
 9 inches 
 
 9 inches 
 
 27 
 
 normal 
 
 half an inch 
 
 normal 
 
 half an inch 
 
 50 
 
 18 inches 
 
 pressure 
 
 18 inches 
 
 24 inches 
 
 20 
 
 2 inches 
 
 4 inches 
 
 normal 
 
 normal 
 
 11 
 
 2 inches 
 
 half an inch 
 
 8 inches 
 
 8 inches 
 
 50 
 
 2 inches 
 
 normal 
 
 normal 
 
 normal 
 
 45 
 
 half an inch 
 
 half an inch 
 
 1 inch 
 
 1 inch 
 
 5 
 
 crack of nails: 
 no cerumen 
 
 2 inches 
 
 crack of nails 
 
 4 inches 
 
 35 
 
 10 inches 
 
 2 inches 
 
 normal 
 
 normal 
 
 28 
 
 1 inch 
 
 24 inches 
 
 24 inches 
 
 24 inches 
 
 41 
 
 normal : no cerumen 
 
 contact 
 
 normal 
 
 24 inches 
 
 14 
 
 12 in.: no cerumen 
 
 2 inches 
 
 12 inches 
 
 24 inches 
 
 24 
 
 pressure 
 
 pressure 
 
 normal 
 
 2 inches 
 
 60 
 
 1 inch 
 
 contact 
 
 1 inch 
 
 contact 
 
 34 
 
 normal: no cerumen 
 
 24 inches 
 
 normal 
 
 normal 
 
 19 
 
 2 inches 
 
 1 inch 
 
 24 inches 
 
 24 inches 
 
 61 
 
 2 inches 
 
 2 inches 
 
 3 inches 
 
 3 inches 
 
 65 
 
 crack of nails 
 
 crack of nails 
 
 crack of nails 
 
 qrack of nails 
 
 24 
 
 contact 
 
 2 inches 
 
 normal 
 
 normal 
 
 40 
 
 normal: no cerumen 
 
 contact 
 
 normal 
 
 8 inches 
 
 60 
 
 contact 
 
 crack of nails 
 
 contact 
 
 crack of nails 
 
 56 
 
 quite deaf: no ceru. 
 
 contact 
 
 quite deaf 
 
 6 inches 
 
 21 
 
 normal : no cerumen 
 
 6 inches 
 
 normal 
 
 normal 
 
 40 
 
 6 in.: no cerumen 
 
 4 inches 
 
 6 inches 
 
 12 inches 
 
 51 
 
 normal: no cerumen 
 
 contact 
 
 normal 
 
 3 inches 
 
 50 
 
 G inches 
 
 6 inches 
 
 normal 
 
 normal 
 
 55 
 
 crack of nails 
 
 contact: no cerumen 
 
 contact 
 
 contact 
 
 41 
 
 12 in.: no cerumen 
 
 contact 
 
 12 inches 
 
 5 inches 
 
 27 
 
 normal: no cerumen 
 
 half an inch 
 
 normal 
 
 4 inches 
 
 50 
 
 normal: no cerumen 
 
 contact 
 
 normal 
 
 1 inch 
 
 46 
 
 2 inches 
 
 half an inch 
 
 24 inches 
 
 G inches 
 
 35 
 
 normal: no cerumen 
 
 pressure 
 
 .normal 
 
 12 inches 
 
 45 
 
 3 inches 
 
 3 inches 
 
 3 inches 
 
 3 inches 
 
 74 
 
 crack of nails 
 
 2 inches 
 
 3 inches 
 
 6 inches 
 
 49 
 
 half an inch 
 
 half an inch 
 
 4 inches 
 
 4 inches 
 
 57 
 
 half an inch 
 
 2 inches 
 
 1 inch 
 
 3 inches 
 
 36 
 
 crack of nails 
 
 crack of nails 
 
 1 inch 
 
 1 inch 
 
 39 
 
 pressure 
 
 crack of nails 
 
 normal 
 
 normal 
 
 39 
 
 4 inches 
 
 contact 
 
 normal 
 
 14 inches 
 
 25 
 
 2 inches 
 
 normal : no cerumen 
 
 normal 
 
 normal 
 
 52 
 
 8 inches 
 
 1 inch 
 
 8 inches 
 
 2 inches 
 
 54 
 
 normal : no cerumen 
 
 contact 
 
 normal 
 
 6 inches 
 
 11 
 
 contact 
 
 contact 
 
 12 inches 
 
 12 inches 
 
THE EXTERNAL MEATUS. 79 
 
 An analysis of the foregoing 100 cases shows the following to be 
 the result of the examination of the 200 ears : — 
 
 Ears restored to a normal condition, ....... 60 
 
 Ears in which the hearing power was greatly improved, . . . .43 
 
 Ears in which the hearing power was only slightly improved, . . .35 
 
 Ears in which tlie hearing power was the same after as before the removal 
 
 of the cerumen, .......... 27 
 
 Ears in which there was no wax, and in which tlie hearing power was 
 
 normal, the opposite ear being affected, ...... 24 
 
 Ears in which there was no wax ; but in which the hearing power was not 
 
 perfect, the opposite ear being affected, ...... 11 
 
 200 
 
 It thus appears that of the 165 ears from which cerumen was re- 
 moved, only GO were cured; that, including the 43 cases which were 
 much improved, there were 103 cases of great amelioration, while 
 there were 62 ears that were either but slightly or not at all im- 
 proved. Thus, out of the 165 ears from which a collection of ceru- 
 men was removed, there were 105 in which there was some other 
 disease, the restoration of the hearing not being perfect. The pre- 
 sence of cerumen in the external meatus may be symjjtomatic of 
 several affections, as obstruction of the Eustachian tubes, or thick- 
 ened condition of the tympanic mucous membrane, debility of the 
 auditory nerve, anchylosis of the stapes, &c. ; it is therefore impor- 
 tant that every case should be carefully examined after a collection 
 of this kind has been removed ; because, if the hearing power be 
 not wholly restored, some other disease is present which requires at- 
 tention. 
 
 The causes producing accumulation of cerumen in cases not com- 
 plicated with other diseases, are, — a narrow calibre of the meatus ; 
 the application of cold ; the admixture of dust with the cerumen ; 
 and, not unfrequently, the practice of pushing into the ear the point 
 of a towel, whereby the cerumen is pressed into a mass toAvards the 
 membrana tympani. 
 
 The symptoms of an accumulation of cerumen are : sudden deaf- 
 ness, often following a cold by which the dermis is tumefied ; bath- 
 ing or the introduction of water into the ear. This deafness is 
 often better in the morning ; is increased by the movements of the 
 jaw during mastication ; and often disappears as suddenly as it 
 came, with a cracking sound in the ear. The cause of the sudden 
 appearance and disappearance of the deafness is the movement of 
 
80 THEDISEASESOFTHEEAR. 
 
 the mass of cerumen : when it is so pUiccd as to allow sonorous vi- 
 brations to pass between it and the wall of the meatus, the hearing 
 returns ; but when it again conies in contact with the meatus, the 
 deafness recurs. Oftentimes a feeling of fulness in the ear is com- 
 plained of; not unfrequently there is singing and giddiness, and 
 sometimes considerable pain. 
 
 The symptoms of a collection of cerumen in the meatus vary 
 according to the nature and position of the mass. Sometimes the 
 whole of the meatus is distended by cerumen, the inner end of which 
 lies in contact with the outer surface of the membrana tympani, of 
 which it often forms a cast. In these cases, there is often giddiness 
 arising from the pressure on the chain of ossicles. The symptoms 
 of pressure on the brain are familiar to most surgeons ; but it is not 
 
 Fig. 18. 
 
 Cerumen in contact with the outer surface of the Membranii Tympani. 
 
 generally known that pressure on the contents of the labyrinth pro- 
 duces somewhat analogous symptoms. A mass of cerumen may 
 force inwards the membrana tympani and the chain of bones, until 
 the base of the stapes is pressed against the contents of the vestibule. 
 In some cases of this nature, constant attacks of giddiness occur ; in 
 others, there is a confusion of ideas and an inability to walk 
 straight ; and in a third class, there is a feeling of weight and pres- 
 sure on the head. These symptoms are often combatted by the use 
 of counter-irritants antl depletion ; but the only proper remedy for 
 them is the removal of the accumulation. 
 
 In certain cases there is a large mass in the outer half or two- 
 thirds of the tubes, while the portion near the membrana tympani 
 is empty ; in others there is only a small quantity, which adheres 
 to the outer surface of the membrana, and gives rise to great irri- 
 
THE EXTERNAL MEATUS. 
 
 81 
 
 tation, and irregular action of the tensor tympani muscle. When 
 the mass is very hard, it is liable to cause inflammation of the der- 
 moid meatus. A collection of cerumen may remain in the ear for 
 many years, and the ears of the patient may have been frequently 
 syringed without the nature of the affection being detected. Those 
 accustomed to pay attention to cases of deafness will, however, 
 generally be able to state when cerumen is present, even without 
 any examination. I have frequently diagnosed the disease from 
 
 Fic. 19. 
 
 Meatus greatly dilated by cerumen. 
 
 the written account of a medical man ; and a repetition of the 
 syringing (which had previously been practised), but with increased 
 vigor, has entirely removed the deafness. An examination with 
 
 Fig. 20. 
 
 Anterior wall of the Osseous Meatus partly absorbed, following the pressure of 
 an accumulation of cerumen. 
 
 the speculum and a strong light should, however, always be made 
 before adopting any treatment. 
 
 The prolonged presence of hardened cerumen in the external 
 
 6 
 
»2 THE DISEASES OF THE EAR. 
 
 meatus is sometimes productive of injury to the walls of the meatus 
 and to the memhrana tympani. In my museum are several speci- 
 mens in which the osseous meatus has been much dilated ; others in 
 which the bone has been absorbed in parts ; and in one instance a 
 portion of wax was imbedded in the mastoid cells, having passed 
 through an orifice in the attenuated posterior wall of tlie meatus. 
 In another instance, wliere the cerumen, by its pressure, had caused 
 an ulcerated orifice in the membrana tympani, a portion of it had 
 found its way into the cavity of the tympanum. 
 
 Fig. 21. 
 
 Cerumen projecting through the Membrana i _ _ mto the Tympanic Cavity. 
 
 The treatment of cases in which there is an accumulation of ceru- 
 men of course consists in its removal. The best, and indeed the 
 only judicious mode of effecting this, is by the use of the syringe, 
 which will thoroughly clear out even the hardest masses. The use 
 of other instruments, as the scoop, has been suggested ; but I have 
 rarely known them to have been used without the production of pain, 
 inflammation, and often of discharge from the dermis. No doubt 
 the ordinary small syringe is not powerful enough to remove a hard- 
 ened mass ; but the one I usually employ, and which is valuable for 
 many other purposes, holds three ounces and a half, and is furnished 
 with two rings, so that it can be held in the right hand, and leave 
 the left at liberty to hold the ear of the patient. 
 
 The nozzle of the syringe consists of a metallic tube of very small 
 size, wliich sliould Ite made to takeoff until the water has been drawn 
 in through the large aperture, and tlien be again fi.xed on. By doing 
 this, air is kept out of the syringe and much time is saved, as it is 
 not easy to fill a large-sized syringe through a small aj)erture. 
 The point of the nozzle should be somewhat larger tlian the body of 
 
THE EXTERNAL MEATUS. 
 
 83 
 
 an ordinary probe, so that the water may be injected Avitli sufficient 
 force, and its return at the orifice be unimpeded. The ear of the 
 patient should be brought opposite to a window, and tlie point of the 
 
 Fig. 22. 
 
 Syringe and Nozzle. 
 
 syringe should be placed at th^ posterior part of the orifice of the 
 meatus, or the stream is liable to strike against the anterior wall of 
 the tube. Whenever the syringe is used, the ear should be drawn 
 backwards so as to straighten the tube ; and if this cannot be ef- 
 fected, on account of the left hand of the surgeon being otherwise 
 engaged, the posterior wall of the meatus may be pressed back- 
 wards by the point of the syringe. Warm water alone is generally 
 sufiicient, without the use of any solvent. It should be quite clear ; 
 and it is always desirable to have two vessels ; one for the water 
 before it is used, and the other to receive it when returning from 
 the ear. If a glass vessel be used for the latter purpose, the condi- 
 tion of the water, and consequently of the ear, is more readily as- 
 certained. The use of an ear-spout is very serviceable during the 
 process of syringing. It consists of a spring to pass over the head, 
 
84 THE DISEASES OF THE EAR. 
 
 at one end of which is a funnel to fit uiKlcr the ear, down which the 
 water can run into the basin. 
 
 In many cases, when the collection of wax is not very hard, the 
 
 Fig. 23. 
 
 Ear-spout, fitted on the lieml. 
 
 injection of one or two syringes full of warm water is sufficient to 
 dislodge the mass ; in others, a much longer time is required, and 
 when the wax has been very hard, I have sometimes injected warm 
 water for twenty minutes or half an hour Avithout removing any 
 particles, or even causing the water to be clouded. At times, it is 
 well to let the wax become softened by the water before using the 
 syringe again ; and where the cerumen is unusually hard, or the 
 meatus so tender that the syringing causes much pain, it is desirable 
 to order a weak alkaline solution to be dropped into the ear in the 
 intervals. As it is not desirable to proceed with the syringe when 
 there is no wax left, the meatus should be frequently inspected to 
 ascertain the progress made, as the deposit frequently comes away 
 slowly in small pieces ; the last portion, however, is usually large, 
 and is often a cast of the membrana tympani. After the extraction 
 of the cerumen, a piece of cotton-wool may be worn for a day or 
 two. 
 
 CASES OF ACCUMULATION OF CERUMEN IN THE MEATUS EXTERNUS. 
 
 Case I. — Mrs, R., aged 38, consulted me in July, 18r)4, on account 
 of great dulness of hearing. She stated tliat. without any previous 
 
THE EXTERNAL MEATUS. 85 
 
 symptoms, ten months previously she had become suddenly deaf, 
 first in one ear and then in the other. After being deaf for a month, 
 there was a crack in each ear, and she regained her hearing, which 
 had remained perfect until Avithin a few days, when, during a severe 
 cold, slie again became deaf. Upon examination, I found the meatus 
 of each ear full of dark cerumen ; the hearing distance Avas only half 
 an inch, and the patient required to be spoken to loudly within a 
 yard. Upon removing the cerumen the hearing was perfectly re- 
 stored. 
 
 Case II. 3Iass of cerumen extremely hard and very difficult to 
 remove. — Lord D., aged between 50 and 60, consulted me, in April, 
 1851, on account of deafness in the right ear, accompanied by a 
 sensation of fulness in that organ. A large mass of cerumen Avas 
 detected in the meatus, Avhich Avas not at all affected by syringing 
 for half an hour. A solution of carbonate of soda in Avater (5j @ Sj) 
 Avas ordered to be dropped into the ear for some days ; but the mass 
 was scarcely at all softened. The application of the solution Avas 
 therefore continued, and it Avas only after several Aveeks that the 
 cerumen was dissoh'ed sufiiciently to be remoA^ed Avith ease. 
 
 Case III. Accumulation of cerumen attetided witJi pain and in- 
 flammation of the dermis. — Miss H., aged 30, consulted me in May, 
 1853, on account of a shooting pain in the right ear which she had 
 experienced, Avith scarcely any intermission, during a fortnight. 
 She was not aAvare that the hearing poAver Avas at all diminished. 
 On examination, each meatus Avas found full of cerumen, the hear- 
 ing distance of the right ear being half an inch ; that of the left, 
 ten inches. The cerumen Avas removed from each ear ; and that in 
 the right was exceedingly hard, requiring frequent syringing. The 
 hearing distance of the right ear rose to six inches ; that of the left 
 became natural. The surface of the right meatus Avas red, and it 
 Avas SAVollen. The pain ceased, and the symptoms of inflammation 
 disappeared, after the cerumen Avas removed. 
 
 Case IV. A mass of cei'umeii producing inflammation of the der- 
 moid layer of the membrana tympani. — J. R. M., aged 55, a surgeon, 
 complained, in 1849, of pain in the right ear, Avith much deafness. 
 The pain Avas paroxysmal ; A^ery acute ; and Avas increased during 
 the act of SAvallowing. The meatus Avas found distended Avith 
 cerumen, the removal of Avhich gave immediate relief to both pain 
 and deafness. The upper half of the dermoid layer of the mem- 
 
86 THE DISEASES OF THE EAR. 
 
 bnuia tynipaiii, against whicli the mass of cerumen had evidently 
 pressed, was red and much swollen ; the lower half Avas healthy. 
 
 Case V. An accumulation of cerumen causing neuralgic pains in 
 the face. — G. W. II., Esq., applied to me, in May, 1853, on account 
 of a dulness of hearing in the right ear, accompanied by slight pain 
 in the ear, and a good deal of pain over the right side of the face. 
 This fiicial pain came on at times very suddenly, was very acute, 
 and then disappeared : it had lasted for eight or nine days. A 
 larfje accumulation of cerumen was found to fill the right ear : and 
 when removed by the syringe, the dulness of hearing, the pain in 
 the car and in the face, entirely disappeared. 
 
 Case VI. An accumulation of cerumen causing 2)itlsation in the 
 ear. — W. E., Esq., aged 53, consulted me, in October, 1851, on ac- 
 count of a pulsation in the right ear whenever he reclines, but which 
 ceases directly he assumes an upright position. He also complained 
 of occasional singing in both ears. For these symptoms he had for 
 some time been under medical treatment, but it had not succeeded 
 in diminishing them. A mass of cerumen was found filling each 
 ear, the removal of which improved the hearing greatly, and en- 
 tirely removed the pulsation. 
 
 Case VII. A collection of cerumen in the external meatus ; giddi- 
 ness and other sgmiytoms of cerebral irritation cured at once by the 
 use of the syringe. — L. S. M., Esq., aged 43, consulted me in No- 
 vember, 1845. He stated that, five or six years previously, he had 
 an attack of deafness in the left ear, attended with a considerable 
 amount of singing noise ; since that time he has occasionally felt 
 deaf in the morning, but has usually recovered his hearing during the 
 day, and at times, after blowing his nose, he has been deaf for a 
 short time. Eleven months ago, after going into the open air from a 
 warm room, a singing suddenly came on in the right ear, and has 
 remained ever since. Latel}' he has had a sensation of weight at 
 the top of the head, and fre(|uc'nt attacks of giddiness, which have 
 caused him great alarm. AVhilc walking in the street, he has ob- 
 served himself noAv and then to make "a lurch." Upon inspecting 
 the ears, each meatus was found to be nearly full of hardened ceru- 
 men ; which was carefully removed by means of the syringe. The 
 symptoms immediately disappeared, and he had no recurrence of 
 them. Another patient, an artist, who suffered in the same way, 
 was so giddy that he was obliged to lean on the railings, and rest, 
 on his way to my house. He was also unable to discern the features 
 
THE EXTERNAL MEATUS. 87 
 
 of his "sitter" for more than a minute at a time, and had the 
 greatest difficulty in writing an ordinary note. He likewise was 
 cured at once by the removal of cerumen from each ear. A third 
 patient was by the same means cured of a constant pain and numb- 
 ness in the head : in a fourth, the pain had extended down the back. 
 The following; case is also interestino- : 
 
 Case VIII. GonfiLsion in the head, inahility to walk straight, 
 caused hy a collection of cerumen. — Mrs. R., aged 45, consulted me 
 in April, 1845. She stated that, four months previously, she first 
 began to experience noises in the ears, which were followed by a 
 great amount of deafness. These symptoms lasted seven weeks, 
 and then disappeared for three weeks, at the expiration of which 
 time they came on again, accompanied by a sense of confusion in 
 the head. This, at times, was so bad, that not unfrequently, for a 
 few seconds, she could not tell Avhere she was. She has at times 
 been so giddy, that she has reeled and fallen in the streets ; and, at 
 other times, she has not been able to retain her hold of things, so 
 that they have fallen from her hands. On examination, a large 
 compact mass of cerumen was found in each ear ; which, after some 
 syringing, was got rid of ; and the operation was followed by the 
 entire disappearance of all the symptoms. 
 
 In some cases, the hard mass of cerumen has pressed against the 
 outer surface of the membrana tympani, with sufficient force to cause 
 inflammation of its substance, and of the mucous membrane of the 
 tympanum. When this has been the case, the application of leeches 
 has been required before the head-symptoms entirely disappeared : 
 in other instances, they have only gradually subsided, though, as a 
 general rule, they disappear with the removal of the cerumen. 
 
CHAPTER V. 
 
 THE EXTERNAL MEATUS {con(inued). 
 THE DERMIS AND ITS DISEASES. 
 
 1. ACUTE INFLAUMATION : — a, ACUTE INFLAMMATION CONFIXED TO THE DERMIS TREAT- 
 
 MENT — CASES, b, ACUTE INFLAMMATION EXTENDING TO THE BRAIN AND ITS 
 MEMBRANES — TREATMENT — CASES. 
 
 2. CHRONIC INFLAMMATION : — a, CHRONIC INFLAMMATION, WITH UVPEUTROruV AND 
 
 ACCUMULATION OF EPIDERMIS TREATMENT CASES. I), CHRONIC CATARRHAL 
 
 INFLAMMATION — TREATMENT — CASES. C, CHRONIC CATARRHAL INFLAMMATION EX- 
 TENDING TO THE BONE AND TO THE BRAIN — TREATMENT — CASES. d, ULCERATION. 
 
 The diseases to whicli the dermis of the external meatus is 
 subject are : — 
 
 I. Acute Inflammation, ending in resolution, discharge of scrum, 
 mucus or pus, or in ulceration. 
 
 II. Chronic Inflammation, Avith or -without discharge, polypoid 
 growths, or caries of the bone. 
 
 I. Acute Inflammation of the Dermis. 
 
 This is one of the diseases hitherto comprised under the term 
 otitis. The external meatus is very sensitive, especially towards 
 the middle. This sensibility is due to the dermis, which is abun- 
 dantly supplied with nerves and bloodvessels, and is covered by a 
 delicate layer of epidermis. This membrane is liable to inflammation 
 from many causes, such as the introduction of foreign bodies or 
 acrid drops into the meatus ; an accumulation of cerumen ; the 
 application of cold or of heat, especially when arising from sudden 
 changes of temperature in the weather ; or any debilitating illness. 
 
 The sijmptomH of this affection, at its connnencement, are a feel- 
 ing of fulness, stiffness, and uneasiness in the meatus, which is in- 
 
THE EXTERNAL MEATUS. 89 
 
 creased wlien the ear is pressed upon, or Avlicn the outer ear is moved 
 by its muscles. This sensation is followed by pain, often very acute, 
 although not so distressing as in severe inflammation of the mucous 
 membrane of the tympanum : throbbing and singing often accom- 
 pany the pain, and there is sometimes a diminution of the power of 
 hearing. The latter symptoms arc probably due to congestion of 
 the middle and internal cars. With these symptoms there is gene- 
 rally a quick pulse, feverishness, and restlessness ; and the pain 
 sometimes extends over the side of the head. On examination in 
 the early stages, the dermoid meatus is seen to be red, its blood- 
 vessels being apparent through the epidermis. This redness some- 
 times extends to the dermoid layer of the membrana tympani, the 
 vessels in the circumference of which become enlarged. Should the 
 affection advance, the dermis becomes tumefied, so as to diminish 
 the calibre of the meatus one-third or one-half, and the pain increases. 
 In some cases, these symptoms subside without the formation of 
 matter ; in others, a copious secretion suddenly takes place, and is 
 followed by such immediate relief that the patient thinks an abscess 
 has burst. Examination, however, reveals the real condition of the 
 meatus. The discharge filling the meatus having been carefully 
 removed by the syringe, the surface of the tumefied meatus is seen 
 to be of a deep red color, wholly denuded of epidermis, and in its 
 place secreting a mucous fluid. In the severe forms of this inflam- 
 matory action, this secretion consists of mucus, which comes away 
 from the ear as a large mass of viscid white matter, somewhat 
 analogous to that secreted by the mucous membrane of the tympanum 
 in cases of catarrh ; the difference being, that in the case of mucous 
 from the tympanum, the circumference of the mass is more fila- 
 mentous, the color not so white, and the substance less consistent. 
 After this discharge has continued for some days, it loses its viscidity, 
 and becomes milky, remaining so as long as the affection continues to 
 be chronic. When the inflammation is not very severe, the character 
 of the secretion is always milky, not mucous. There are cases in 
 which the secretion is thin, and nearly as transparent as sermn ; at 
 times it is tinged with blood. The quantity of this serous secretion 
 astonishes both patient and medical man, I have never had the 
 opportunity of collecting the secretion, so as to be able to form a 
 correct estimate of the quantity effused in twenty-four hours ; but, 
 judging from the saturation of handkerchiefs, linen, and pillows, it 
 must amount to several ounces. The source of this large quantity 
 
90 TIIEDISEASESOFTHEEAR. 
 
 of secretion is the bloodvessels of the dermoid meatus, -wliieli are 
 extremely numerous, and very large. 
 
 Some ])atit'iits are subject to frequent attacks of acute inflamma- 
 tion of the meatus, but in them tlie symptoms are not very severe ; 
 in others, however, the inflammation extends to the bone, and thence 
 to the membranes of the brain. It is not uncommon to see patients 
 in whom there are some symptoms of cerebral irritation, though not 
 of a serious character; -while, in other instances, they are so for- 
 midable as to destroy life. These cases will hereafter be more fully 
 described. 
 
 Acute inflammation of the dermoid meatus sometimes occurs from 
 injury, but it usually subsides under the use of leeches and fomen- 
 tations. 
 
 Tlie treatment of acute inflammation of the dermoid meatus con- 
 sists, in the milder cases, of the application of evaporating lotions, 
 or of hot fomentations and poultices ; in the more severe, leeches 
 should be applied to the margin of the orifice of the meatus, so as to 
 remove the blood directly from the congested vessels ; and the 
 meatus itself should be syringed with hot water, the head being 
 slightly raised. The patient should be kept in bed, perfectly free 
 from all noise, and small doses of opium may be administered. After 
 the disappearance of the pain, the ear is to be washed out thoroughly 
 with warm water, three or four times, or even oftener, daily; so as, 
 in the first place, to insure the removal of the whole of the dis- 
 charge, which is apt to cause irritation, and, in the second place, to 
 act as a warm bath to the inflamed membrane. Unless there is con- 
 stitutional del)i]ity, or the ear has been weakened by previous dis- 
 ease, the discliarge usually ceases in the course of a few days ; the 
 epidermis is again naturalh^ secreted ; and the power of hearing re- 
 turns. Cases of acute inflammation of the dermis depending upon 
 constitutional causes, and usually following nervous excitement, re- 
 quire to be treated by tonics in addition to the local applications. 
 In some cases, however, foundation is laid for chronic catarrhal in- 
 flammation of the dermis, of which I shall presently speak. 
 
 CASES. 
 
 Case I. Aciifc injlammation of the dermoid vwatus, arhing from 
 cold. — M. F., Esq., aged 26, a medical man, consulted me in January, 
 
THE EXTERNAL MEATUS. 91 
 
 1853, on account of great pain in each ear. He said that fourteen 
 days previously, after being wet through, he had an attack of violent 
 pain in both ears, — but especially in the left : after twenty-four 
 hours' pain, discharge appeared and relief ensued. The day before 
 consulting me, during a journey, pain Avas again felt in each ear, 
 but more particularly in the right : at times the pain was greatly 
 aggravated. On examination^ the dermis of each meatus was seen 
 to be very red and SAVollen ; the epidermis was absent, but there was 
 no discharge. The hearing distance of each ear was eighteen inches. 
 An evaporating lotion Avas applied on cotton-wool, and the affection 
 subsided. 
 
 Case II. Acute inflammation of the dermis; cojnous secretion of 
 mucus. — Miss M., aged 17, tall, and rather delicate, consulted me, 
 December 20, 1853, on account of pain in the right ear, accompanied 
 with discharge. 
 
 History. — Ten days previously she felt a slight pain in the ear, 
 which gradually increased so as to interfere with her rest at night. 
 This continued for eight days, though better at times. Two days 
 previous to seeing me, a discharge appeared from the ear, and has 
 continued. 
 
 On examination, the meatus was seen to be filled with discharge, 
 which, when removed by the syringe, was found to consist of a large 
 white mass of mucus, about the size of an ordinary horse-bean, and 
 of scales of epidermis. The membranous meatus was much tume- 
 fied, its surface being red ; the dermoid layer of the membrana tym- 
 pani was also red and swollen. The hearing distance was only eight 
 inches. 
 
 Treatment. — Two leeches were applied to the orifice of the meatus, 
 which was syringed out with warm water twice daily. The pain 
 gradually subsided, and in six days the discharge had disappeared. 
 
 Case III. Acute inflammation of the dermis; great deafness, and 
 copious secretion of serum. — A. H. H., Esq., aged 38, of a weakly 
 constitution, sent for me in January, 1854. 
 
 History. — For three weeks he had been suffering from an attack 
 of inflammation of the lungs, and four days previously, when becom- 
 ing convalescent, was seized in the night with a violent pain in the 
 left ear. This, in spite of treatment, lasted for about twelve hours, 
 when a sudden burst of discharge took place from the ear, which 
 much diminished the pain. "When seen by me on the fourth day 
 after the discharge had appeared, there was still great sensitiveness 
 
92 T 11 E D I S E A S E S F T II E E A R. 
 
 of tlic meatus, and so great an amount of deafness, that the watch 
 Avas not heard even when in contact with the ear. On examination, 
 the dermis was found swollen and red, and the dermoid layer of the 
 membrana tympani in the same state. So copious was the secretion 
 of serum, that in half an liour a white handkerchief was perfectly 
 saturated with it. Great fear was felt lest the car should have been 
 seriously injured by the inflammation ; but finding that the mem- 
 brana tympani stood out naturally, and feeling that congestion of 
 the tympanic mucous membrane Avas quite suflfiicient to produce the 
 deafness, hopes were held out that the hearing would return as soon 
 as the congestion subsided. A leech was ordered to be applied to 
 the margin of the orifice every second day : the meatus was syringed 
 out with warm water twice daily, and slight vesication was used at 
 the back of the ear. In the course of three days the discharge began 
 to subside, the pain ceased, and at the end of ten days the hearing 
 was restored. 
 
 Case IV. Frequent attacks of inflammation of the dermis; hear- 
 ing power natural. — Miss C, aged 28, consulted me on March 7th, 
 1854. 
 
 History. — During two years has been subject to attacks of pain 
 in each ear, followed by discharge, after which there has been an 
 intolerable itching. Three months ago, she suffered from one of 
 these attacks of pain, since which she has had a constant irritation. 
 On examination, the dermis lining each meatus was observed to be 
 red and swollen. The hearing distance of each ear was natural. 
 By applying leeches to the margin of the orifice of the meatus the 
 irritating symptoms disappeared, and the recurrence of the attacks 
 of inflammation was prevented. 
 
 ACUTE INFLAMMATION OF THE DERMOID MEATUS EXTENDING 
 TO THE BRAIN. 
 
 Anatomical observations. — The bloodvessels ramifying through 
 the membranous meatus are directly continuous with those entering 
 and supplying the osseous meatus ; the intimate connection between 
 the dermis of the meatus and the bone is therefore very obvious. 
 The relations of the osseous walls of the external meatus to the 
 cavity of the cranium are deserving attention. In the adult, it will 
 be found that the upper wall of the meatus consists of a solid 
 lamina of bone, varying from a line to two lines in thickness, which 
 
THE EXTERNAL MEATUS. 93 
 
 separates the cavity of the meatus from that occupied by the middle 
 lobe of the cerebrum. In some cases, a prolongation of the tym- 
 panic cavity is found extending into the substance of the upper wall 
 of the meatus. In the child, these relations differ remarkably from 
 those just detailed. At birth, and for the first year subsequently, 
 the only rudiment of the osseous external meatus is the superficial 
 depression situated in the middle of the outer and lower part of the 
 pars squamosa, immediately posterior to the root of the zygomatic 
 process. This depression, to which the name "fossa auditoria" may 
 be appropriately applied, has the rudiments of the mastoid process 
 posterior to it ; its surface is smoother, and its substance denser, it 
 also contains fewer foramina for the transmission of bloodvessels, 
 than the surrounding bone. At the period of birth, the portion of 
 bone forming the fossa is not more than half or three-quarters of a 
 line thick, and the membranous meatus is attached to the outer, the 
 dura mater of the middle cerebral cavity to the inner surface. Its 
 structure is far from being compact or dense, and in its substance 
 the bloodvessels from the meatus communicate with those of the 
 dura mater. 
 
 As the bone approaches maturity, the fossa assumes an oblique 
 position, and forms the upper wall of the external auditory meatus, 
 while it is separated from the cavity of the middle cerebral fossa by 
 a dense layer of bone, into which cells communicating with the tym- 
 panic cavity are not unfrcquently prolonged. In the adult, the 
 fossa auditoria has nearly lost its oblique direction, and become a 
 horizontal lamina of bone. 
 
 From the foregoing remarks, it will be evident that disease of the 
 membranous meatus externus is liable to extend to the outer surface 
 of the bone, and thence to the interior. In the only case of fatal 
 chronic disease which has fallen under my notice, the disease ad- 
 vanced, posteriorly, to the lateral sinus. 
 
 Acute injlammation of the dermoid meatus may arise from the 
 application of cold to the ear, or from the irritation of a foreign 
 body : but neither cause is usually sufficient to produce extensive 
 inflammation of the brain or its membranes, unless considerable con- 
 stitutional irritation coexists. 
 
 For the particulars of the following case I am indebted to Dr. 
 Nairne, who gave me the opportunity of dissecting the ear. 
 
 Case V. Acute inflammation of the dermis of the external meatus, 
 extending to the brain and its membranes, caused by jJieJcine/ the ear 
 
94 THE DISEASES OF THE EAR. 
 
 with a pin. — Mary Wells, a single -woman, aged 24, of a scrofulous 
 family, was attacked on the 1st April, 1841, with severe pain in the 
 right ear, Avhich for some hours was distracting, and was followed by 
 a sensation of something bursting, and by a discharge of blood and 
 water, that afforded immediate relief. She had, prior to this, suf- 
 fered no pain, and could only account for what happened from 
 having picked her car with a pin, to relieve a tingling in it. The 
 discharge was mixed with blood for two days, and ceased entirely at 
 the end of the week, when she felt pretty well. In a few days, 
 however, she had a rigor, followed by violent pain in the ear, which 
 lasted twenty-four hours, when a copious purulent discharge took 
 place, giving relief as before. She was now free from pain, and felt 
 in good health. The discharge continued profuse until the 24th of 
 April, when it again ceased. The next day she was seized with 
 violent pain in the right ear and side of the head, accompanied by 
 vomiting and symptoms of general fever. As the bowels were con- 
 fined, she was purged. On the 28th, the pain in the head returned 
 with great severity, and towards evening extended towards the right 
 ear, unaccompanied with pain or redness, or increase of pain on 
 pressure. She vomited twice. Ever since the first attack, the 
 hearing on the right side had been aff"ected, and during the last few 
 days she had complained of noise in the ear and giddiness, and car- 
 ried her head bent backwards.^ The pain increased, and on the 30th 
 she was admitted into St. George's Hospital, and ordered a calomel 
 pill and haustus sennte. 
 
 On the 1st of May, her state was as follows : — Pulse 104, full, 
 sharp, and compressible ; tongue red and glazed ; the skin hot and 
 dry; the conjunctiva slightly injected. There was slight intolerance 
 of light, and a peculiar sensitiveness of the sense of touch, so that she 
 shrank from the approach of a finger, though, when touched, she felt 
 no pain. Iler eyes were bright, and in constant motion ; the right 
 pupil was a little more dilated than the left. The respiration was 
 quick (thirty-two per minute). The countenance was placid, though 
 the manner was rather hurried. The catamenia were present. She 
 was cupped, had cold lotion applied to the head, and calomel and a 
 black dose were administered. During the following night she was 
 delirious, though the senses could be recovered by an effort. 
 
 May 2d, 1 P.M. — There Avas a slight degree of opisthotonos this 
 morning, and the nurse remarked that, on her getting out of bed, 
 
 ' Mr. Mauie, who saw the patient two or three time?, was of opinion that an abscess was 
 forming in the internal ear. 
 
THE EXTERNAL MEATUS. 95 
 
 there was a peculiar rigidity of the muscles. She was, however, 
 quite comfortable, and said that the headache went awaj about an 
 hour after the cupping. Pulse 120, sharp but compressible ; tongue 
 red and glazed. She was ordered a blister behind the right ear, and 
 three grains of hydragryrum cum creta, were administered night and 
 morning. 
 
 3d. — The feverish symptoms were somewhat abated, and she had 
 some quiet sleep in the morning. The urine passed in natural quan- 
 tity. 
 
 4th, 1 P.M. — Pulse again sharper, though the tongue was moist. 
 The eyeballs were tender and suifused. No pain complained of, but 
 she moans on being moved. The countenance is depressed, and she 
 throws the clothes off her ; she is, however, quite sensible when spoken 
 to. Ice was ordered to be applied to the head. To proceed with 
 other medicines. 
 
 3 P.M. — Is heavier and less sensible. 
 
 6 P.M. — The ice was applied about 4 o'clock, soon after which she 
 went into a comatose state, occasionally, however, waving her hands, 
 and appearing to recognize her friends. 
 
 5th, 11 A.M. — Became perfectly comatose about 4 A.M. She is 
 now perspiring profusely. Pupil of right eye contracted. She 
 died at 12. 
 
 Dissection of the body tivcnty-six hours after death. The iveather 
 warm. Head. — There were a few patches of lymph upon both 
 hemispheres of the brain, immediately beneath the arachnoid, which 
 was more vascular than natural. The convolutions of the brain 
 were flattened and its substance was watery, but not soft, with the 
 exception of the corpus callosum, fornix, and the parts contained 
 in and near the lateral ventricles, which broke up easily on a slight 
 touch. The cavities of the ventricles were large, and contained a 
 quantity of turbid fluid. The pons Varolii, medulla oblongata, 
 and adjacent nerves Avere smeared with concrete, purulent lymph, 
 effused into the cavity of the arachnoid. The cellular tissue around 
 the optic nerves and their union, contained pus. The cerebellum 
 Avas somewhat softer than natural. The dura mater coverina: the 
 surface of the petrous bone was very vascular, and its vessels were 
 distended Avith blood ; it Avas also separated from the bone by a 
 small quantity of serous fluid. The substance of the bone Avas of a 
 dark color, its bloodvessels being distended. On examining the in- 
 ternal ear, the membrana tympani Avas found to be entire, but both 
 
96 TIIEDISEASESOFTIIEEAR. 
 
 it and the mucous meinbane liiiin<i; tlie tympanic cavity were more 
 vascular than natural. The chief" disease was found in the external 
 meatus, of which the membrane lining the inner third was soft, 
 highly vascular, easily detached from the bone, and covei-ed by 
 purulent matter. There was no appearance of ulceration on the 
 surface. 
 
 II. CuRONic Inflammation of the Dermis lining the Meatus. 
 
 This affection may be divided into — 
 [a.) Simple Chronic Inflammation. 
 (Z».) Chronic Catarrhal Inflammation. 
 
 {a.) Simple chronic inflammation. 
 
 This form of disease, without discharge, is frequently met with, 
 and is often associated with a declining state of health, though it 
 occasionally occurs as a purely local affection. One of the most 
 common predisposing causes is residence in a moist atmosphere. In 
 some very obstinate cases, change of air has been requisite before 
 the affection could be abated. The exciting causes appear to be the 
 same as those of acute inflammation, viz., the application of cold, or 
 of any irritating substance to the meatus ; perhaps the most common 
 exciting cause is the habit of picking the ear with some foreign body. 
 The symptoms of chronic inflammation arc a feeling of distention in 
 the ear, often coupled with slight pain, or with an intense itching. 
 Sometimes the dermis is tumefied, so that the canal is diminished to 
 one-half, or even to one-fourth of its natural size. In other cases, 
 the dermis is scarcely at all swollen, but its free surface is red, and 
 the epidermis is thrown off in large flakes. These flakes of epidermis 
 accumulate and form large masses, which consist of several layers, 
 and these masses are apt to block up the meatus, and produce a 
 serious diminution of the hearing power. Occasionally this epider- 
 mis collects in such large masses as to dilate the meatus, or to cause 
 disease of the bone ; in other instances, it produces acute inflamma- 
 tion of the dermoid meatus, and of the dermoid layer of the mem- 
 bran a tympani. 
 
 Treatment. — AVhcn there is hypertro})hy of the dermis, Avithout 
 much tenderness, a solution of nitrate of silver (5j @ SJ) may be 
 applied twice a week ; and slight counter-irritation be kept up at 
 
THE EXTERNAL MEATUS. 97 
 
 the same time over the mastoid process. If the surface of the dermis 
 is denuded of epidermis in parts, and more vascuhir than natural, 
 the meatus should, in the first place, be syringed with warm water, 
 
 Fig. 24. 
 
 Epidermis from the External Meatus in the form of a tubular cul-de-sac, and a layer 
 arranged circularly. 
 
 in order to remove all the particles of epidermis which are apt to 
 cause irritation, and at the same time soothe the dermis. While the 
 syringing is being carried on, an astringent lotion may be applied, 
 on cotton- wool, to the surface of the meatus. After the inflamma- 
 tory symptoms are subdued, a weak solution of nitrate of silver 
 (gr. X. @ Ij) may be applied twice daily. Should the epidermis 
 continue to collect within the meatus, it must be removed by the 
 syringe, which is generally sufficient for that purpose, notwithstand- 
 ing that the removal of masses of epidermis, on account of its den- 
 sity, and the close way in which one layer folds within another, re- 
 quires considerable patience. 
 
 CASES. 
 
 Case I. Simple chronic inflammation of the dermoid meatus. — R. 
 P. A., Esq., aged 47, in good health, consulted me on July 4, 1853. 
 
 History. — During the last year and a half, he has suffered at 
 times from extreme itching, with dulness of hearing, followed by 
 slight discharge. Upon examination, the meatus of each ear, near 
 the orifice, w\as found to contain a large quantity of soft cerumen ; 
 at the middle part the dermis was of a deep red color, and the blood- 
 vessels were enlarged and tortuous. The hearing distance with the 
 right ear was eighteen inches ; with the left, seven. 
 
 Treatment. — Each meatus was washed out with half a pint of 
 warm- water, twice daily ; and at night a lotion, consisting of a 
 solution of chloride of zinc in water (gr. ij @ 5j), was applied on 
 
 7 
 
98 THEDISEASESOFTHEEAR. 
 
 cotton-wool to each meatus. In the course of a fortniirht he was 
 quite cured. 
 
 Citse II. SimpU chronic inflammation, with desquamation of the 
 epidermis. — Miss E. P., aged 39, in a somewhat debilitated state, 
 consulted me on July 1, 1853. 
 
 History. — During the last two or three winters, after attacks of 
 cold, had suffered a good deal of pain in each ear, accompanied by 
 deafness. The pain remains for two or three days, then a skin 
 comes away followed by relief to the pain, and improvement in the 
 hearing. Six months *ago had a very bad attack, succeeded by dis- 
 charge, which continued for a few days. During the last three 
 years has suffered from considerable irritation in the ears. On 
 examination, the meatus of each ear was found red in parts — a red- 
 ness that, on the left side, extended to the dermoid layer of the 
 membrana tympaiii. Portions of epidermis adhered to the sur- 
 face of the dermis ; and when these were removed, the dermis was 
 quite denuded. The hearing distance of the right ear was three 
 inches ; of the left, one inch. 
 
 Treatment. — Two leeches were applied to the margin of the 
 orifice of each meatus ; warm water was syringed into each ear twice 
 daily ; and, when the congestion was diminished, a solution of nitrate 
 of silver in water (gr. v. @ 5J) was daily applied to both. A small 
 portion of vesicating paper Avas also applied over each mastoid 
 process, and tonic medicines were administered. This treatment 
 afforded great relief; and when I saw the patient again in December, 
 the hearing Avas very much improved, and there was an abundant 
 secretion of cerumen in each ear. There had been one attack in 
 the left ear in the month of August. 
 
 Case III. Clironic inflammation of the dermis, with great hyper- 
 trophy. — Miss T., aged 57, in tolerable health, consulted me in 
 January, 1853, on account of great irritation and deafness in each 
 ear. 
 
 History. — During the last five or six years has had attacks of 
 deafness, accompanied by a considerable swelling in each ear. When 
 the swelling decreased, the hearing power partially returned. About 
 three weeks ago felt mirch irritation in both ears, accompanied, at 
 times, by pain and much dulness of hearing, but not by discharge. 
 On examination, cacli meatus was discovered to be so tumefied that 
 the tube would only admit an ordinary sized probe ; the surface of 
 
THE EXTEKNAL MEATUS. 99 
 
 the dermis was of a plum color : the watch was not heard, except 
 when pressed on the ear. 
 
 Treatment. — Leeches Avere ordered to be applied to the orifice of 
 each meatus, and to be followed by the use of a solution of nitrate 
 of silver (5ss @ oj). I did not hear the result. 
 
 Case IV. Chronic inflammation of the dermoid meatus ; accumu- 
 lation of epidermis. — The Rev. G. T., aged 55, consulted me in July, 
 1850, on account of pain in the left ear, with accompanying deafness. 
 
 History. — During several months has had a tenderness in the left 
 ear, with a sensation of fulness, and a diminution of the hearing 
 power: latterly these symptoms have increased. On examination, 
 the surface of the outer half of the meatus was observed to be red, 
 and somewhat tumefied, and the inner half was completely full of 
 epidermis. Hearing distance with the watch, two inches. 
 
 Trcat?nent. — The collection of epidermis was removed by the 
 syringe and warm water. This operation, however, required the 
 greatest care, on account of the extreme tenderness of the surface 
 of the meatus ; even the ordinary stream of water from the syringe 
 being productive of great pain. After the removal of the collection, 
 the hearing power was greatly improved. The surface of the dermis 
 being red, a weak solution of nitrate of silver was applied to the sur- 
 face of the meatus twice a week, which effected further improve- 
 ments ; but the epidermis again collected. After its removal, mild 
 astringents were used, and the ear was syringed frequently with 
 warm water, which diminished the inflammation, but the epidermis 
 still continues to collect, and requires removal by the syringe every 
 two or three months. The moist atmosphere in which this patient 
 lives, is probably a cause of the unyielding character of the affection. 
 
 (5.) Chkonic catarrhal inflammation of the dermoid 
 
 MEATUS. 
 
 This disease has been frequently classed among the cases of otor- 
 rhoea. As its name implies, it consists of chronic inflammation of 
 the dermoid meatus, with accompanying discharge. In many in- 
 stances, the disease is confined to the meatus ; but in others, it 
 advances to the dermoid layer of the mcmbrana tympani. It most 
 commonly occurs in children ; though by no means rare in adults. 
 In childhood, it is usually accompanied by a tendency to glandular 
 enlargements or some other sign of constitutional debility. In the 
 adult, it is also too often symptomatic of a depressed state of health. 
 The exciting cause may be an attack of acute inflammation of the 
 
100 THE DISEASES OF THE EAR. 
 
 dermis, an injury, the use of stimulating applications, or attacks of 
 measles, scarlatina, or catarrh. Often this affection has no assign- 
 able cause, and appears with a sliglit itching in the ear ; sometimes, 
 indeed, the appearance of discharge is the first indication of diseased 
 action. In the early stages, there is usually but little diminution 
 of the power of hearing, even •when the inflammation and hyper- 
 trophy extend to the dermoid layer of the membrana tympani. 
 When the disease has remained for some time, the mucous mem- 
 brane of the tympanum is apt to participate, and deafness to result. 
 It must, however, be borne in mind, that catarrh of the dermoid 
 meatus, and of the dermoid layer of the membrana tympani, are 
 frequently symptomatic of irritation within the tympanic cavity, 
 and that these exterior symptoms cease as soon as the internal irri- 
 tation is overcome. In these cases of sympathetic catarrh of the 
 dermoid meatus, there is usually a history of previous irritation in 
 the tympanum, and much dulncss of hearing commonly precedes the 
 appearance of the discharge. After this affection has persisted some 
 time, there is often a great degree of irritation in the meatus ; some- 
 times there is pain, and now and then a discharge of blood. The 
 latter symptom, however, is more common where a polypus is pre- 
 sent. 
 
 On examination of cases of catarrh of the dermoid meatus, the 
 dermis is generally found thicker than natural ; sometimes so much 
 so as nearly to close the tube. While in some cases the surface 
 (denuded of epidermis) is red, in others it is blanched. The dis- 
 charge has usually a very offensive odor ; and its hue varies from 
 milky white to dark slate color. The peculiarity of this discharge 
 is, that Avhatever may be its quantity, color, or consistence, there 
 are no masses of mucus floating in it : but it mixes freely with 
 water, producing a general opacity. In cases, however, in which a 
 polypus coexists with this form of inflammation, the discharge con- 
 tains flocculent mucus, as also in cases of ulceration of the fibrous 
 laminae of the membrana tympani : sometimes there is also discharge 
 of blood. Wiicn chronic catarrhal inflammation extends to the der- 
 moid layer of the membrana tympani, the structure of this mem- 
 brane, like that of the dermoid meatus, becomes hypertrophicd, and 
 often mucli congested ; the membrane itself loses both its natural 
 color and form ; its outer surface is flattened ; while the processus 
 longus, an<l frequently the processus brevis, are completely con- 
 cealed bv it. 
 
THE EXTERNAL MEATUS. 101 
 
 The treatment of chronic catarrh of the dermoid meatus consists 
 in the efficient and frequent use of the syringe and warm water, to 
 thoroughly remove the discharge, and cleanse the tube. Should 
 there be symptoms of pain or irritation, one or two leeches should be 
 applied to the margin of the orifice of the meatus, and be followed 
 by the use of warm fomentations, steam-baths, or poultices. On the 
 disappearance of the irritation, weak astringent injections may be 
 used, and slight counter-irritation be kept up over the mastoid pro- 
 cess. These measures, coupled with the administration of tonic 
 medicines, and attention to the general health, will frequently put 
 a stop to the affection. In more obstinate cases, it is requisite to 
 keep up a discharge over the mastoid process by means of vesication 
 or croton oil liniment: a solution of nitrate of silver (10 to 40 grains 
 to the ounce) should also be applied to the surface of the meatus 
 every third day. Some cases, in spite of all remedies, are but 
 slightly ameliorated, after two or three months' treatment ; it is, 
 notwithstanding, of great importance that the treatment be perse- 
 vered in to prevent the supervention of caries of the bones, ulcera- 
 tion of the membrana tympani, and the development of polypus. 
 
 Case V. Chronic catarrhal inflammation of the dermoid meatus 
 during teething. — J. A., aged nine months, pale, and weakly, was 
 admitted under my care at St. Mary's Hospital, in November, 1854, 
 on account of an offensive discharge from the left ear. 
 
 History. — The mother stated, that about two months previously, 
 when the child was irritable and restless from teething, a discharge 
 took place from the left ear. Small at first, the quantity had gra- 
 dually increased and become very offensive. 
 
 On examination, the left external meatus was seen to be full of a 
 Avhite milky discharge, that, when the ear was syringed, mixed with 
 the water, Avhich became opaque and milky, and masses of epidermis 
 floated; but there was no appearance of mucus. After the discharge 
 had been removed, the calibre of the tube was observed to be dimi- 
 nished one-half by the swelling of the dermis, whose inner surface 
 was denuded of epidermis and somewhat redder than natural : the 
 dermoid layer of the membrana tympani was flat and white. 
 
 Treatment. — Daily exercise in the open air was ordered, and cod- 
 liver oil administered. The surface of the body was to be sponged 
 daily with tepid water, and the ear to be syringed out with warm 
 water twice daily, and a solution of chloride of zinc (one grain to an 
 ounce of water) to be applied on cotton to the tube of the ear during 
 
102 THE DISEASES OF THE EAR. 
 
 the night. The health of the child soon greatly improved, the quan- 
 tity of discharge diminished, and, in six weeks, entirely ceased. 
 
 Case YI. Catarrh of the dermis in both ears of a child, causing 
 dulness of hearing. — Master E. M., aged three years and a half, 
 was brought to me on April 6, 1855, on account of a discharge from 
 the ear, with dulness of hearing. He was pale and thin, his general 
 health not good, and he was subject to enlargements of the cervical 
 glands. 
 
 History. — About two years previously, without assignable cause, 
 a discharge suddenly flowed from the right ear, and after another 
 month the left ear was similarly affected ; the discharge being abun- 
 dant and the odor very off"ensive. After continuing for three or 
 four months, the discharge disappeared from both ears ; but about 
 a month before consulting me, it had reappeared with the same symp- 
 toms as at first. 
 
 On examination, each meatus was found full of milky discharge, 
 and rod on the surface : the substance of the dermis swollen. The 
 dermoid layer of the membrana tympani Avas red and thick. The 
 hearing power was so diminished that he required to l^e loudly spoken 
 to at the distance of two yards. The watch was unheard except 
 when in contact with the right ear, or when pressed upon the left. 
 It was evident that inflammation had extended to the tympanic 
 cavity as well as to the membrana tympani. 
 
 Treatment. — Both ears to be washed out with tepid water thrice 
 daily, and afterwards to be syringed with a solution of acetate of 
 zinc (five grains to the ounce) ; a portion of vesicating paper to be 
 applied over each mastoid process every second night, and two tea- 
 spoonfuls of steel wine to be given twice daily. This treatment in 
 two months produced considerable benefit, the (quantity of discharge 
 diminished, and the power of hearing improved. This improvement, 
 however, did not continue, and at the end of the year I saw him 
 much in the same state as when first brought to me. I then found 
 that the syringing had been very imperfect, a large quantity of dis- 
 charge being left in the ears after the operation. Strict attention 
 to this point was enjoined ; a solution of nitrate of silver (gr. x. @ 
 5J) was applied to the surface of the dermis by means of a camel's 
 hair pencil, night and morning ; the vesicating paper was again used, 
 and cod-liver oil prescribed. This treatment having been pursued 
 for three months, the discharge had ceased, although the power of 
 hearing was not wliollv restored. 
 
THE EXTERNAL MEATUS. 103 
 
 Case Yll. Chronic catarrhal inflammation of the dermis: great 
 irritation. — Mrs. A., aged 30, consulted me in August, 1856. She 
 was in tolerable healtli. 
 
 History. — Two years previously she experienced at times great 
 irritation and pain in the tube of each ear, followed by discharge : 
 thinks the affection was caused by residence, in a damp house ; it 
 was aggravated by exposure to cold air. Since the above period 
 has had several similar attacks, and the ears are never quite free 
 from itching and discharge. The power of hearing has not been 
 diminished. 
 
 On examination, the surface of the dermis in both ears was found 
 denuded of epidermis, red, slightly tumefied, and covered by a mu- 
 cous discharge. Each membrana tympani was healthy. The hear- 
 ing was natural. 
 
 Treatment. — As there was evidently much congestion, two leeches 
 were applied to the margin of the orifice of each meatus, and both 
 ears syringed with warm water twice daily. In the course of a week, 
 the congestion having much diminished, a solution of nitrate of silver 
 (gr. vj @ 5J) was applied to the surface of each meatus by means of 
 a camel's hair brush, twice daily. Under this treatment, and the 
 occasional use of the syringe with warm water, the irritation sub- 
 sided and the discharge disappeared. The affection, however, was 
 slightly reproduced by a continuance of damp weather, or a reduc- 
 tion of the state of health ; but speedily subsided under treatment. 
 
 Case VIII. Chronic catarrh of the 7neatus extei'nus after scarlet 
 fever, accompanied by j^^'^'^^ ^'^^ t^^^ head. — E. D., aged 7, Avas ad- 
 mitted under my care at St. George's and St. James's Dispensary 
 on the 21th February, 1815. At three years old, he had an attack 
 of scarlet fever, followed by ear-ache and discharge from each ear : 
 after every attack of pain, discharge appeared. At present, and 
 for the last two years, has complained of pain at the back of the 
 head. On examination, the membranous meatus of each ear Avas 
 found red, thicker than natural, and pouring out a milky secretion. 
 Each membrana tympani was opaque, and its dermoid layer thick 
 and vascular. The treatment consisted in the frequent use of the 
 syringe and warm water, the application of a leech now and then to 
 the margin of the orifice of the meatus, and tonic medicines. At 
 the end of ten weeks under this plan the hearing greatly improved, 
 and the symptoms of pain in the head disappeared. 
 
10-1 THE DISEASES OF THE EAR. 
 
 (c.) Chronic catarrhal inflammation of the dermoid mea- 
 tus EXTENDING TO THE BRAIN. 
 
 It is not common for chronic catarrhal inflammation to extend to 
 the bone and the brain ; at least I have met with but one well- 
 marked case, in which death was the result. 
 
 Case. IX. Catarrhal injlammation of the dermoid layer of the 
 external meatus, with caries of the jJosterior ivall ; disease extending 
 to the lateral sinus and cerebellum. — Harriet Baker, aged three 
 years and a half, was admitted under my care at the St. George's 
 and St. James's Dispensary, on the 6th December, 1848. Her 
 motlier stated that the child had always been sickly ; and at five 
 months old a thick creamy discharge had been seen to ooze from 
 the left ear, which, though not abundant, was very ofiensive. The 
 child had not till recently complained of pain, but now and then 
 asked to have the ear picked, because of its itching. Three weeks 
 ago the discharge ceased, violent pain ensued in the ear, with a 
 swelling over the region of the mastoid and squamous processes, 
 which caused the car to project from the side of the head : great 
 restlessness and delirium followed, and she was constantly throwing 
 herself iibout. 
 
 On examination, the surface of the dermis was red and denuded 
 of epidermis; it was smooth but not ulcerated, and much thicker 
 than natural, so that the cavity of the meatus was only one-third 
 of its proper calibre. The membrana tympani was absent. The 
 abscess behind the ear had opened ; and about a wine-glassful of 
 pus, of a most offensive odor, having been discharged, the sur- 
 face of the squamous and mastoid processes was felt to be rough 
 and carious. Linseed-meal poultices were applied. 
 
 Dec. 9th. — The discharge continues very copious ; the pain and 
 tumefaction have extended to the temporo-maxillary articulation, so 
 that the jaw can be opened but a very little way. 
 
 14th. — The discharge, lately so abundant, has now ceased, while 
 the pain and restlessness have greatly increased ; the hands liave 
 been kept applied to the head. 
 
 The head-symptoms continued to increase till the 29th, when the 
 patient died in a state of great emaciation. 
 
 Post-mortem inspection. — On removing the calvarium, the dura 
 mater appeared healthy, as well as the arachnoid and pia mater. 
 The lateral ventricles contained about half an ounce of perfectly 
 clear serum. Upon the removal of the cerebrum there was no ap- 
 
THE EXTERNAL MEATUS. 
 
 105 
 
 pearance of disease ; the dura mater and arachnoid covering the 
 upper part of the left petrous hone were quite healthy. When the 
 tentorium was removed, the left hemisphere of the cerebellum was 
 
 Fig. 25. 
 
 The Internal Surface of the Temporal Bone, showing the two orifices in the Lateral Sinus 
 which were filled by the cerebellum, and also showing the carious Sulcus Lateralis. 
 
 observed to be much softer than natural, and the portion in contact 
 Avith the posterior surface of the pars petrosa was dark in color and 
 very soft. Upon gently drawing it backwards, it was found to be 
 applied against two orifices in the posterior part of the lateral sinus, 
 and to be separated from the cavity of the sinus by the thickened 
 arachnoid and pia mater. A considerable vessel in the pia mater, 
 opposite the orifice, was distended by a firm and dark coagulum, 
 half an inch in length. The anterior membranous wall of the 
 lateral sinus was absent ; the bone forming the sulcus lateralis in 
 the mastoid process was carious, and the sinus full of a dark-colored 
 coagulum and purulent matter ; pus was also found in the jugular 
 veins. 
 
 The ear. — The dermis lining the whole of the external meatus 
 was soft, tumefied, and dark-colored, and its surface Avas devoid of 
 epidermis ; beneath it, posteriorly, Avas purulent matter, Avhich sepa- 
 rated it from the carious bones. The membrana tympani Avas absent ; 
 but there Avas no more appearance of disease in the tympanic cavity 
 than might have been produced by the afi"ection of the meatus. The 
 
100 
 
 THE DISEASES OF THE EAR, 
 
 bone was carious anteriorly as far as the root of the zygomatic pro- 
 cess and the fossa for the articuhition of the lower jaw ; superiorly 
 and posteriorly, the caries extended for the distance of an inch and 
 
 Fig. 26. 
 
 The External Surface of the Temporal Bone, showing the carious portion extending from 
 the Mastoid Process posteriorly to the root of the Zygomatic Process anteriorly. 
 
 a quarter, nearly to the margin of the parietal bone ; but in some 
 parts the external table only Avas affected, while in others it ex- 
 tended to the diploe and thence to the internal table. On holding 
 the bone up to the light, small orifices were seen through it ; so that 
 its external surface, or that part which was covered by the mem- 
 branous meatus, was directly continuous with the lateral sinus. 
 
 The progress of the disease in this case from without inwards, is very 
 remarkable; for there is no evidence to prove that the disease origina- 
 ted elsewhere than in the meatus ; and it is apparent, from the direct 
 communication by bloodvessels between the membranous meatus 
 and the bone forming the lateral sinus, that disease could easily be 
 transferred from the inflamed meatus to the bone beneath. Careful 
 consideration of the subject has, however, induced me to believe that 
 the progress of disease from the meatus, inwards, to the internal 
 sinus and cerebellum, is of rare occurrence ; and to think that the 
 majority of the cases of this kind recorded as having oc(?urred to 
 previous inquirers, were really instances of disease advancing from 
 the tynipanic cavity or mastoid cells outwards, to the meatus, in 
 which process the cerebellum and lateral sinus were implicated. 
 
 Treatment. — I have already stated it to be my opinion, founded 
 
THE EXTERNAL MEATUS. 107 
 
 on a consideration of some of the cases already adduced, that when 
 a disease of the brain originates in a chronic affection of the ear, 
 the cause of its prolongation to the brain may be traced to the want 
 of a free egress for the matter. 
 
 The modes in which this matter may be confined are various. In 
 the case of the external meatus, the tumefied walls, together Avith its 
 peculiar valvular disposition as seen in infants, create a sufficient 
 barrier to the free egress of the secretion. In the tympanic cavity, 
 the matter is usually retained by the membrana tympani, Avhicli 
 either Avholly or partially prevents its escape ; sometimes, however, 
 the hypertrophy of the mucous membrane is itself sufficient to shut 
 up the secretion in parts internal to it ; and occasionally even the 
 thick accumulated matter itself may prove a bar to the egress of 
 that which is beyond it. In the case of the mastoid cells, it appears 
 that the matter may be retained by the peculiar position of their 
 horizontal portion, the floor of Avhich is often below that of the 
 orifice into the tympanum ; or it may occupy the vertical portion of 
 the cells, Avhicli is quite beloAV the part leading into the tympanum. 
 The rules to be laid doAvn in the treatment of chronic catarrh of the 
 dermoid meatus, the mucous membrane of the tympanum, and the 
 mastoid cells, are as follow : — 
 
 1. By attention to the general health to attempt to diminish the 
 catarrh. 
 
 2. To secure, if possible, a free exit for the secreted matter. 
 
 3. By keeping up an external discharge, to cause that within the 
 ear to be absorbed ; and thus to arrest further secretion, and allay 
 the diseased action. 
 
 General Treatment. — As far as general measures go, the same 
 observations will apply to the diseases of each of the different parts 
 of the ear. As it seems probable that the usual predisposing cause 
 of these diseases is a scrofulous diathesis, every means should be 
 taken to invigorate the health. Abundant exercise in the open air, 
 especially in the country or by the sea-side, simple, nutritious, but 
 not stimulating diet, and mild tonic medicine, are to be specially 
 recommended. Great care should be taken that the patient sleeps 
 in a Avell-ventilated room, in a bed without curtains, the head being 
 kept high and cool, and above the bed-clothes. Everything which 
 is liable to excite must be sedulously avoided ; and rough play, in 
 which the head is apt to receive a blow, must not be allowed. From 
 whatever source the discharge comes, it is desirable, when practi- 
 
108 THE DISEASES OF TUE EAR. 
 
 cable, that the membrane whence it issues should be washed fre- 
 quently with tepid water ; hence the use of the syringe is of great 
 importance.^ When there is congestion, the application of one or 
 two leeches is desirable, and sometimes gentle counter-irritation 
 should be resorted to. This may be eflfected by a liniment to be 
 rubbed over or around the ears and down the spine. Gentle astrin- 
 gents may also be used. "Whatever may be the source of the dis- 
 charge, as a general rule, its continuance for some months after the 
 exciting cause is symptomatic of a scrofulous or otherwise unhealthy 
 diathesis ; and, in spite of every effort, the hypertrophied membrane 
 is but very slowly affected, and consequently the discharge is gene- 
 rally of long duration. It is important, however, that the medical 
 man, knowing the exact nature of the disease, and its peculiarly 
 chronic character, should inform the parents or friends of the patient 
 that any attempt to stop the discharge by powerful astringents, or 
 otherwise than by gentle means, may be attended with serious con- 
 sequences, as the production of acute inflammation. Here, perhaps, 
 I may be excused a few words on a subject so frequently adverted 
 to as the danger of stopping a discharge from the ear. The sup- 
 posed danger of an arrest of the discharge by local applications 
 seems to have originated in the knowledge of the fact, that one of 
 the most common symptoms in the early stages of acute inflamma- 
 tion of the ear, following upon a chronic disease, is the cessation of 
 the discharge which previously, and often for many years, had been 
 constant. There can be no doubt that in these cases the cessation 
 of the discharge is one of the effects, and not one of the causes of 
 the inflammation ; for other symptoms of inflammatory action may 
 usually be observed before the discharge disappears. In cases 
 where strong astringents have been employed in order to arrest a 
 discharge from the ear, the symptoms that follow are not dependent 
 upon the cessation of the discharge (for, indeed, the discharge does 
 not always diminish), but upon the inflammation caused by the irri- 
 tant. 
 
 To sum up what has been said respecting the general treatment, 
 
 ' Many of the syringes in common use are very inefficient, as tbey do not send the water 
 into the ear with sufficient force to remove the discharge. The best and most simple for 
 patients to use, is the four ounce vulcanized india rubber bottle, made by Bell & Co. The 
 metal nozzle should be made so as to allow of being easily removed. When the syringe is 
 to be filled, the nozzle should be taken rut, and the fluid to be injected should be poured 
 into the bottle , or it may be allowed to fill itself, the air having been previously expelled 
 by pressing the sides together. 
 
THE EXTERNAL MEATUS. 109 
 
 where there is simple chronic catarrh from the dermoid meatus, mem- 
 brana tympani, or the tympanic mucous membrane, with free egress 
 for the matter : when there are symptoms of congestion, apply one 
 or tAvo leeches near the part aftected ; syringe the ear frequently 
 Avith an abundant supply of Avarm Avatcr ; use mild astringent lotions, 
 and endeaA'or to improve the health by every means possible to the 
 patient. In face of all these measures, the medical man may expect 
 to see the disease make very sIoav progress toAA'ards amelioration ; 
 but he must be content that its advance iuAvards toAvards the bone 
 and the brain is averted. 
 
 In cases of catarrh of the dermoid meatus there is A^ery frequently 
 some source of irritation of the tympanic mucous membrane, of 
 which the catarrh of the meatus is but a symptom. Thus it is not 
 uncommon to find obstruction of the Eustachian tube, even at the 
 faucial orifice, attended by catarrhal inflammation, and even by 
 polypus in the meatus ; both of Avhich secondary affections wholly 
 disappear Avhen the primary disease is removed. Cases of simple 
 catarrh of the dermoid meatus do, hoAvever, occasionally occur : and 
 one Avhich terminated fatally has already been cited. As a general 
 rule they may be distinguished from the secondary cases by the 
 absence of all appearance of disease in the tympanic cavity ; by the 
 power of hearing being but slightly aff'ected, and by the healthy 
 state of the membrana tympani, except an occasional increased 
 vascularity of its dermoid layer. Primary catarrh from the dermoid 
 layer usually occurs in children suff"ering from debility ; when the 
 dermis, instead of secreting its epidermis, pours forth a Avatery fluid 
 composed of serum, in Avhich float epidermoid cells in different stages 
 of development. This discharge has often an extremely offensive 
 odor, dependent generally, not upon the presence of dead bone, 
 but upon a deranged action of the ceruminous glands. The discharge 
 from the meatus, in cases of chronic catarrh, diff"ers from that which 
 attends the same affection in the tympanum in the Avay already 
 pointed out ; and it usually subsides under the use of a syringe and 
 tepid Avater, tonic medicine, and the ordinary plans for strengthening 
 the constitution of the patient. When the health is much deranged, 
 it may take some months to eff'cct a cure ; but during the Avholc of 
 this period daily syringing must be practised. 
 
 (d.) Ulceration of the dermoid meatus. 
 
 Cases of catarrh of the dermoid meatus, if neglected, may advance 
 to ulceration ; the bone mav become diseased, and a small osseous 
 
110 THE DISEASES OF THE EAR. 
 
 lamina may eventually be discharged ; but ulceration of the soft 
 meatus usually arises from the pressure of dead bone from the mas- 
 toid cells making its way tlirough the orifice of the meatus. 
 
 Besides the ulceration of the dermis, alluded to above, as resulting 
 from disease of the bone, a second kind of ulceration, viz., having a 
 syphilitic character, is also met with. Its local treatment does not 
 differ from that pursued in other ulcerations of the dermoid structure. 
 
CHAPTER VI. 
 
 THE EXTERNAL MEATUS {continued). 
 POLYPI. 
 
 CAUSES OF POLYPUS SYMPTOMS — THREE SPECIES OF POLYPUS: 1. THE CELLULAR RASP- 
 BERRY POLYPUS — STRUCTURE — TREATMENT WITH POTASSA CUM CALCE — CASES — TREAT- 
 MENT BY REMOVAL WITH THE LEVER-RING FORCEPS — CASES. 2. THE FIBRO-GELATINOUS 
 POLYPUS — STRUCTURE — TREATMENT — CASES. 3. THE GLOBULAR CELLULAR POLYPUS 
 — STRUCTURE — TREATMENT — CASES. 
 
 Polypi. — Polypoid groAVths are not unfrequently met with in the 
 meatus, and, as already stated, are generally the result of long-con- 
 tinued irritation of its dermoid layer; sometimes, however, they 
 arise from chronic inflammation of the mucous membrane of the 
 tympanum, or from obstruction of the Eustachian tube. As a rule, 
 polypi are attached to the surfiice of the dermoid layer of the meatus, 
 although I have met with cases in which they sprang from the outer 
 surface of the membrana tympani, and in one dissection I found 
 what appeared to be a polypus growing from the inner surface of 
 the latter. The existence of a polypus is always attended with a 
 discharge of matter ; arising usually from two sources, — the dermoid 
 layer of the meatus, and the surface of the polypus itself. In some 
 cases there is a flow of blood, and generally a very offensive odor. 
 A polypus, when small, usually causes little inconvenience, nor is 
 its presence commonly detected, except by careful inspection ; — when 
 it grows large, however, a sensation of fulness is felt in the ear, and 
 not unfrequently there is a sense of heaviness, giddiness, and con- 
 fusion in the head. These latter symptoms are greatly increased 
 when the polypus projects beyond the meatus, and happens to be 
 pressed upon. Such pressure I have known to produce complete 
 insensibility. Sometimes there is also a shooting pain extending 
 from the car to the temple. These symptoms of cerebral irritation 
 
112 THE DISEASES OF THE EAR. 
 
 frequently cause great alarm to the patient and his friends, and appear 
 to be the result of pressure of the polypus on the outer surface of the 
 membrana tympani, and chain of ossicles, ^vhich causes a movement 
 inwards, towards the cavity of the vestibule, of the inner extremity 
 of the chain, producing continuous tension of the fluid of the vesti- 
 bule. This is clearly shown by careful inspection of a specimen 
 prepared by me for the purpose, by which it is manifest, that although 
 there are two articulations between the long process of the malleus 
 and the base of the stapes, yet the slightest movement inwards of 
 the processus longus mallei causes the base of the stapes to be 
 pressed inwards towards the cavity of the vestibule : and, as has 
 been already stated, pressure on the contents of the vestibule 
 appears to produce results very similar to those of pressure on the 
 brain. According to my own observation, the former gives rise to — 
 first, a sensation of noises ; secondly, confusion of ideas ; thirdly, 
 giddiness and insensibility. 
 
 In all cases of discharge from the meatus, the first step is by the 
 syringe to cleanse the tube. This done, there is no difficulty in 
 determining Avhether a polypus be present, even though it should be 
 situated close to the membrana tympani. 
 
 Polypi of the external meatus may be divided into three classes. 
 
 1. The one of most frequent occurrence, and which may be called 
 the raspberry cellular polypus. 
 
 2. That Avhich has been termed the fibro-gelatinous polypus. 
 
 3. The globular cellular polypus. 
 
 Each of these classes, and its treatment, will now be separately 
 described. 
 
 1. The Raspberry Cellular Polypus. 
 
 I have given this name to the polypus most frequently met with, 
 which consists of numerous round beads, very similar in appearance 
 
 Fig. 27. 
 
 Raspberry Cellular Polypus. 
 
 to the free surface of the raspberry. These beads are attached by 
 small filaments to a central stem, which forms the root. Frequently 
 
THE EXTERNAL MEATUS. 
 
 113 
 
 it is covered by ciliated epithelium, and Avhen examined micro- 
 scopically, its interior is found to be composed of small rounded 
 
 Fig. 28. 
 
 Cellular structure of the Raspberry Polypus. 
 
 cells. So soft is it usually, that upon being seized by the ordinary 
 dressing forceps, it breaks up, and bleeds freely. This kind of 
 polypus varies much in size ; being sometimes not larger than a 
 grain or two of mustard-seed, and at others so largo as to fill the 
 whole of the meatus, and project from the orifice. It is attached to 
 various parts of the meatus, but generally to the inner half of the 
 tube, and frequently close to the membrana tympani. When small, 
 its color is usually deep red ; but as it grows, it becomes paler, and 
 the rounded masses considerably increase in size. The formation 
 of these polypi is often attended with considerable pain, and by a 
 
 Fig. 29. 
 
 A large Raspberry Polypus, visible at the orifice of the Meatus. 
 
 discharge of blood ; but it is not uncommon for them to remain un- 
 disturbed for several years, during the whole of the time throwing 
 off a most offensive secretion, and yet not producing symptoms suflS- 
 
 8 
 
114 THE DISEASES OF THE EAR. 
 
 cientlj urgent to induce tlie patient to apply for relief; while in 
 other cases, again, the head-symptoms are so distressing as to cause 
 serious alarm. 
 
 The treatment usually adopted consists either in applying astrin- 
 gent lotions and drops, or in endeavoring to remove the mass hy in- 
 strumental means. As to astringent applications, there can be no 
 doubt that they are usually ineffectual in preventing the growth of 
 the polypus, in diminishing its vascularity, or in abating the quan- 
 tity of secretion. The same remark applies to the use of nitrate of 
 silver ; for even under the influence of a strong solution of this sub- 
 stance, or of the solid nitrate of silver itself, I have seen the cellular 
 polypus not only retain its vascularity, but rapidly increase in size. 
 The two plans adopted by me ior the removal of this kind of poly- 
 pus, are the application of the potassa cum calce, and the use of the 
 lever-ring forceps. 
 
 1st. Of the use of the jjotassa cum calce. — In the early part of 
 1852, a series of papers were published by me in the Medical Times 
 and Gazette^ advocating the use of the potassa cum calce ; but since 
 then I have suggested the use of the lever-ring forceps, the employ- 
 ment of which is so satisfactory that now I seldom resort to the 
 former method. As, however, few medical men are likely to pos- 
 sess that instrument, and as the use of the potassa cum calce ap- 
 pears to be the next best plan for the removal of this excrescence, 
 it is as well to give the result of my experience in that respect. In 
 the first place, it is of consequence that the substance used should 
 be made into very thin sticks. Those supplied to me by Mr. Squire, 
 in the form recommended by Dr. H. Bennet, answer the purpose 
 extremely well so long as they retain their size and form ; but as 
 this substance deliquesces very rapidly, the greatest care should be 
 taken to exclude it from the air. For use at St. Mary's Hospital, 
 the potassa cum calce has been manufactured by Bailey, of Wolver- 
 hampton, and recast into smaller sticks by Hopkins <5c AVilliams, of 
 New Cavendish Street. This material contains a small quantity of 
 iron, which makes its firmer and less deliquescent than that made in 
 the usual way. The latter preparation, as not requiring so much 
 care, may perhaps suit those better Avho are not often required to 
 apply the remedy ; though that which is free from iron is decidedly 
 the most efficacious. 
 
 In applying the potassa cum calce, the first step is to syringe out 
 the ear with warm water, and the next to dry it with cotton-wool. 
 
THE EXTERNAL MEATUS. 115 
 
 The patient should then be phiced before a strong light, so that the 
 surgeon, having a distinct view of the polypus, may take a stick of 
 the caustic in the right hand, while he liolds the ear back with the 
 left ; but the greatest care must be taken not to touch the surface 
 of the meatus, which is so extremely sensitive that the pain produced 
 by the action of an escharotic upon it is most acute. For the pur- 
 pose of shielding the meatus, an oval glass tube may be used ; it is 
 to be passed down the meatus as far as the polypus, when, by 
 gentle pressure, a portion of the excrescence may be made to enter 
 the distal end of the tube. The polypus, unlike the meatus, has but 
 little sensibility, and the potassa is to be pressed gently against it, 
 the immediate effect of which is to decompose the whole of the sub- 
 stance to which it extends. If a pair of rectangular forceps be em- 
 ployed, neither the hand of the surgeon, nor the instrument he em- 
 ploys, will prevent the operator from seeing the polypus while he is 
 making the application, and he can be sure that he touches the Avhole 
 of the free surface. If this opei'ation be carefully effected, the 
 patient scarcely complains of pain ; but if any portion of the escha- 
 rotic happens to reach the surface of the tube, the acute pain it 
 causes can be immediately arrested by syringing the ear with warm 
 water, which should always be at hand. Supposing the potassa to 
 have been thoroughly applied, the color of the polypus at once 
 changes from a bright red to a livid hue. After the operation, the 
 patient should sit still for three or four minutes ; and if the glass 
 tube has been employed, it should be allowed to remain fixed as 
 during the operation. Upon inspecting the polypus after three or 
 four minutes, it will be found to be broken up, and blood to be ooz- 
 ing from it ; while instead of its former rounded head, it presents 
 an uneven pulpy mass. The meatus should next be syringed out 
 with tepid water, when blood mixed with the debris of the polypus 
 in a filamentous form comes away. The surface of the polypus still 
 retains its dark color, and, during several hours, a process of slow 
 dissolution takes place in all that part which the escharotic has 
 reached. If tlie cotton-wool has rendered the polypus quite dry, it 
 is desirable to moisten the potassa very slightly. As a general 
 rule, the potassa may be again applied the following day ; and the 
 process, already described, repeated, until the Avhole mass is de- 
 stroyed. 
 
 Case I. Vascular jJolypi near the memhrana tympani; singing in 
 the car ; power of hearing diminished; treated ivith potassa cum 
 
116 THE DISEASES OF THE EAR, 
 
 calce; cure. — Mr. W. L., aged 40, was sent to me on the 20tli July, 
 1850, by Mr. Cock, of Guy's Hospital. He was a large, strong 
 man, and in good health. He stated that five or six months ago he 
 found that he was dull of hearing in the left ear ; this dulness was 
 removed by the use of the syringe, which brought away a large 
 quantity of cerumen. He remained without cause of complaint 
 until three months ago, Avhen the symptom returned in the left ear. 
 He was again in some measure relieved by syringing ; but this ope- 
 ration was followed by a discharge of very offensive character, at- 
 tended by a sensation of singing in the ear. He has at times com- 
 plained of slight pain in the ear. On examination, the meatus was 
 found to be full of matter, Avhicli, after being removed, was seen to 
 consist of adhesive mucus mixed with epidermoid cells ; the latter 
 giving a milky aspect to the matter. The former presented nume- 
 rous small flocculi, or rather little particles like cotton thread, from 
 a line and a half to three lines in length. On re-examination of the 
 meatus, after this mucous fluid had been withdrawn, a red-colored 
 polypus was seen, situated deep in the meatus, of which it apparently 
 occupied the inner fourth, entirely obstructing the view of the mem- 
 brana tympani. The power of hearing was much diminished, a watch 
 not being heard except when pressed upon the outer ear. From 
 the treatment of similar cases, I thought it undesirable to attempt a 
 removal of this mass by instruments, not only on account of the soft 
 nature of the polypus and its extreme sensitiveness, but also from the 
 uncertainty as to the part to Avhich the roots of the polypus Avere 
 attached ; I felt also that if it were fixed to tlie membrana tympani, 
 the use of any force might be injurious to that organ. Having since 
 ascertained by dissections^ that the dermoid layer of the meatus is 
 continuous with the dermoid lamina of the membrana tympani, it 
 appears desirable on this account also not to use any force to a 
 polypus attached to the vicinity of the membrana tympani, since a 
 laceration of the meatus is likely to extend to the membrane. 
 
 July 21st. — The potassa cum calce was applied' to the surface of 
 the polypus in the way previously described ; and in the course of 
 a minute the whole of that part of the polypus which could be seen 
 became of a livid hue, and, when tlie ear was syringed with tepid 
 water five minutes afterwards, numerous small particles of the poly- 
 pus, softened and disintegrated, were brought away. The patient 
 
 'See, by the author, "On the Structure of the Membrana Tympani in the Human 
 Ear."— Philos. Trans. Part I, 1851. 
 
THE EXTERNAL MEATUS. 117 
 
 complained of but very slight pain, -wliicli entirely disappeared on 
 using the syringe. 
 
 29th. — The polypus is smaller and less red ; the discharge from 
 the meatus very copious. The potassa cum calce Avas again applied 
 with similar results. 
 
 August 13th. — The polypus is observed to be much smaller. In- 
 stead of the mass which, at the first examination, had an appearance 
 like a raspberry, there was now only a rounded button, about a line 
 and a half in diameter. The potassa cum calce repeated. 
 
 Oct. 18th. — The discharge is much diminished ; its odor is less 
 fetid ; polypus nearly gone ; and the power of hearing much im- 
 proved. 
 
 Nov. 13th. — Since the last visit, a lotion, composed of a drachm 
 of tannin to eight ounces of water, has been used twice daily. The 
 discharge has now nearly disappeared, and consists almost entirely 
 of epidermoid cells. The only vestige of the polypus consists in the 
 presence of two very small buttons, each the size of a small pin's 
 head ; these are attached to the upper part of the membranous mea- 
 tus, close to the membrana tympani. 
 
 29th. — The use of the injection has been continued ; there is now 
 no vestige of the polypus ; the singing noise has ceased ; but the 
 surface of the membrana tympani is dull. Hearing distance of the 
 watch, six inches. 
 
 The features of interest in this case appear to be : first, that al- 
 though the escharotic Avas only applied at intervals of several weeks, 
 the polypus did not increase in those intervals, but, on the contrary, 
 gradually diminished ; secondly, with the destruction of the polypus 
 the singing also entirely disappeared ; thirdly, the return of the 
 power of hearing to so great an extent. 
 
 Case II. Discharge from the left ear during many years ; giddi- 
 ness ; polypus; treated by jjotassa cum calce ; cure. — The Rev. H. 
 C, aged 40, consulted me on the 21st April, 1851. His constitu- 
 tion was not robust, as he had spent some time in India. The his- 
 tory of his case is, that the left ear has been deaf from childliood : 
 that since early life he has been troubled with a discharge of offen- 
 sive matter from tliat ear ; and that lately he has complained of 
 attacks of giddiness, especially upon suddenly rising from his chair. 
 Upon examination, a red polypus was observed to fill the inner half 
 of the meatus. The same treatment was adopted in this case as in 
 the last, with the exception that, as the patient lived in the country, 
 
118 THE DISEASES OF THE EAR. 
 
 he luul the potassa cum calce applied two or three times in the space 
 of nine or ten days, and then a larger interval elapsed hefore it 
 was affain used. The same result, however, ensued ; and at the 
 end of six months the pol^-pus had disappeared, and the symptoms 
 of friddiness wholly vanished. 
 
 In another case, that of a patient aged 26, where the polypus filled 
 the whole of the meatus, portions were removed by forceps and the 
 remainder destroyed by potassa cum calce. The symptom of spe- 
 cial interest in this case was the production of giddiness by pressure 
 on the outer part of the polypus. 
 
 In cases of polypus which coexist with catarrhal inflammation of 
 the dermoid meatus, it is desirable to keep a slight counter-irritation, 
 by vesicating paper, over the mastoid process, Avhile the polypus is 
 being treated by the potassa cum calce. In order to remove the 
 unpleasant odor of the discharge, an injection, composed of one part 
 of the solution of chloride of lime to twelve parts of water, may be 
 used three or four times daily. 
 
 2d. On the removal of the vascvlar jyoli/pns hy the lever-ring foreeps. 
 — Every surgeon who has attempted to remove a polypus, especially 
 when situated near to the membrana tympani, must have found him- 
 self unsuccessful, if he has used the ordinary forceps. In the first 
 place, it is almost impossible to lay hold of the growth, on account of 
 the small size of the tube preventing him from separating the blades 
 of the instrument ; and should a large meatus enable him to do this, 
 the instrument blocks up so much of the tube that he cannot see 
 whether he lays hold of the polypus or not. Should the surgeon 
 even succeed in seizing the polypus, he will find that it breaks up 
 and the roots are not touched. 
 
 Various instruments have been invented, having for their object 
 the removal of the small vascular polypi from the external auditory 
 meatus. Of these, one of the best is the snare of Mr. "Wilde, thus 
 described at page 420 of that gentleman's work on " Aural Sur- 
 gery :"— 
 
 " It consists of a fine steel stem, five inches long, and bent in the 
 centre, with a movable bar sliding on the square portion near the 
 handle, which latter fits over the thumb. The upper extremity is 
 perforated with holes running parallel with the stem, and loops at 
 the angle serve the same purpose. A fine wire, fastened to the 
 cross-bar, passes through these loops and holes; it should be of such 
 length, that when the cross-bar is drawn up tight to the handle, the 
 
THE EXTERNAL MEATUS. 
 
 119 
 
 ligature is fully on the stretch. ... In using it, the cross-bar is 
 pushed forward, and a noose made of the wire at the small extre- 
 
 FiG. 30. 
 
 mity, of sufficient size to include the morbid growth, which it is then 
 made to surround, and towards the roots of which it is pressed by 
 means of the stem ; the cross-bar is then drawn up smartly to the 
 handle, while the point of the stem is pressed downwards ; and it 
 never fails of either cutting across, or of drawing with it whatever 
 was included in the noose." 
 
 The difficulty attendant upon the use of this instrument, consists 
 in getting the wire noose around the polypus, which frequently is of 
 very small size ; another disadvantage is, that it cuts off a portion 
 of the growth, instead of withdrawing it entire. 
 
 The instrument which I have been in the habit of using during 
 several years at St. Mary's Hospital, as well as in private practice, 
 with most satisfactory results, I have called the lever-ring forceps. 
 In the interior of a tube is a delicate steel rod, the end of which is 
 split into two portions, each having a small oval ring at its extre- 
 mity, measuring four or five lines long, and from tAvo to three broad. 
 These rings (the inner surfaces of which are slightly serrated) are 
 separated from each other when the lever is not pressed ; but as soon 
 as it is pressed, the rings are brought into contact. The instrument 
 
 Fig. 31. 
 
 The Lever-ring Forceps, open. 
 
 is introduced into the meatus with the rings apart, which having 
 been made to inclose the polypus, or a portion of it, between them, 
 the lever is pressed down, the polypus seized, and instantly drawn 
 out. 
 
120 THE DISEASES OF THE EAR. 
 
 Case III. A cellular raspbc7-ri/ j^olypus in each ear removed hy the 
 lever-ring forceps; great improvement. — M. I., aged 20, in good 
 health, but having a tendency to glandular enlargements, consulted 
 me on March 7th, 1853. 
 
 History. — "When a child, suffered on several occasions from attacks 
 of deafness, Avhich lasted from ten days to three or four months, but 
 by degrees disappeared. Between three and four years ago, the 
 left ear began to discharge, and has ocntinued to do so up to the 
 present time. Within the last two months, the power of hearing in 
 the left ear has so much decreased that he requires to be loudly 
 spoken to close to it. A month ago, the right ear began to discharge, 
 and is nearly as deaf as the left. 
 
 On examination, the Avatch was heard by the left ear when pressed 
 against it ; by the right when in contact. In each ear, near to the 
 membrana tympani, was a large vascular polypus. When an attempt 
 at a forcible expiration was made with closed nostrils, air passed 
 freely out of the left meatus, but not through the right. The mucous 
 membrane of the fauces was thick and red. 
 
 Previous treatment. — Excision of the tonsils, and the introduction 
 of cotton-wool into the bottom of the meatus. Neither operation was 
 productive of benefit. 
 
 Treatment. — The polypus, by means of the lever-ring forceps, was 
 first removed from the right ear. The patient stood upright, and 
 reclined the head slightly towards the left shoulder. The gas lamp 
 being held between the teeth, the patient's car was drawn backwards 
 by the left hand, so as to dilate and straighten the meatus as much 
 as possible ; a large-sized speculum was next introduced ; and then, 
 with the right hand, the lever-ring forceps was gradually pushed 
 down to the polypus with the rings in contact. As soon as the rings 
 reached the polypus they were allowed to separate, and when thus 
 apart were made to surround the growth ; when this was effected, 
 the rings were brought into contact by pressing on the lever. The 
 instrument Avas then AvithdraAvn, bringing with it the polypus, and 
 leaving the membrana tympani exposed. During the whole of the 
 operation I Avas able to see Avhat I Avas doing, the rod of the instru- 
 ment being so small as to occupy only a trifling portion of the tube. 
 On the folloAving day the hearing of the patient Avas much improved, 
 the Avatcli being heard at a distance of tAvo inches ; and the quantity 
 of discharge had greatly diminished. The polypus in the left meatus 
 Avas noAv attacked ; but as only small portions of it came aAvay at a 
 
THE EXTERNAL MEATUS. 121 
 
 time, three or four operations were required, wliicli were followed by 
 mueli improvement. A large aperture was detected in the membrana 
 
 Fig. 32. 
 
 The Lever-ring Forceps holding a Polypus. 
 
 tympani, and, by the aid of the artificial membrane, the hearing 
 power was still further improved. 
 
 Case IV. Obstruction of the Eustachian tiihe atthefaucial orifice; 
 cellular i^olypus in the external meatus; removal; cure. — H. W., 
 Esq., aged 19, pupil to an architect, consulted me on February 
 19th, 1854, on account of deafness in both ears, and discharge from 
 the right. 
 
 History. — From childhood has been subject to attacks of deafness 
 during a cold ; but they have disappeared after a duration of three 
 or four weeks. About two years ago, he had an attack of deafness, 
 which was folloAved by discharge from the right ear ; this has lately 
 increased, while the hearing power has considerably diminished. At 
 the present time he has to be spoken to in a loud voice within the 
 distance of a yard. On examination, the watch was heard only 
 when in contact with the right ear. There was a large quantity of 
 mucous discharge in the meatus, on removing which, a red polypus, 
 with numerous projections from its surface, Avas seen to occupy the 
 inner half of the tube. The Eustachian tube was impervious. Left 
 ear — hearing distance six inches ; membrana tympani opaque and 
 partly calcareous ; the Eustachian tube impervious ; and the mucous 
 membrane of the fauces red and thick. 
 
 Treatment. — On the 25th February, by means of the lever-ring 
 forceps, I removed a polypus as large as a horse-bean, which was 
 attached to the posterior surface of the meatus, close to the mem- 
 brana tympani. On the 1st March, the discharge had nearly 
 
122 THE DISEASES OF THE EAR. 
 
 vanished ; and the membrana tympani vas seen to be entire, though 
 calcareous at parts. The hearing was much improved ; the ■\vatch 
 being heard at the distance of two inches. Tonic medicines were 
 administered ; the surface of the body to be sponged Avith vinegar 
 and water ; and an acid astringent gargle to be used thrice daily. 
 
 March 8th. Hears much better. Two days before, after garg- 
 ling, a sudden crack was felt in the right ear, after which he heard 
 most acutely. Does not hear quite so well to-day, but still hears 
 general conversation. 
 
 April 3d. — The left ear has also much improved : can now hear 
 perfectly. 
 
 March, 1855. — Have seen this patient recently, and he has re- 
 mained quite well. 
 
 CaseY. Cellular poll/pus, causing deafness and serious cerebral 
 symptoms; removal; cure. — I. E., Esq., aged 21, was sent tome 
 by Dr. Conolly on the 10th February, 1855, on account of deafness 
 in the left ear, accompanied by occasional giddiness. 
 
 History. — Since six years of age has been subject to an offensive 
 discharge from the left ear, with an occasional flow of blood : has 
 not experienced pain, but has frequently had a sensation of fulness 
 in the ear ; and Avhen the ear has been pressed upon, there has been 
 considerable giddiness. Recently, symptoms of unnatural mental 
 excitement have been experienced. On examination, it was found 
 that the watch could not be heard, though the crack of the nails 
 was distinguishable. On looking into the ear, a polypus was seen 
 within half an inch of the orifice of the meatus, deep red in color, 
 and covered by a transparent discharge. Pressure at once produced 
 a sensation of giddiness. 
 
 Treatment. — The polypus being of a large size, and somewhat 
 firm, it was resolved to attempt its removal by the ring forceps ; a 
 considerable portion of the mass was thus extracted but the roots 
 remained. Great relief at once followed the operation ; and ulti- 
 mately the lever-ring forceps succeeded in removing the rest of the 
 morbid growth. The membrana tympani was found to be entire ; 
 the hearing was greatly improved, and the head-symptoms wholly 
 disappeared. 
 
THE EXTERNAL MEATUS. 123 
 
 2. The Fibho-Gelatinous Polypus. 
 
 Next in frequency of occurrence to the vascular is the one termed 
 the gehitinous polypus. This name has been given to it from the 
 soft jelly-like appearance of its free portions, and from the similarity 
 of its general aspect to the gelatinous nasal polypus. Careful and 
 minute examination, aided by the microscope, docs not, however, 
 confirm the propriety of the designation, for, as will be seen pre- 
 sently, the term '■'■fibro-gelatlnous polypus" would be the more ap- 
 propriate appellation. 
 
 Structure of gelatinous jjolt/pus. — This morbid growth generally 
 attains to a large size. There are in my museum specimens vary- 
 ing from the size of the last joint of the thumb to that of a small 
 bean. Sometimes this polypus has a single root and body, but more 
 usually two or more bodies have a common base. The root, which 
 is attached to the wall of the meatus, is generally not larger than a 
 line or two lines in diameter. Examining the polypus as it ap- 
 proaches the orifice of the meatus, near the root will be found at- 
 tached numerous small rounded growths very like delicate granula- 
 tions, which appear to be the rudimentary growths prevented from 
 developing by the pressure exerted upon them by the Avails of the 
 meatus and the larger expanded part of the outer portions of the 
 
 Fig. 33. 
 
 Fibro-gelatinous Polypus ; the pedicle is to the right, the two rounded masses 
 projected from the orifice of the meatus. 
 
 growth. Approaching the orifice of the meatus the polypus assumes 
 a globular form, consisting of from one to as many as six or eight 
 rounded heads. When. these heads are numerous, they have pedicles, 
 varying in length from a quarter to half an inch, and connecting 
 them with the root. The surface of this polypus is smooth, and is 
 constituted of a layer of about a quarter of a line thick, which may 
 
124 TUE DISEASES OF THE EAR. 
 
 be separated from it l)y maceration, and Avliicli consists of cells bear- 
 ing every resemblance to those of the epithelium covering the buccal 
 mucous membrane. This epithelial layer is as thick and Avhite as 
 ordinary writing-paper ; and ■when detached and floating about, it 
 retains the shape of the polypus of •which it had formed the surface. 
 The interior of the gelatinous polypus is composed of corpuscles and 
 fibrous tissue, varying in proportion in different specimens ; but the 
 fibrous tissue generally predominates. The corpuscles have a rounded 
 form, but vary in size and shape. In a specimen ■which Avas a fair 
 example of this kind of polypus as it comes under the notice of the 
 surgeon (it being Avhite and soft, and readily compressible by the 
 thumb and finger), I found these cells varied in shape from a perfect 
 round to an irregular oval, — and in size, from that of a blood-cor- 
 puscle to a half or one (juarter of its dimensions, the greater number 
 appearing certainly smaller than the blood-disc ; but they presented 
 every variety of size between that disc and a fine granule ; and there 
 ■was very little symmetry in form or size even between those which 
 were nearest to each other. These cells are not generally in close 
 contact, but are separated by a delicate gelatinous substance, which 
 is sometimes quite transparent and structureless, and occasionally so 
 abundant as to form by far the largest portion of the mass. In parts 
 where the polypus is resisting, these cells are separated by delicate 
 wavy bands, having the appearance of fibres ; and to the surface of 
 these fibres the cells arc observed to adhere. In some parts these 
 ■wavy gelatinous-looking fibres form almost the entire substance of 
 the polypus, the rounded cells being scattered very sparingly ; in 
 others these fibres are absent. The wav}^ fibres run in the long dia- 
 meter of the polypus, possess considerable toughness, and although 
 
 Fio. 34. 
 
 Structure of the Fibro-gelatinou? Polypus. 
 
 easily separated from each other and isolated, they cannot be torn 
 across without considerable force. In some instances these fibres 
 are extremely firm, and the polypus is entirely composed of them, 
 
THE EXTERNAL MEATUS. 125 
 
 SO as to become solid and very hard. When separated from each 
 other, they wear the appearance of transparent lines, whose diameter 
 varies from half to a ({uarter of that of the blood-disc. Interspersed 
 through the substance of the polypus Averc many spindle-shaped 
 crystals. On the application of acetic acid, the fibres became 
 swollen, and assumed a confused gelatinous appearance, losing all 
 their fibrous character ; the corpuscles were also converted into a 
 similar mass, in which, however, a large number of granules were 
 observable. The action of the acetic acid also brought into view 
 a large addition to the number of fine spindle-shaped crystals pre- 
 viously seen. The gelatinous polypus sometimes attains to so great 
 a degree of hardness that it is Avith difficulty cut through by a pair 
 of scissors ; a condition Avhich appears to be produced by the in- 
 crease in quantity and solidity of the fibrous tissue, the diminution 
 of the quantity of corpuscles, and the absence of the gelatinous 
 matter betAveen them. It has been already stated that the Avascular 
 polypus is composed of rounded cells ; which, however, differ very 
 much from the cells of the gelatinous polypus, in being all of nearly 
 the same size and shape, and larger than those previously described. 
 The cells of this polypus do not appear to be separated by any 
 substance, but they are agglomerated together and form the entire 
 mass of the polypus. Its exterior also is smoother than that of the 
 gelatinous kind, is always covered by its secretion, and is composed 
 of a layer of epithelial cells Avhich frequently terminate in ciliae, that 
 often continue in active motion for a long time after the removal of 
 the portion of polypus AA-hich they cover. 
 
 Treatment of the gelatinous polypus. — The diiference in the struc- 
 ture of the three kinds of aural polypi, naturally prepares the sur- 
 geon for a difierence in their treatment. This is undoubtedly neces- 
 sary. The use of the potassa cum calce, which has proved so effica- 
 cious in the destruction of the vascular polypus, is of but little 
 service in the treatment of the gelatinous, or, more properly speak- 
 ing, the fibro-gelatinous polypus. The escharotic produces so trifling 
 an effect upon fibrous tissue, that removal by extraction must always 
 be resorted to. For this purpose, the best instrument is a pair of 
 ring forceps, the ends of Avhich should be reduced in size so as not 
 to be larger than from two to three lines in diameter. These for- 
 ceps should be introduced into the meatus to the distance of half or 
 three-quarters of an inch, and the polypus seized as near as possible 
 to its roots ; the forceps should then be used as a lever, the outer 
 
126 THE DISEASES OF THE EAR. 
 
 part of the car being tlie fulcrum, and the polypus turned out of the 
 cavity. But little force is required ; and, as a general rule, the 
 diseased growth is extracted without difficulty in an entire state. 
 
 Fig. 35. 
 
 The Ring Forceps. 
 
 In one case, that of the wife of a medical man, a large gelatinous 
 polypus, which filled the greater part of the meatus, was removed 
 by the frequent use of the syringe and Avarm water. The traction 
 produced by the water in making its way outwards, seemed in the 
 first place to diminish the supply of blood to the growth, which gra- 
 dually darkened in color, and was ultimately expelled. On exam- 
 ining the meatus after the removal of the polypus, the surface to 
 which it was attached is distinctly discernible, and, for a short time, 
 there is a slight oozing of blood from it. In some cases, portions 
 of the root of the polypus remain ; they do not, however, generally 
 require any further treatment, but gradually wither and disappear. 
 If, on the other hand, any of the small globular bodies remain at- 
 tached to the root, they rapidly increase, and the diseased growth 
 has again to be submitted to operation. The removal of the fibro- 
 gelatinous polypus is generally productive of relief, not only to the 
 unpleasant head-symptoms caused by its pressure on the contents of 
 tlie vestibule, but to the diminished power of hearing. The latter 
 improvement does not, as might be supposed, take place at once ; 
 on the contrary, it is not unusual for there to be at first no increase 
 of hearing power, though it gradually and very slowly improves. 
 This may, perhaps, be accounted for by the circumstance, that the 
 polypus has for a long period exerted considerable pressure upon 
 the membrana tympani, or, where that structure no longer exists, 
 upon the tympanic ossicles; which organs only slowly return to their 
 natural state. 
 
 Case Yl. Crelatinoiis j)olypus in the left ear for sei^en years — in 
 the right ear for one year ; noises in the right ear; giddiness upon 
 
THE EXTERNAL MEATUS. 127 
 
 pressure of the polypus. Cure hy extraction, folloived hy the appli- 
 cation of alum and chloride of zinc. — Harriet Wenlock, aged 58, a 
 washerwoman, strong, rather stout, and in good health, Avith the ex- 
 ception of the symptoms produced by the polypus, consulted me in 
 the beginning of April, 1850. She stated that seven years pre- 
 viously, without any other symptoms, a discharge issued from the 
 left ear, which has never disappeared ; and shortly after the appear- 
 ance of the discharge, a rounded body Avas visible at the orifice of 
 the ear. About a year ago, the right ear also began to discharge, 
 and there soon appeared a swelling at the outer orifice. She com- 
 plains of great noises in the right ear ; these vary much : sometimes 
 they appear like a humming, at others like the tinkling of a bell, — 
 then as if it were loudly ringing. When the surface of the tumor 
 in the left ear is pressed upon, she feels giddy, and if it is continued, 
 loses her consciousness, and falls. At present, and for a long time, 
 she has been so hard of hearing, that she requires to be loudly ad- 
 dressed close to the head. On examination of the right ear, a 
 round, pale-colored polypus, more than half an inch in diameter, 
 was seen protruding from the orifice of the meatus, beloAV which 
 Avas another groAvth about half the size. At the external meatus of 
 the left ear a rounded body Avas observable, of not more than a line 
 in diameter, and not extending beyond the orifice. Not finding any 
 symptoms which indicated an affection of the bone, I thought it best 
 at once to remove the polypi, and selected the right ear to begin 
 upon. The diseased groAvth Avas remoA'ed with the greatest ease by 
 the use of the ring dressing forceps in the manner before described ; 
 the patient suffered only a slight and momentary pain, and there 
 Avas a very trifling oozing of blood. On examining it after removal, 
 the polypus Avas found to consist of the tAvo rounded heads already 
 noticed, each having a second mass, about half the size, continuous 
 Avith it, and extending nearly as far as the root, Avhich was A'ery 
 narroAv, not being more than a line or a line and a half in diameter. 
 The surface of the expanded part of this polypus was found to be 
 covered Avith flat scabs, like those of epidermis ; but nearer to the 
 root, elongated cells, armed with ciliae, Avere also distinguishable. 
 The rounded parts, Avhich were exposed to the air, AA'ere smoother 
 and Avhiter than those which were concealed ; the latter presenting 
 a somewhat rugous surface. On April 22, a fortnight after, exa- 
 mination shoAved the quantity of the discharge to be greater than 
 usual, and a rounded growth Avas perceived near to the membrana 
 
128 THE DISEASES OF THE EAR. 
 
 tjnipani, as if the roots of the polypus still remained ; to this sub- 
 stance a solution composed of half a drachm of alum to two ounces 
 of Avatcr Avas directed to be applied thrice daily. The polypus Avas 
 removed from the left ear, and found to consist of a pedicle, a body, 
 and three rounded heads, tAvo of Avliich had been visible at the orifice 
 of the meatus during life. 
 
 April 20. — The poAver of hearing is improved. Has had slight 
 pain in each ear, also some giddiness. The discharge, though less 
 abundant, is still of an offensive odor. In the right ear the rem- 
 nant of the polypus is seen attached to the upper part of the meatus 
 near to the membrana tympani : in the posterior part of the latter 
 an orifice Avas observed. In the left ear the roots of the polypus 
 appeared to fill as much as one-half of the meatus. The drops of 
 the solution of alum to be continued. 
 
 May 6. — Iliglit ecw. — The discharge has ceased, the hearing has 
 improved, and is much better after bloAving the nose. The polypus 
 has entirely disappeared, and the mucous membrane of the tym- 
 panum, Avliich is thick and red, is seen through the orifice of the 
 membrana tympani. 
 
 Left ear. — The roots of the polypus are much in the same state. 
 
 May 13. — The roots of the polypus remain as a Aveek ago. Ap- 
 plied the chloride of zinc to their surface. 
 
 May 27. — Polypus of left ear smaller ; again applied chloride of 
 zinc. 
 
 June 24. — Discharge from left ear gone. The polypus much di- 
 minished in size. Air passes through the left membrana tympani. 
 The solution of alum Avas continued, and in a fortnight the polypus 
 had Avholly A'anished. 
 
 Case VII. Gelatinous polyims cured hij extraction; hearing poiver 
 improved. — J. W., Es(|., aged 24, a medical student, pale and not 
 strong, consulted me on the 24th Octolier, 1851, on account of so 
 great a degree of hardness of hearing, that he Avas obliged to be 
 spoken to at a distance not further than a foot from his head. He 
 had also an abundant discharge from the left ear. The Itistori/ of 
 the case Avas, that tAvelve years ago he had an attack of porrigo, for 
 Avhich the head Avas shaved. During this attack he AAas very deaf 
 in both cars, but quite recovered. A year ago, he became sloAvly 
 dull of hearing in the right ear ; and for eight months the left ear 
 has been gradually losing its poAver of hearing. Has had pain in 
 the left car lately, Avith a discharge, Avhicli varies much in quantity. 
 
THE EXTERNAL MEATUS. 129 
 
 and has a very offensive odor. On examination, the hearing power 
 of the right ear, tested by the watc]!, was only half an inch ; the 
 surface of the membrana tympani, was dull, and its substance 
 opaque. 
 
 Left ear. — Watch only heard when pressed upon the ear. A 
 polypus filled the meatus and extended as far as the outer orifice : 
 it was removed by the forceps, and the power of hearing sloAvly 
 improved. 
 
 Case VIII. G-elatinous jyolijpus removed hy forceps, and potassa 
 cum calce applied to the roots; cure. — Miss E. II., aged 26, con- 
 sulted me on April 4, 1851, on account of a discharge from the 
 right ear. The lustory of the case, as detailed to me, was, that at 
 the age of sixteen, she had an attack of scarlet fever, with pain in 
 both ears, especially in the right. The pain in the right ear was 
 followed by a discharge, which has continued to the present time, 
 with the exception of its once disappearing for a fortnight, when 
 the pain greatly increased. On examination, a leaden-hued polypus 
 was seen projecting from the orifice of the meatus, which was stated 
 to have been seen there during the four months preceding the appli- 
 cation for advice : pressure upon it had always produced giddiness. 
 This polypus was found to be attached to the posterior and inferior 
 part of the meatus, close to the membrana tympani. It was removed 
 by the dressing forceps ; and as the roots had a tendency to increase 
 in size, the potassa cum calce was applied once, and the growth was 
 effectually destroyed. 
 
 Case IX. Gelatinous polypus folloiving bathing; removed by ope- 
 ration; cure. — J. D., Esq., aged 36, consulted me on May 20, 
 1853, on account of deafness in the right ear, Avith discharge. 
 History. — Five years ago, after bathing in the sea, had pahi in the 
 left ear, followed by a discharge, that has continued ever since, and 
 at times been very offensive. For the last two or three months this 
 ear has become so deaf that he can scarcely hear at all Avith it. On 
 examination., a large gelatinous polypus Avas found occupying the 
 meatus nearly as far as the orifice. It Avas taken out by the ring 
 forceps, and the hearing Avas immediately improved. An orifice 
 Avas detected in the posterior part of the membrana tympani. The 
 patient's hearing continued to improve ; the Avatch Avas heard at a 
 foot from the ear ; and the discharge Avholly disappeared. The 
 roots of the polypus Avere found to have been attached to the sur- 
 face of the meatus in the vicinity of the membrana tympani. 
 
 9 
 
130 the diseases of the ear. 
 
 3. The Globular Cellular Polypus. 
 
 The third kind of polypus developed in the external meatus is the 
 globular cellular species. I have thus named a growth which essen- 
 tially differs from those belonging to the preceding classes. It consists 
 of a single globular mass, perfectly smooth on the surface, and with- 
 
 FiG. 36. 
 
 Globular Cellular Polypus. 
 
 out any appearance of granulation. It is confined to the inner fourth 
 or sixth of the meatus, from the upper part of which it is usually de- 
 veloped, and it hangs down like a curtain, wholly or partially con- 
 cealing the mcmbrana tympani. It is of a deep red color, is softer 
 than the ordinary cellular polypus, and does not generally attain 
 a size larger than a small pea. This growth usually occurs in chil- 
 dren or in young persons ; it is attended by a mucous discharge, 
 which is often very offensive ; and the secretion, like that from other 
 forms of polypus, consists of epidermoid cells, which give a milky 
 appearance to the water after syringing : — it also contains fine 
 threads of mucus. This kind of polypus may exist for several 
 years without producing any severe symptoms ; and it has not 
 hitherto been distinguished from the other varieties of polypus. It 
 may be discriminated from the disease I have called chronic catar- 
 rhal inflammation of the dermoid meatus, by the discharge contain- 
 ing flocculi of mucus, like small particles of thread, and from its 
 always presenting a red mass at the inner extremity of the meatus. 
 This affection also differs from catarrlial inflammation of the meatus, 
 in never terminating in disease of the bone ; the discharge appear- 
 ing to proceed from and be confined to the surface of the polypus 
 only. The aural disease with which the globular cellular polypus 
 is most likely to be confounded, is catarrhal inflammation of the 
 mucous membrane of the tympanum : since, in some cases of the 
 latter, the mucous membrane is of a deep red color, and so much 
 tumefied that it projects into the meatus for a line or a line and a half 
 beyond the position occupied by the membrana tympani previous to 
 
THE EXTERNAL MEATUS. 131 
 
 its destruction. On examining the growth by means of the specu- 
 lum and lamp, it is not always easy to determine which of the two 
 diseases just described is present. The examination of the dis- 
 charge, however, is suflScient to decide the question ; for, although 
 in both aflFections floccular mucus is present, that accompanying the 
 polypus is composed of small thread-like particles, while that emana- 
 ting from the mucous membrane of the tympanum presents large 
 irregidar-shapcd masses, generally of a yellow color. The history 
 of the case will also usually aid the surgeon in forming a diagnosis, 
 as the globular cellular polypus ordinarily appears without the mani- 
 festation of any very decided symptom ; perhaps the appearance of 
 the discharrre is the first indication of its existence : whereas the 
 affection of the tympanum generally originates in an attack of acute 
 inflammation, and often arises during scarlet fever or measles. 
 
 Treatment. — The treatment of this kind of polypus is much more 
 simple than that of the two species first described ; nevertheless, 
 except the true nature of the disease be ascertained, it is useless to 
 employ the astringent applications commonly prescribed to arrest 
 discharjres from the ears. This affection stands between the ordi- 
 nary vascular polypus and catarrhal inflammation of the dermoid 
 meatus ; the former being wholly uninfluenced by the use of the 
 strongest astringents, and the latter being generally curable by 
 weak solutions of them : while the globular cellular polypus, though 
 affected by astringent applications, requires them to be of conside- 
 rable strength. The course of treatment followed by me, consists 
 in syringing out the meatus of the affected ear with tepid water, to 
 remove all discharge ; and after the ear has been turned towards 
 the shoulder of the side affected, to alloAV of the water running out, 
 then to let three or four drops of an astringent solution fall into the 
 meatus, and close the ear for half an hour by a portion of cotton- 
 wool, moistened with the solution. This course may be repeated 
 twice, thrice, or oftener, during the day, care being taken that the 
 sediment from the solution be removed before the drops are repeated. 
 The preparations used by me are the acetate of lead, zinc, alum, or 
 tannin ; but the first-named has, I think, answered best. This 
 species of polypus may often be removed in a week, or from that to 
 a fortnight ; and, to prevent any congestion in the tympanic cavity, 
 a slight discharge from the surface of the mastoid process has gene- 
 rally been kept up during the employment of the astringent solu 
 tion. 
 
132 THE DISEASES OF THE EAR. 
 
 Cane X. Globular ccUuIar iwlypus ; discharge for three years; 
 cured hy the soJutlun of liquor plumhi. — Miss F. A., aged 12, of a 
 rather -weakly constitution, Avas brought to consult nic on the 30th 
 of March, 1850. Iler mother stated that she had been dull of hear- 
 ing during several years, in the left ear ; and this dulncss has of 
 late so much increased, that Avhen the right ear is pressed upon the 
 pillow, she cannot hear even loud voices. During the last three 
 years there has been a discharge from the ear, which has sometimes 
 been very offensive, and at times, especially in the morning, it has 
 been of a dark color. There has been no complaint of pain in the 
 ear ; but a tenderness below it has been felt. At times there has 
 been pain over the left eyebrow, extending occasionally to that side 
 of the head. On examination, it was found that the watch was 
 heard only in contact with the car. By the aid of the speculum, a 
 globular red growth, like a polypus, Avas discovered, concealing the 
 membrana tympani, with the exception of a small semilunar shaped 
 portion at its inferior margin (about half a line in diameter at its 
 centre), which was quite opaque. As this growth did not extend far 
 into the meatus, — as it was of a deep red color, and its surface quite 
 smooth, it presented an appearance very analogous to that of the 
 thickened mucous membrane of the t^nnpanum ; which, as has been 
 stated, becomes sometimes so much hj-pertrophied, as to project into 
 the meatus, and occupy a position nearer to the orifice than the 
 membrana tympani did previous to its destruction. The presence 
 of the latter membrane was in this case, however, ascertained ; by 
 the use of the otoscope, air was heard to enter the tympanic cavity 
 without passing into the meatus ; and the small portion of the mem- 
 brana tympani which was visible, could be observed to be pressed 
 out, and rendered tense and white, when the tympanic cavity was 
 filled with air. It was clear, therefore, that the diseased growth 
 was a polypus. 
 
 The treatment ■^\}iVS'\xQi\ consisted in applying to the surface of the 
 polypus, thrice daily, a solution of the diacetate of lead ; and, as I 
 was not to have the opportunity of seeing the patient for two or 
 three months, it appeared desirable that the solution should not be 
 so strong as would otherwise have been advisable, so only six drops 
 of liquor plumbi were added to an ounce of water. 
 
 June 18th. — The discharge has nearly disappeared, and examina- 
 tion shows the polypus to be reduced to the size of a large pin's 
 
THE EXTERNAL MEATUS. 133 
 
 head. The hearing was improved, the watch heing heard at two 
 inches instead of only Avhen in contact. 
 
 I had no opportunity of seeing this patient again; hut some little 
 time after the last visit, I heard that the discharge had ceased, and 
 the hearing so much improved that she was considered cured. 
 
 Case XI. Globular poll/pus in right ear broken up by forceps, and 
 a solution of liquor plumbi applied; cure. — Master A. H., aged 16, 
 was first seen hy me on the 13th of April, 1850. Both tonsils were 
 enlarged ; he had a tendency to glandular enlargements ; and was 
 at the time of his visit far from being in strong health. The history 
 of the case Avas as follows : — At six years of age he had an attack 
 of scarlet fever, Avhich left him dull of hearing, a dulness that has 
 increased during the last two years and a half; has had discharge 
 of an offensive character from the right ear during the last eighteen 
 months. 
 
 Right ear. — On inspection, a polypus was observed at the inner 
 extremity of the meatus, growing from its upper part, near to the 
 membrana tympani. The polypus was red and globular, with a 
 smooth shining surface. The discharge removed from the meatus 
 was white like milk, not viscid ; and it consisted of rounded cells 
 similar to those excreted in catarrhal inflammation of the mucous 
 membrane of the tympanum, and the nuclei of which were rendered 
 very distinct by the addition of acetic acid. By aid of the otoscope, 
 air is heard to enter the tympanic cavity ; and in doing so, to pro- 
 duce a loud sound, like that attendant upon the sudden distention of 
 a bladder by air. The watch was not heard over the ear, but only 
 when pressed upon the temple. 
 
 Left ear. — The membrana tympani was dull on its surface, and 
 white. Air passed into the tympanic cavity, producing a sound 
 similar to that in the right ear. Hearing distance, a quarter of an 
 inch. 
 
 April 17th. — By means of the rectangular forceps, the outer part 
 of the polypus was broken up ; it was very sensitive, and bled 
 slightly. A solution of diacetate of lead in water (four grains to the 
 ounce) was ordered to be dropped into the ear thrice daily, and a 
 cantharidine cerate was applied to the nape of the neck. 
 
 2oth. — The discharge much diminished, and its offensive odor has 
 disappeared ; the polypus is only one-third its former size, and the 
 membrana tympani is seen beyond its lower border. 
 
134 TlIK DISEASES OF THE EAR, 
 
 May 4tli. — ^lucli the same ; prescribed a solution of chloride of 
 zinc (ten grains to the ounce) to be dropped inlo the ear. 
 
 IGth. — The discharge has disappeared ; the hearing so greatly 
 improved that the patient thinks he sometimes hears quite well ; 
 the roots of the polypus alone remain. The treatment was con- 
 tinued ; and when I last saw the patient, on the 13th September, 
 he was quite well. 
 
 In the following case, I adopted a more active plan of treatment. 
 Being aware, from actual examination, that polypoid growths of the 
 nature now under consideration are extremely soft, in order to re- 
 move them more rapidly, I resolved to apply an astringent to them 
 of much greater strength than those previously used ; and the com- 
 plete success of this proceeding was very manifest. 
 
 Case XII. Grhhilar cellular polypus destroyed by a strong solu- 
 tion of acetate of zinc. — Miss T., aged 21, of fair complexion, and 
 in good health, applied for advice on January 13th, 1852. The 
 history of the affection is, that seventeen years ago, after an abscess 
 behind the right ear, its hearing power greatly diminished, and has 
 never returned. Six months ago, a discharge issued from this ear, 
 which has continued without intermission to the present period. On 
 examination of the right ear, the watch could be heard only when 
 in contact, and the meatus contained a considerable quantity of dis- 
 charge, consisting of tenacious thready particles of mucus, and 
 mucous cells. At the inner extremity of the tube, a globular- 
 shaped polypus, of a red color, was discovered, attached to the 
 upper part of the membranous meatus, close to the membrana tym- 
 pani, which it wholly concealed, with the exception of a small semi- 
 lunar shaped portion seen at its lower border. 
 
 Left ear. — Hearing distance one inch. Membrana tympani white 
 like cartilage. 
 
 Treatment. — The right ear to be syringed out Avith tepid water 
 thrice daily, and, after each operation, four minims of a solution of 
 acetate of zinc (forty grains to the ounce) to be dropped into the 
 ear. A small portion of vesicating paper to be kept over each mas- 
 toid process. 
 
 January IStli. — Slight })ain Avas felt for half an hour after three 
 applications of the drops ; and yesterday the patient complained of 
 a sensation as if the ears were distended. The discharge is di- 
 minished in quantity. The polypus had a grayish hue, bled on 
 
THE EXTERNAL MEATUS. 135 
 
 being touched, and appeared partially broken up. Large particles 
 of the acetate of zinc had collected on the surface of the polypus. 
 
 19th. — Polypus smaller ; no discharge ; has had a good deal of 
 ear-ache. To syringe with warm water, and omit the use of the drops. 
 
 22d. — The pain is gone ; there is no discharge ; the polypus has 
 wholly disappeared. The membrana tympani is now seen ; its upper 
 and posterior part is Avhite and thick ; at its anterior part, there are 
 two small apertures, through which the mucous membrane of the 
 tympanum is seen to be red and thick ; the hearing has improved : 
 the watch is now heard by the right car at a distance of three 
 inches ; by the left, at a distance of two inches. Subsequent re- 
 ports from this patient state that the discharge has not returned, 
 and that the hearing continues to improve. 
 
CHAPTER VII. 
 
 THE EXTERNAL MEATUS [concluded). 
 
 TUMORS. 
 
 OSSEOUS TUMORS — STRUCTURE TWO CLASSES — TREATMENT — CASES — MOLLUSCOUS 
 
 TUMORS — STRUCTURE — EFFECTS ON THE BONE — TREATMENT — CASE — CONCLUSION OP 
 THE SUBJECT OF THE DISEASES OF THE EXTERNAL MEATUS — TABULAR VIEW OF 
 THE MORBID CONDITIONS FOUND IN THE MEATUS EXTERXUS IN 1013 DISSECTIONS. 
 
 I. Osseous Tumors. 
 
 However little it may have hitherto attracted the attention of 
 the profession, there is reason to suppose that the growth of osseous 
 
 Fig. 37. 
 
 Two Osseous Tumors projecting from the anterior and posterior walls of the Meatus Exter- 
 nus, leaving a small triangular aperture below. 
 
 tumors in the external meatus of the ear is a (li.><ease of no unfre- 
 quent occurrence. Such tumors appear to be the result of a rheu- 
 
THE EXTERNAL MEATUS. 137 
 
 matic or gouty diathesis, and may be developed in any portion of 
 the length of the tube ; but the part from which they most com- 
 monly originate is about the middle third of the passage. In one 
 case, however, the tumor extended beyond the outer orifice of the 
 osseous meatus, and could be felt by placing the little finger at the 
 meatus. Occasionally the posterior wall aftords the point of origin 
 to the tumor, and then it nut unfre({uently resembles a simple bulg- 
 ing of the wall. In other cases, a similar tumor is also developed 
 from the anterior part, and the two protuberances meet and lie in 
 contact in the middle, leaving an inferior and superior triangular 
 space in the place of the original opening of the tube. Sometimes 
 the external surfaces of the tumors are in contact for nearly the 
 entire length ; and the only passage is a small orifice below. The 
 tumor may also grow from the upper surface of the tube, and, by 
 gradually increasing in size, almost or quite fill up the passage. 
 Two or more tumors, again, extend sometimes from various parts of 
 the circumference of the meatus, and, converging towards the 
 centre, fill up nearly the whole cavity. 
 
 As far as my opportunities have permitted examination, these 
 tumors, as in the one delineated below, appear to consist of ex- 
 
 FiG. 38. 
 
 The vertical section of the External Meatus and Osseous Tumor, from without inwards. 
 
 tremely hard and dense bone. In one case, where a portion of bone 
 was denuded of membrane, it appeared shiny, white, and polished, 
 like ivory. In 'another, where, under the misapprehension of the 
 body being a polypus, caustic had been applied, the bone was ex- 
 posed, and found to be extremely hard and devoid of sensibility. 
 In a third instance, where I observed the membrane to be absent, 
 
138 THE DISEASES OF THE EAR. 
 
 there was a thin Layer of cartiUige on the surface, beneath ^vhich 
 the bone was very haril. 
 
 The tumors are usually covered by the lining membrane of the 
 meatus, which is frequently thick, spongy, and less sensitive than 
 is natural. "When, by irritation, chronic inflammation is set up, 
 this membrane pours forth a discharge whose odor is most offensive. 
 
 The development of these tumors is frequently unattended with 
 any symptoms calculated to attract the attention of the patient ; and 
 therefore it is only Avhen by their increase of size they act as an 
 impediment to the passage of the sonorous vibrations to the mem- 
 brana tympani, that the patient is inconvenienced by the deafness, 
 and seeks relief. Deafness may result in these cases, first, from a 
 collection of cerumen or epithelium lodging in and blocking up the 
 small passage of the tube left unoccupied by the tumors ; secondly, 
 a drop of water may have entered the ear during the ordinary 
 ablutions, and produced the same effect ; thirdly, the growth of the 
 tumor may have proceeded unchecked till the entire cavity of the 
 meatus is filled up. In some, cases, however, the growth of the 
 tumors produces a feeling of distention in the ear, and weight in the 
 affected side of the head ; while in others, again, they appear symp- 
 tomatic of, and consequent on, exostosis forming in the deeper 
 regions of the ears ; as, for instance, in the tympanic or vestibular 
 cavities, — a condition I have sometimes detected in the course of my 
 dissections. In three instances, subsequently cited, there seemed 
 great probability of this being the case ; and the distressing noises 
 and sense of giddiness may probably have depended upon the pres- 
 sure exerted on the expansion of the auditory nerve by an exostosis 
 in the vestibule. 
 
 The only diseased substance with which the tumors are likely to 
 be confounded, are polypi ; from which, however, by very slight 
 attention, they may readily be discriminated. When inspected by 
 means of the speculum, the polypus is seen to be darker in color, 
 and glistening, from being generally lubricated by discharge ; the 
 osseous tumor, on the other hand, is white ; and though smooth, free 
 from moisture. The base of the polypus is also generally narrow, 
 while that of the osseous tumor is broad. Any doubt, however, is 
 easily removed by the use of the probe, which being pressed against 
 the bony protuberance, at once reveals its nature. 
 
 The disease under consideration may be divided into two classes. 
 
 The first and most common is that in which the disease appears 
 
THE EXTERNAL MEATUS. 139 
 
 associated with congestion of the mucous membrane of the ear. 
 Most of the patients who have consulted me on account of it were 
 in the habit of partaking freely of stimulating food and beverages. 
 
 The second class showed symptoms indicative of disease in the 
 cavities containing the expansion of the auditory nerve. 
 
 I Avill now proceed to point out some of the modes of treatment. 
 In those cases where the tumors occupy a considerable space in the 
 tube, and the deafness depends upon the occlusion of the canal by the 
 accumulation of cerumen or epithelium, it is important at once to 
 remove it, and prevent future accumulations. Where water pene- 
 trates into the orifice of the meatus, and fills up the only remaining 
 pervious portion of the tube, wool should be placed in the orifice of 
 the meatus when the patient is washing. Should the membrane 
 covering the tumor, as is not infrequent, be very thick, a certain 
 degree of relief may be afforded by the application of remedies which 
 shall reduce its substance. In one case of this kind I was enabled 
 to increase the size of the tube, and much improve the power of 
 hearing, by applying a solution of nitrate of silver. 
 
 In order to diminish the size of the tumor itself, after the avoid- 
 ance of a stimulating diet, the l)cst remedy is that usually employed 
 by surgeons in osseous growths, viz., iodine. This medicine I have 
 prescribed internally, and have applied it behind the ear, and also 
 to the surface of the tumors, with o-reat advantao;e. In some cases 
 large tumors Avere so much reduced as to allow of the passage of 
 sonorous vibrations ; and the patients regained in a measure that 
 power of hearing of which they had for many months been deprived. 
 
 If further experience should establish the fact that these tumors 
 can be arrested in their progress, especially at that early period 
 when the area of the tube is but slightly encroached upon, much 
 good may be accomplished and much suffering prevented or relieved. 
 And while there are many weighty objections to any attempt to re- 
 move these tumors by operation or by escharotics, there are none to 
 the use of iodine and the otlier absorbent medicines, from which 
 there is every prospect, by persevering use, of successful results. 
 
 In consulting authorities on this interesting subject, the only ob- 
 servations I have met with in Kramer are the following : — 
 
 " They (polypi) are even of cartilaginous and bony hardness. 
 
 " A stalactite-shaped growth hung from the superior surface of 
 the meatus, very near the membrana tympani, and was of so remark- 
 
140 THE DISEASES OF THE EAR. 
 
 able a bony hardness and density, that it was impossible to pierce it 
 even with the sharpest knife. "^ 
 
 Itard, although he states that the principal causes of the diminu- 
 tion of the external auditory meatus are the enlargement of the 
 osseous, cartilaginous, and membranous structures forming the mea- 
 tus, says : — 
 
 " I have never had an opportunity of observing the enlargement 
 {gonjlement) of the osseous part of the external meatus, and the ex- 
 treme hardness which it possesses would tend to make this kind of 
 alteration very rare."^ 
 
 Case I. Tumors in each ear, with deafness; tuinors diminished in 
 size; deafness cured. — June, 1848 : D. N., aged Go, for the last 
 few weeks has been feeling somewhat deaf, especially in the loft ear. 
 This deafness is increased by an attack of cold, to Avhich the patient 
 is subject. 
 
 Might ear. — Meatus partly filled Avith bony growths ; one rising 
 from the anterior, the other from the posterior part of the meatus. 
 Membrana tympani dull. Hearing distance less than that of a 
 healthy ear. 
 
 Left ear. — Meatus blocked up, except a small orifice, by three 
 tumors which project from the walls of the meatus. The space left 
 between these bony growths was occupied by a collection of cerumen, 
 which being removed, the power of hearing, though still deficient, 
 was to a certain extent improved. 
 
 Considering that every attack of cold increased the deafness, and 
 that the membrana tympani was dull, — a thickened state of the 
 mucous membrane seemed also indicated, — the following course of 
 treatment was adopted. Alterative doses of blue pill were admi- 
 nistered, and the surface of the meatus was washed with a solution 
 of argenti nitras, one drachm to the ounce, every fourth or fifth, and 
 afterwards every seventh day. This course of treatment was con- 
 tinued for three or four weeks, and the power of hearing was largely 
 extended. The plan was resumed tlie following year, and the ulti- 
 mate result was a perceptible diminution of the tumor, arising, as I 
 believe, from a decrease in the thickness of the investin<i mem- 
 brane ; and the power of hearing was completely restored. 
 
 Case II. Tumors in both ears; deaf ness produced b>/ the presence 
 
 On the Nature and Treatment of Diseases of the Ear. Longman. 1S4". P. U7. 
 ' Traite des Maladies de I'Oreille et de lAudition. 1821. Tome i, p. 328. 
 
THE EXTERNAL MEATUS. 
 
 141 
 
 of a drop of water in the meatus. — July, 1846 : E. F., aged 60, has 
 been so deaf in the right ear, for some years, as to derive little use 
 
 Fig. 39. 
 
 Three Osseous Tumors projecting from the walls of the Meatus. 
 
 from it. Has several times lately become suddenly so deaf in the 
 left ear as scarcely to be able to hear a conversation. These attacks 
 
 Fig. 40. 
 
 ) 
 
 A large Osseous Tumor and two smaller ones in the Meatus E.xternus. 
 
 have usually come on in the morning after washing, and frequently 
 lasted for some hours. 
 
142 TUE DISEASES OF THE EAR. 
 
 Right ear. — Two bonv tumors were observed in the meatus, occu- 
 pying about one-half of its calibre, Membrana tympani dull. 
 
 Left ear, meatus. — Extending from the upper part of the meatus 
 is a long bony tumor, taking up two-thirds its calibre. This tumor 
 is covered by a thick soft membrane, excepting at one point of about 
 half a line in length, and a quarter of a line in breadth. From the 
 anterior and posterior parts of the lower half of the tube projected 
 two small elevations of bone, about three-quarters of a line in thick- 
 ness, in the direction of the large tumor, so as to leave but a very 
 small triangular space between them. This space was the only open- 
 ing by which the sonorous undulations could pass to the membrana 
 tympani ; and it was found that, during the operation of washing, 
 it was liable to be filled up by water, which produced temporary 
 deafness. The opportunity of carrying out a course of treatment 
 for the diminution of the tumors was not given to me ; but by adopt- 
 ing means to prevent the entrance of water into the meatus, the at- 
 tacks of deafness were entirely prevented. 
 
 Case III. Tumor in the meatus of the right ear ; orifice in mem- 
 brana tympani of left ear. — Nov. 13, 1845 : P. H., aged 56, eleven 
 years before, when in Russia, fell asleep in a garden. The next day 
 felt severe pain in the left car, which lasted during fourteen days, 
 when matter began to discharge. Has had several attacks of pain 
 in the left ear since that period, which have been accompanied by 
 beatinrj and sinfrin"". 
 
 About six months ago, being then in the AVest Indies, had an 
 attack in the right ear, followed by a diminution in the power of 
 hearing, but there was no discharge. Two months ago he returned 
 to England, and entirely recovered the use of the right ear, hearing 
 better also with the left. Within the last four days pain came on in 
 the left ear and rapidly increased, followed by pain in the right ear, 
 and so great an extent of deafness in both ears as to require him to 
 be shouted to. 
 
 Right ear, meatus externus. — The middle two-thirds of the lower 
 wall are occupied with a bony tumor filling half the calibre of the 
 tube. 
 
 Left ear. — Meatus externus red, and covered by discharge. Mem- 
 brana tympani white, soft, and tliick, witli a small orifice, through 
 which air passes. 
 
 Case IV. Osseous tuinors in each ear ; feeling of confusion in the 
 head. — Nov. 4, 1848 : T. T., aged 38. Last year deafness gradu- 
 
THE EXTERNAL MEATUS. 143 
 
 ally came on in the left ear, with occasional attacks of deafness in 
 the night. This deafness has of late very much increased, and been 
 also attended with a feeling of confusion, and a sense of oppression 
 in the head. 
 
 Right ear. — Projecting from the whole of the anterior and poste- 
 rior surfaces of the external meatus, are two osseous growths, which 
 come into contact in the centre of the tube. Hearing distance one 
 foot. 
 
 Left ear. — Two similar tumors likewise exist in the meatus of this 
 
 Fig. 41. 
 
 Two Osseous Tumors of the External Meatus in contact internally. 
 
 ear ; but at the superior part they have so increased as to be in con- 
 tact throughout, save a small orifice at the lower part. The deaf- 
 ness in this ear has been greatly increased by the presence of a small 
 quantity of cerumefi, which had filled up the small orifice just de- 
 scribed, and its removal gave temporary relief ; but it Avas evident 
 that the tumors would go on increasing until the entire passage of the 
 meatus was blocked, unless remedial measures were at once adopted. 
 For these no opportunity was afforded me. 
 
 Case V. Large tumor in left ear, causing deafness ; diminished 
 hy the use of iodine. — Feb. 1849. S. P., aged 17, states that deaf- 
 ness commenced in the left ear, about two years and a half ago, 
 and has been gradually progressing, till at length he cannot hear 
 at all with that ear. Sometimes there is a violent itching, followed 
 by discharge, and the tube of the ear is so sensitive, that the least 
 
144 
 
 THE DISEASES OF THE EAR. 
 
 touch causes exquisite pain. There is also a continuously unplea- 
 sant sensation, as if the ear -were being distended. He complains 
 of dulness of hearing in the right ear. Has been to various sur- 
 geons and public institutions, but without obtaining any relief. 
 Riglit ear. — A large osseous tumor occupies nearly the -vvhole of 
 
 Fig. 42. 
 
 An Osseous Tumor growing from the Upper Wall of the Meatus, and occupying nearly 
 the whole of its calibre. 
 
 the meatus, and is attached to its upper part. It is covered by the 
 dermoid lininfr of the meatus, which is about a third of a line thick. 
 
 Left car. — Healthy. 
 
 Tincture of iodine Avas applied to the surface of the tumor, as also 
 behind the ear, and four grains of iodide of potassium were given 
 thrice daily for between two and three months. Great relief was 
 the result ; the size of the tumor diminished ; the power of hear- 
 ing greatly increased ; the tube of the ear lost its unnatural sensi- 
 bility ; and the unpleasant sensation of distention completely va- 
 nished. 
 
 Case VI. A tumor in the right ear, filling nearly the entire tube ; 
 slight protHhcranees in the left ear. — Nov. 25, 1848 : J. S., aged 65, 
 states that ten years ago he had a gathering in the right ear, with 
 great pain and much discharge. Continued, however, to hear pretty 
 well until witliin about a month previous to applying to me, during 
 
THE EXTERNAL MEATUS. 145 
 
 which he has grown so very deaf that he cannot hear, unless the 
 speaker's mouth approaches close to the ear. 
 
 Ri(jlit car. — The external meatus contained a collection of epithe- 
 lium, on the removal of which an osseous tumor was disclosed, filling 
 nearly the whole of the tube. The tumor projected from the upper 
 and lateral surfaces, and nearly touched the lower wall of the tube. 
 Watch not heard in contact with the ear. 
 
 Left ear. — The lower wall of the meatus presents two slight and 
 quite hard elevations. 
 
 Treatment. — Alterative doses of blue pills were prescribed, and 
 tincture of iodine was directed to be applied behind the cars. The 
 result I have not heard. 
 
 Case VII. Tumor in the right ear following the extraction of a 
 polypus. — June, 1847 : Rev. J. D., aged 47, consulted me for a 
 continued discharge from the right ear. He stated that twenty 
 years previously, after the forcible removal of a collection of Avax 
 from the right ear, he experienced great pain, followed by an offen- 
 sive discharge, that had lasted to the present time. On examination, 
 a large, red, and firm polypus was perceived to fill the whole of the 
 meatus, nearly as far as the orifice. It was attached to the wall of 
 
 Fig. 43. 
 
 Osseous Matter developed from the walls of the Meatus E.\ternus, leaving a triangular 
 
 space in the centre. 
 
 the meatus, near to the membrana tympani, and on its removal the 
 latter was found to be very thick and vascular, with a small orifice 
 at its lower part. The discharge wholly disappeared. 
 
 10 
 
146 THE DISEASES OF THE EAR. 
 
 In July, 1857, the patient again consulted me on account of a 
 slight return of the discharge, accompanied by some degree of pain 
 in the right side of the head, with an unpleasant sensation of fulness 
 and pressure in the ear. On inspection, the meatus was found con- 
 tracted to one-fourth its natural size by the growth of osseous matter 
 from its walls, especially anteriorly and posteriorly, thus leaving a 
 mere triangular opening, through which only the central part of the 
 membrana tympani was visible, and that was Avhite and thick, 
 
 I recommended the use of a strong solution of liquor plumbi to 
 stop the discharge from the tube, and the application of the tincture 
 of iodine behind the ear. 
 
 In this case there had been long standing disease of the tympanic 
 cavity, membrana tympani, and meatus, consequent on local injury. 
 The disease was attended with so great an amount of deafness, that 
 it appeared as if the cavities containing the expansion of the audi- 
 tory nerve might also be implicated. 
 
 Case A'^III. A protuberance of the lower wall of the meatus in the 
 left ear. — December, 1848 : L. E. 11., aged 25, ten years previously 
 experienced a singing in the left ear, Avhich during a cold became 
 much worse, and was attended Avitli a feeling of numbness. A cold 
 has lately aggravated all the symptoms in the left ear, and called 
 forth a noise like a bell in the right ear. 
 
 Right ear. — Membrana tympani dull ; hearing distance two feet. 
 Left ear. — Meatus contained a large quantity of cerumen, after 
 the removal of which the passage was observed to be red. At the 
 lower wall near the membrana tympani there is a considerable bulg- 
 ing of the osseous wall. Hearing; distance half an inch. 
 
 In this case the diminished degree of hearing in the left ear did 
 not depend upon the enlargement of the external meatus, for there 
 was no doubt of a thickening of the mucous membrane lining the 
 tympanic cavity. 
 
 Case IX. Osseous tumor in the external meatus, causing a collec- 
 tion of epidermis and serious cerebral st/mptoms ; relieved. — J. J. S., 
 Esq., aged 5G, consulted me on the 27th April, 1850. lie stated 
 that when a boy he had a discharge from the right ear, since which 
 period he has been deaf at times, and been subject to a noise in the 
 ear, together with a feeling of pressure on the head. Two months 
 ago he complained of an attack of toothache, during which the deaf- 
 ness was partially relieved ; but lately it lias become worse again, 
 accompanied by a feeling of pressure in tlie cars ; he has also had 
 
THE EXTERNAL MEATUS. 147 
 
 frequent attacks of giddiness and confusion in the head. On exa- 
 mining the right ear, the middle part of the meatus was seen to be 
 occupied by a bony tumor which fills the whole of the tube, with the 
 exception of a small space about three-quarters of a line in diameter, 
 situated at its superior part. This space was observed to be closed 
 by a white substance, which, on being touched with the probe, proved 
 to be of great density. As it appeared probable that part, at least, 
 of the symptoms above detailed depended upon the collection of epi- 
 dermis behind the bony tumor, and its pressure upon the membrana 
 tympani, it was thought desirable to attempt its removal. Small 
 portions Avere picked away by the point of a probe, and the syringe 
 was used ; it was, however, so hard that only minute particles could 
 be detached. A solution of carbonate of soda Avas directed to be 
 applied constantly for some days, and then a further quantity was 
 extracted, Avhich mitigated the symptoms. By pursuing this plan, 
 the whole of the matter beyond the tumors, which was found to be 
 epidermis, was got rid of ; and the patient not only heard better, 
 but the unpleasant symptoms of giddiness and cerebral irritation 
 entirely disappeared. Judging from the large quantity of epidermis 
 removed in comparison with the small space between the tumor and 
 the membrana tympani, that substance must have been greatly com- 
 pressed, and tlie membrana tympani also subjected to much pressure. 
 In the year 1852, and again in the present year, the same gentle- 
 man consulted me on account of similar symptoms, which were wholly 
 removed by the use of the syringe alone. 
 
 II, Molluscous Tumors. 
 
 Molluscous tumors are sometimes formed in the external meatus, 
 and lead to very serious results. I first met with these tumors when 
 making dissections of the ear, and several specimens are in my 
 possession, which well illustrate the nature of the disease. These 
 excrescences seem to have their origin in the dermis of the meatus, 
 and they gradually increase in size so as not only to fill the Avhole 
 of the meatus, but to encroach upon and cause absorption of the 
 bone. Thus, in some instances, the lower osseous wall of the 
 meatus is affected, and in part absorbed, while in others the tumor 
 extends upwards, and the whole of the upper wall of the meatus 
 effaced by the pressure exerted upon it. I have met with cases 
 
148 
 
 TUE DISEASES OF THE EAR. 
 
 wliicli tlic tumor has extended into the cerebral cavity. These 
 cases are liable to be overlooked, and classed "with those in which 
 there is a simple accumulation of epidermis in the meatus. 
 
 Fig. 44. 
 
 Molluscous Tumor filling the whole of the Meatus Externus. 
 
 The treatment of molluscous tumors consists in removing the 
 large mass of scales contained in the tumor, and afterwards syringing 
 the meatus abundantly Avith warm water twice or thrice daily. 
 
 Fig. 45. 
 
 C.ivity in the Mentus Externus from which a Molluscous Tumor has been removed. 
 
 Case. Molluscous tuino?' in the external meatus ; discharge from 
 he ear. — Mr. G., between 40 and 50, consulted me for a discharge 
 
THE EXTERNAL MEATUS. 
 
 149 
 
 from the right ear, accompanied by deafness. On examination, the 
 meatus Avas observed to be nearly full of a white caseous-looking 
 matter, from which oozed a discharge. By persevering use of the 
 
 Fig. 46. 
 
 Apertures in the upper wall of the Meatus Externus communicating with the Cerebral 
 Cavity, produced by a Molluscous Tumor. 
 
 syringe, aided by the forceps, a large Avhite mass was removed, 
 which was found to consist of layers of white matter, composed of 
 large scales, similar to those of other molluscous tumors. On the 
 removal of the mass the discharge disappeared. 
 
 In bringing to a conclusion these observations on the diseases of 
 the external meatus, it will be well to draw attention to the morbid 
 conditions disclosed by the dissection of 1013 diseased ears. They 
 were as folloAvs : — 
 
 Containing a collection of cerumen, ....... 71 
 
 Containing a collection of cerumen and epidermis, ..... 9 
 
 Distended and dilated by a collection of cerumen, ..... 5 
 
 Distended and dilated by a collection of cerumen and epidermis, . . 1 
 
 Containing a collection of cerumen and rye-seeds, ..... 2 
 
 Containing a collection of cerumen, the osseous walls being absorbed in 
 
 parts, ............. 3. 
 
 Containing a collection of cerumen and epidermis, the osseous walls being 
 
 absorbed in parts, .......... 4 
 
 Containing a collection of cerumen, the osseous walls being absorbed in 
 
 parts, so as to expose the cavities of the mastoid cells, ... 1 
 
 Containing a collection of hairs, ........ 1 
 
 Containing a collection of cotton-wool, ....... 1 
 
150 THE DISEASES OF THE EAR. 
 
 Containing a molluscous tumor 5 
 
 Containing a molluscous tumor, the osseous walls being absorbed in 
 
 parts 3 
 
 Containing a molluscous tumor which projects through the bone into the 
 
 cerebral cavity, ........... 1 
 
 Containing a molluscous tumor which projects into the mastoid cells, . 1 
 
 Containing a collection of pus, ........ 10 
 
 Containing a collection of pus mixed with epidermis, .... 1 
 
 Having polypi growing from its walls, ....... 1 
 
 Having polypi growing from its walls, the bone being carious, . . 1 
 
 The dermoid layer so much atrophied as to leave the bone denuded, . 2 
 
 The dermoid layer hypertrophied, ........ 2 
 
 The dermoid layer congested, ......... 7 
 
 The dermoid layer soft, .......... 1 
 
 The dermoid layer soft and red, ........ 2 
 
 The dermoid layer soft and detached from the bone, .... 2 
 
 The dermoid layer soft and thick, the bone being carious, ... 1 
 
 The dermoid layer ulcerated, the bone being carious 1 
 
 Osseous walls rough, .......... 1 
 
 Osseous walls carious, .......... 7 
 
 Osseous walls absorbed in parts, ........ 2 
 
 Osseous walls presenting an orifice superiorly, ...... 3 
 
 Osseous walls presenting an orifice inferiorly, . . .... 1 
 
 Osseous canal much contracted, ........ 3 
 
 Having bony growths from the osseous walls : canal much contracted. . 14 
 
CHAPTER VIII. 
 
 THE MEMBRANA TYMPANI. 
 STRUCTURE AND FUNCTIONS. 
 
 THE EPIDERMOID LAYER — THE DERMOID LAYER — THE FIBROUS LAYERS — THE RADIATE 
 FIBROUS LAYER — THE CIRCULAR FIBROUS LAYER — THE MUCOUS LAYER — TENSOR LIGA- 
 MENT — FUNCTIONS OF THE MEMBRANA TYMPANI. 
 
 Anatomical Observations. — There are so many points of interest in 
 Pathology connected with the structure of the membrana tympani, 
 which bear upon its morbid conditions, but which have not hitherto 
 been sufficiently recognized, that the subject deserves a full exami- 
 nation. Looked at from without inwards, the membrana tympani 
 may be described as consisting of the following layers : — 
 
 1. The epidermis. 
 
 2. The dermis. 
 
 3. The fibrous layer, composed of — 
 
 a. The lamina of radiating fibres. 
 h. The lamina of circular fibres. 
 
 4. The mucous membrane. 
 
 The epidermis is a thin layer, covering the outer surface of the 
 dermoid lamina ; it is continuous with the epidermis of the external 
 meatus, and, when subjected to the process of maceration, can be 
 removed in the form of a small blind pouch, which presents, as it 
 were, a cast of the meatus and of the external surface of the mem- 
 brana tympani. When floating in water, the pouch reassumos the 
 form it had when in contact with other tissues, and its internal 
 extremity is convex, corresponding with the external concavity of 
 the membrana tympani. The layer of epidermis forming the outer 
 coat of the membrana tympani is thin, and in the living subject so 
 transparent that the dermoid layer can be distinctly seen through 
 its substance ; its outer surface is very smooth, and capable of re- 
 
lo2 THE DISEASES OF THE EAR. 
 
 fleeting light ; and there is usually seen at its anterior and inferior 
 part, a triangular shining spot. 
 
 In the course of dissection, I have more than once found this 
 delicate epidermis to be the only layer remaining, over portions vary- 
 
 FiG. 47. 
 
 The Triangular Shining Spot at the anterior and inferior part of the outer surface of the 
 
 Membrana Tympani. 
 
 ing from a line to a line and half in breadth, and yet appearing to 
 have been sufficient to close the cavity of the tympanum and to pre- 
 serve the power of hearing nearly perfect. The knowledge of this 
 condition of the membrana tympani ought to lead to a cautious use 
 of the syringe when no cerumen is present, since its application may 
 cause a rupture of the epidermis. 
 
 The dermoid layer, as its name implies, is continuous with the 
 dermis lining the external meatus, and is situated between the epi- 
 dermis and the radiate fibrous layer. It is extremely thin, and 
 secretes the epidermis. Previous -to the publication of a paper by 
 me on the structure of the membrana tympani, in the " Philosophi- 
 cal Transactions," for 1851, it had l)een supposed that the epidermis 
 was secreted by the radiate fibrous layer. The presence of the der- 
 mis is best demonstrated by carefully dissecting, under water, the 
 membranous meatus from the upper surface of the osseous tube, as far 
 as the attachment of the membrana tympani ; at which point the peri- 
 
THE MEM BR AN A TYMPAXI. 153 
 
 osteum of the meatus is seen to become continuous with the radiate 
 fibrous hxmina; this being cut through, the dermoid hiyer is detected 
 passing down over the outer surface of the radiate fibres, and sepa- 
 rating them from the epidermis. If the upper portion of tliis hayer 
 be drawn gently downwards by one hand, by means of a fine needle 
 in the other, the delicate cellular tissue which connects it with the 
 fibrous lamina can be broken up, and the dermis removed entire. 
 The presence of this lamina may also be shown by introducing be- 
 tween it and the radiating fibrous layer, at the superior part of the 
 membrana tympani, a fine bristle, by passing which down the cel- 
 lular tissue is lacerated. 
 
 In a healthy state, when uninjected by blood or by artificial 
 means, the dermoid lamina is thin and transparent, and its structure, 
 under the microscope, looks like areolar tissue. When injected, 
 however, this membrane is seen to have numerous bloodvessels rami- 
 fying through it, so as to foi-m an elaborate plexus : these vessels, 
 when enlarged, impart the red appearance to the surface of the mem- 
 
 FiG. 4S. 
 
 The Dermoid Layer of the Membrana Tympani continuous with the Dermis lining the 
 upper wall of the Meatus Externus. 
 
 brana tympani so frequently met with during life. It is upon the 
 supply of nerves to this lamina that the exquisite sensibility of the 
 membrana tympani depends. 
 
 A knowledge of the existence of the membrane just described is 
 of interest to the anatomist, who recognizes in it the secreting organ 
 of the epidermoid layer of the membrana tympani ; and to the sur- 
 geon, who through its presence is enabled to understand phenomena 
 occurring in certain diseases of the ear. There are pecidiar diseased 
 conditions in which the dermoid layer of the membrana tympani be- 
 comes much hypertrophied. 
 
 The Y*ro])cr Jibroiis layer of the membrana tympani can be easily 
 separated into two lamina), which are named from the direction of 
 their component fibres. Previous to describing these structures, it 
 
154: TUE DISEASES OF THE EAR. 
 
 is desirable to cite the opinions of eminent anatomists concerning 
 them. 
 
 In the Croonian Lecture, published in the 19th volume of the 
 "Philosophical Transactions," Sir Everard Home advanced the 
 opinion that the membrana tympani in the human subject was mus- 
 cular. Ilis words are : " When viewed in a microscope, magnified 
 twenty-three times, the muscular fibres are beautifully conspicuous, 
 and appear uniformly the same throughout the whole surface. There 
 being no central tendon as in the diaphragm, the muscular fibres 
 appear only to form the internal layer of the membrane, and are 
 most distinctly seen when viewed on that side."^ The use of this 
 radiated muscle. Sir Everard states, is " to give those difibrent de- 
 grees of tension to the membrane which empower it to correspond 
 with the variety of external tremors."- Since the first publication 
 of this opinion as to the muscularity of the membrana tympani, ana- 
 tomists, though generally conceding that it is fibrous, have widely 
 differed as to its composition. According to Mr. Quain and Dr. 
 Sharpey, " It is made up of fine closely-arranged fibres, the greater 
 number of which radiate from near the centre to the circumference ; 
 but within these are circular fibres, which are more scattered and 
 indistinct, except close to the margin of the membrane, where they 
 form a dense, almost cartilaginous ring."^ Mr. "Wharton Jones 
 writes : " The proper membrane can be divided into two layers — an 
 outer thin one, consisting of radiating fibres, and an inner thicker 
 layer, which is less distinctly fibrous, though when torn it does indi- 
 cate a fibrous disposition, and that in a direction opposite to the 
 former. . . . The fibres which cross the radiating ones are more 
 aggregated at the centre ; they run parallel with the handle of the 
 malleus, and turn round its extremity. At the circumference of the 
 proper membrane, there is a thick, firm, ligamentous or cartilaginous 
 ring, which is fixed in the groove of the bone. The ligamentous 
 ring appears to be formed by an aggregation of the circular fibres 
 interwoven with the peripheral extremities of the radiating ones."^ 
 
 By careful dissection the fibrous layers of the membrana tympani 
 may be separated into two distinct laminse, the fibres of which have 
 no intercommunication. The external layer may be called the radi- 
 ate fibrous lamina, since its fibres radiate from the malleus to be at- 
 
 • Loc. cit. p. 5. ' Loc. cit. p. 11. 
 » Elements of Anatomy, 5th Edition, 1848, vol. ii, p. 932. 
 
 * Cyclopsedia of Anatomy and Physiology, vol. ii, p. 545. 
 
THE MEMBKANA TYMPANI. 155 
 
 taclied to the cartilaginous ring; and the internal, lk\Q circular fibrous 
 lamina. The radiate layer is the thicker and stronger of the two. 
 So readily may the layers be separated from each other, that they 
 are detached Avith more facility than the circular layer can be freed 
 from the mucous membrane. 
 
 {a.) The radiate fibrous la^cr. — If the whole of the membrana 
 tympani be carefully removed, there will be observed at its cir- 
 cumference a white, dense ring, apparently cartilaginous, which is 
 received into the osseous groove of the temporal bone appropriated 
 to it. It Avill be remembered, however, that this groove occupies 
 only about five-sixths of the circumference of the inner extremity 
 of the meatus, the upper sixth being smooth instead of grooved. 
 The cartilaginous ring at the upper part is attached to the malleus, 
 the anterior extremity being inserted into the anterior, and the pos- 
 terior extremity into the posterior, part of the cervix of this bone : 
 to the outer surface of this ring is attached the periosteum lining 
 the external meatus. If the radiate lamina be examined with a 
 magnifying power of ten or twelve diameters, fibres will be observed 
 whose peripheries are attached to the cartilaginous ring, and their 
 other extremities to the malleus. The uppermost of these fibres, 
 however, must be excepted from the observation just made ; for in- 
 stead of passing from the superior part of the ring to the malleus, 
 they take their course in front of the processus brevis, and form a 
 distinct layer of membrane covering its outer surface. The dispo- 
 sition of this portion of the radiating fibrous lamina is interesting 
 alike to the anatomist and surgeon, for it is observed to be con- 
 tinuous with the periosteal lining of the upper part of the external 
 
 Fig. 49. 
 
 The Radiate Fibrous Layer of the Membrana Tympani. 
 
 meatus. Mr. Shrapnell, perceiving that this portion of the mem- 
 brana tympani Avas not so tense as the rest, considered it to be a 
 distinct structure, and named it the "membrana flaccida." 
 
 Directly below the processus brevis of the malleus, the radiating 
 fibres are attached to the ridge occupying the external surface of 
 
156 
 
 THE DISEASES OF THE EAR. 
 
 the bone ; but at 4his part the fibres from each half of the mcm- 
 brana tympani are inserted so near to each other that no portion of 
 the malleus is visible -when viewed exteriorly. Towards the inferior 
 extremity of the long process, however, the fibres being attached to 
 the sides and not to the anterior surface, a small portion of the ex- 
 ternal surface of the long process, at its inferior part, is left bare 
 and in contact with the dermoid layer ; as may be distinctly seen in 
 
 Fig. 50. 
 
 The Fibres composing the Radiate Fibrous Lamina (magnified about 300 diameters).' 
 
 the healthy living ear by the aid of the speculum auris and a mag- 
 nifying lens. The fibres extending from the malleus, and forming 
 
 Fig. 51. 
 
 The Radiate Fibrous Lamina ; external surface displajing the peculiar markings caused 
 by the interlacement of the fibres. 
 
 the posterior, are one-fourth larger than those forming the anterior 
 segment of the membrane. The thickest part of this layer sur- 
 
 ' In the other drawings from the microscope, the same magnifying power was used. 
 
THE MEMBRANA TYMPANI. 
 
 157 
 
 rounds the extremity of the long process of the malleus, and the 
 most attenuated lies bet-ween the posterior margin of the long pro- 
 cess of the malleus and the circumference of the membrana tym- 
 pani. 
 
 Structure of the radiate lamina. — The fibres composing the ra- 
 diate lamina, when examined in a fresh state by the microscope, are 
 translucent, and, with the exception of a few transparent globules, 
 present no peculiarity of structure. The longitudinal parallel Avavy 
 lines, however, characteristic of ordinary fibrous membranes, are 
 absent. The fibres are flat, and vary from 40'ou to gj>g^ of an inch 
 in breadth. In passing from the circular cartilage to the malleus 
 these fibres interlace, giving rise to the peculiar diamond-shaped 
 markings observable on the outer surface of the membrane. When 
 treated with acetic acid, this lamina becomes opaque, and sometimes, 
 
 Fig. 52. 
 
 m^r \k'MM^ 
 
 ijlf 
 
 '1 
 
 '^^pfii^ii 
 
 The Radiate Fibrous Lamina, after having been treated with Acetic Acid. 
 
 but not invariably, elongated oval nuclei are detected, the long axes 
 of which correspond with the course of the fibres. In no instance, 
 liowever, was an oval nucleus visible in an isolated fibre. 
 
 Fig. 53. 
 
 The Circular Cartilaginous Band, after having been treated by Acetic Acid. 
 
 The circular white hand at the circumference of the radiate fibres 
 consists of a firm, slightly elastic mass of tissue, and presents an in- 
 distinct appearance of fibres intermixed with oval-shaped nuclei. 
 
158 THE DISEASES OF THE EAR. 
 
 Under acetic acid this structure loses its white aspect, becomes 
 translucent, and discloses a great number of the oval nuclei. 
 
 (b.) The circular Jibrous lamina. — This membrane, as previously 
 stated, is attached to the radiating fibres by fine cellular tissue, and 
 can be readily separated ; for, as before observed, the fibres of each 
 lamina are quite distinct and never intermingle. As its name im- 
 plies, this lamina consists of circular fibres, which are firm and 
 strong at the circumference, but so attenuated towards the centre, 
 as to be detected only by careful observation. The strong fibres at 
 the circumference of the layer form a complete circle, and are at- 
 attachcd to each side of the body of the malleus, and to the sides of 
 the upper third of the processus longus. When closely examined 
 
 Fig. 54. 
 
 ^^ 
 
 The External Surface of the Circular Fibrous Lamina the fibres being attached to 
 the Processus Longus of the Malleus. (Slightly magnified.) 
 
 by a magnifying power of thirty to forty diameters, the circular 
 fibres are seen to be intersected by others of an extremely delicate 
 character, which, increasing in number towards the centre of the 
 lamina, become there so intimately blended with the circular fibres 
 that the latter are not easily distinguishable. The central thin por- 
 tion of the circular lamina is not attached to the malleus, but the 
 fibres from each side are continuous, and form a membranous layer 
 by a series of concentric fibrous circles ; the outer surfiice being in 
 contact with the inner surface of the lower half of the long process 
 of the malleus, to which it adheres by loose cellular tissue. The 
 circular fibrous lamina is entirely unconnected with the cartilagi- 
 nous ring into which the radiating fibres are inserted ; but is con- 
 tinuous with, and may be considered a modification of, tlie periosteal 
 lining of the tympanic cavity. When the lamina of circular fibres 
 is detached from the radiating layer, it will be found slightly con- 
 cave externally, though less so than the outer layer. In its sepa- 
 rate condition it is also not quite so concave as when it was con- 
 nected with the inner surface of the radiating fibres ; but when its 
 central portion is pressed inwards, so as to increase the concavity. 
 
T n E M E M B R A X A T Y M P A N I. 
 
 159 
 
 its inherent elasticity causes it quickly to resume its former saucer- 
 like shape. If the two layers, when detached, be placed side by 
 
 Fig. 55. 
 
 The Internal Surface of the Circular Fibrous Lamina : the Long Process of the Mal- 
 leus is seen through the translucent central part. (Slightly magnified.) 
 
 side, the greater degree of external concavity in the radiating 
 fibrous layer is very perceptible. 
 
 Structure of the circular lamina. — When highly magnified, the 
 fibres of the circular lamina are found to be smaller than those of the 
 radiate fibrous layer, and to vary from the 6000th to the 10,000th 
 of an inch in breadth. The outer fibres run parallel with each other, 
 and do not interlace ; they are diaphonous, and free from any wavy 
 longitudinal lines. Under acetic acid, the fibres enlarge and assume 
 
 Fig. 56. 
 
 The Fibres composing the Circular Fibrous Lamina. 
 
 a certain degree of opacity ; and in some instances this lamina also 
 presents distinct oval nuclei elongated in the direction of its fibres ; 
 but as in the radiate lamina, never in the separate fibres, and most 
 commonly they are not present. 
 
 It is often not easy to decide Avhether a structure is muscular : 
 hence doubts may arise as to the true nature of the two fibrous 
 laminse of the membrana tympani. My own researches do not seem 
 to favor the view of that membrane being a contractile tissue. The 
 
160 
 
 THE DISEASES OF THE EAR. 
 
 facts -vvliicli appear to militate against the idea of its being muscu- 
 lar, arc : — 
 
 1st. The absence of distinct nuclei in the fibres. 
 
 Fig. 
 
 The Fibres of the Circular Fibrous Lamina, treated with Acetic Acid. 
 
 2d. The great denseness and hardness of the latter, and their firm 
 and unyielding structure, they being so strong as to be Avith diflH- 
 culty torn across. 
 
 (c.) The mucous membrane forming the inner layer of the mem- 
 brana tympani is, in the healthy ear, so extremely thin as to be with 
 difficulty detected ; though by careful dissection it may be removed 
 entire from the inner surface of the circular fibres, with which it is 
 connected with considerable firmness by fine cellular tissue. 
 
 It will now be evident that of all the laminte Avhich constitute the 
 membrana tympani, not one is proper to that organ ; all of them 
 being directly continuous with other structures, of which they appear 
 to be modifications. Thus : — 
 
 Fig. 58. 
 
 The Radiate Fibrous Lamina, the Circular Fibrous Lamina, and the IMucous Membrane of 
 the Membrana Tympani, seen to be continuous with the other structures. (Slightly 
 magnified.) 
 
 1st. The epidermis is continuous with that lining the external 
 meatus. 
 
 2d. The dermis is continuous with the dermis of the meatus. 
 
THE MEM BR AN A TYMPANI. 161 
 
 3d. The fibrous lamina consists of the radiate fibrous lamina, 
 which is a prolongation of the periosteal lining of the external 
 meatus ; and the circular fibrous lamiiia, a prolongation of the peri- 
 osteum of the tympanum. 
 
 4th. The layer of mucous membrane forms part of the lining of 
 the tympanic cavity. 
 
 Previous to considering the functions of the fibrous laminae of the 
 membrana tympani, it is desirable to advert to another point in the 
 structure and relations of this organ. It has been already stated 
 that the membrana tympani is attached, at its circumference, to the 
 temporal bone, and, at its central part, to the malleus, which latter 
 bone is so suspended by means of the processus gracilis and the 
 short process of the incus, that the long process can move inwards 
 towards the tympanic cavity, and outwards towards the meatus. It 
 must be evident, therefore, that in order to prevent the concave 
 membrana tympani, with the above attachments, from remaining in 
 a state of relaxation, either the tensor tympani muscle must be in a 
 state of continual contraction, or some other provision must exist 
 for retaining the membrana tympani in the moderately tense con- 
 dition fitting it to receive the sonorous undulations. This provision 
 actually exists, and, as far as I am aware, has hitherto escaped the 
 attention of anatomists : it is the tensor ligament of the membrana 
 tympani. 
 
 The ligament in question is about three-fourths of a line in length, 
 and is attached internally to the cochlcariform process, and exter- 
 nally to that part of the inner surface of the malleus where the long 
 process joins the neck. In the interior of this ligament, which 
 
 Fic 5'J. 
 
 The Attachments of the Tensor Tympani Ligament ; the tendon of the Tensor Tymyiani 
 Muscle is drawn upwards so as to leave the ligament isolated. (Slightly magnified.) 
 
 is tubiform, is placed the tendon of the tensor tympani muscle. 
 Anteriorly the ligament is thin, consisting of very delicate fibres ; 
 but the remainder is thick, dense, and composed of firm ligamentous 
 
 11 
 
162 THE DISEASES OF THE EAR. 
 
 tissue. So long as it remains entire and the membrana tympani 
 uninjured, the latter structure retains its natural degree of con- 
 cavity and tenseness ; but when the ligament is cut through, or 
 there is a solution of continuity, resulting from disease, the mem- 
 brana tympani becomes very flaccid, even though the tendon of the 
 tensor tympani muscle remains entire. When the tensor tympani 
 muscle is pulled, in a preparation of the parts, the membrana tym- 
 pani is rendered very tense, and the tensor tympani ligament re- 
 laxes ; but so soon as the muscle relaxes, the membrana tympani 
 returns to its original state, and the ligament again becomes tense. 
 
 On the functions of the Jibrous lamina' of the membrana tympani. 
 — It is obvious that one use of the fibrous laminse of the membrana 
 tympani is to present a firm but delicate membranous septum for the 
 reception of sonorous undulations. The arrangement of the two 
 sets of fibres at right angles to each other, has the efi'ect of impart- 
 ing great strength, combined with extreme delicacy and tenuity, to 
 the membrane. As stated, there is no evidence to prove that the 
 fibres of which the membi'ana tympani is composed possess in them- 
 selves any contractile power ; neither do the component fibres of the 
 laminixi appear to evince more than an extremely slight degree of 
 elasticity. An examination, however of the structure after death, 
 shows that it has an inherent power of returning to its natural state 
 after being unusually distended. Thus, if the membrana tympani be 
 exposed without interfering Avith its natural state of tension, and the 
 canal containing the tensor tympani muscle be laid open, so that the 
 muscle can be drawn towards its origin, the external concavity of 
 the membrana tympani can be increased until it becomes very tense ; 
 but as soon as the muscle is let go, the membrana tympani will be 
 observed to resume its former condition. This action is explainable 
 partly by the slight elasticity of the circular cartilaginous band, into 
 which the peripheral extremities of the radiating fibres are inserted, 
 and partly by the slight elasticity of these fibres themselves ; but more 
 especially by the peculiar arrangement of the circular fibrous lamina, 
 which has always a tendency, Avhen left to itself, to assume a more 
 shallow form. Thus when the membrane is rendered very concave, 
 the circular fibres are slightly separated from each other ; but when 
 the extra tension ceases, the fibres intersecting the circular ones aid 
 in drawing the latter together again. 
 
 The disposition of the central region of the circular lamina also 
 assists it in bringing back the membrana tympani to its natural 
 
THE MEMBRANA TYMPANI. 163 
 
 State after tension hj the tensor tjmpani muscle. It has been 
 stated that the middle part of these circular fibres, instead of being 
 attached to the handle of the malleus, is applied against its inner 
 surfjice, and thus the membrane is further rendered tense by the 
 pressure of the long process of the malleus against its outer surface 
 during the action of the tensor tympani muscle ; and when this 
 muscle ceases to act, the central part of the circular layer reacts on 
 the malleus and constrains it to resume its usual position. Besides 
 the office of bringing the membrana tympani to its natural state 
 after the action of the tensor tympani muscle, the circular fibrous 
 layer would appear to be always acting as an antagonist to the 
 tensor tympani ligament ; so that by the continued action of these 
 two tissues — the one drawing it inwards, the other outwards — the 
 membrana tympani is kept in a state adapted to receive all the ordi- 
 nary sonorous undulations, independent of any exercise of muscular 
 power. 
 
 T/ie functions of the memhrana tympani. — Anatomists generally 
 consider that the use of the membrana tympani is to receive the 
 sonorous undulations from the air of the meatus, and conduct them 
 to the ossicles, by which they are conveyed to the labyrinth. 
 Whether vibrations are conducted to the labyrinth through two 
 media, or through the air alone, there can be no doubt that the 
 membrana tympani is the agent whereby the vibrations are con 
 veyed from the meatus externus to the tympanum. I shall, in a 
 future part of this volume, try to prove that another function of the 
 membrana tympani is, in conjunction with the muscles and bones of 
 the tympanum, to act as the analogue of the iris of the eye : and 
 thus, firstly, shut out from the internal ear, or at least modify, the 
 effect of loud vibrations ; and, secondly, render the ear susceptible 
 of the more delicate undulations. 
 
 Whatever opinion may be held respecting the functions of the 
 membrana tympani, there can be no doubt that its integrity is 
 essential to the due performance of its functions, as also that it 
 should retain its natural degree of resiliency, and that its muscles 
 should be able to move it with ease. 
 
CHAPTER IX. 
 
 THE MEM BR AN A TYMPANI {continued). 
 
 THE EPIDEUMOID LAYER — DERMOID LAYER — {(l) AC'fTE IXFLAM JIATIOX — TREATMENT — 
 
 CASES (A) CHRONIC INFLAMMATION — CASES — (c) ULCERATION — CASES. FIBROUS 
 
 LAMINAE — {a) ACUTE INFLAMMATION — {!)) CHRONIC INFLAMMATION — {c) ULCERATION 
 
 {fl) CALCAREOUS DEGENERATION — (c) RELAXATION OF THE MEMBRANA TYMI'ANI — 
 
 TREATMENT — CASES. 
 
 In describing tlie diseases of tlie membrana tympani, I shall speak 
 in succession of its epidermoid, dermoid, and fibrous layers, leaving 
 the consideration of the mucous layer till the diseases of the tym- 
 panic cavity come under review. 
 
 I. The Epidermoid Layer. — This layer is sometimes secreted in 
 such large quantities as to form a mass several lines in thickness 
 on the outer surface of the dermis. In some cases I have known 
 this mass to be composed of six or seven lamint^, closely packed 
 upon each other. The symptoms attendant upon this accumulation 
 
 Fig. 60. 
 
 I '■ ' %^_ 
 
 Epidermoid Layer of the Membrana Tympani liypertroiihied. (Magnified three diameters.) 
 
 are analogous to those of accumulation of epidermis in the meatus ; 
 tlicre is also often a great degree of cerebral irritation from the pres- 
 sure on the chain of ossicles. The treatment is similar to that em- 
 ployed ■where there is accumulation of epidermis in the meatus exter- 
 nus. A syringe and warm water arc usually sufficient to loosen and 
 bring away the mass. Should they not be so, a few drops of water 
 or soap and water, dropped into the meatus for a day or two, will 
 
THE MEM BR AN A TYMPANI. 165 
 
 loosen and facilitate the removal of the mass. As a general rule, 
 the symptoms of deafness and discomfort in the head •wholly dis- 
 appear with the extraction of the collection. 
 
 II. The Dermoid Layer. — This layer of the membrana tympani, 
 like the dermis of the meatus, is subject to acute and chronic inflam- 
 mation, and also to ulceration. On account of the intimate relations 
 existing between the dermoid and fibrous layers of the membrana 
 tympani, it is of great importance to put a stop to these affections 
 of the dermis, since they are apt to be prolonged to the deeper- 
 seated layers of the organ. 
 
 [a.) ACUTE INFLAMMATION OF THE DERMIS. 
 
 Acute inflammation of the dermis usually occurs in debilitated 
 subjects, and is produced by the application of cold, or cold water, 
 or any foreign body to the surface. The exciting causes are sudden 
 exposure to cold air after being in a warm room, or cold water find- 
 ing its way into the ear while bathing ; often also it arises from the 
 extension of inflammation from the dermis covering the meatus. 
 The symptoms of this kind of inflammation are slight pain at the 
 bottom of the meatus (aggravated by coughing, sneezing, and at 
 times b}' swallowing), also not unfrequently an itching, with slight 
 dulness of hearing. On examination, the outer surface of the mem- 
 brana tympani is seen to be dull, and the dermoid layer opaque ; its 
 bloodvessels being distended with blood. All the vessels bordering 
 on the malleus are very much larger than natural, and frequently 
 form tAvo red lines, one running on each side of the long process of 
 the malleus. After a few days a discharge of mucus often takes 
 place. This affection, if left unsubdued, is apt to advance to ulcera- 
 tion, and the fibrous layers are also liable to be destroyed. 
 
 Treatment. — The treatment is very similar to that for acute in- 
 flammation of the dermoid meatus. One or more leeches should be 
 applied to the margin of the orifice of the meatus, warm water should 
 be syringed into it thrice or oftener daily, hot fomentations used all 
 around the ear, and, if requisite, aperient medicines and calomel ad- 
 ministered. Most usually the inflammation (seldom accompanied 
 by discharge, though a small quantit}^ sometimes issues from the 
 surface of the membrane) soon succumbs to this treatment, and the 
 fibrous lamince escape uninjured. 
 
166 THE DISEASES OF TUE EAR. 
 
 Case I, Acute injlammation of the dermoid layer of the memhrana 
 tympani. — G. W., Esq., aged 00, consulted me on February 15th, 
 1858, on account of pain in his right ear. 
 
 History. — Witliout assignable cause, slight pain occurred in the 
 right ear several days ago, which has remained till now, being aggra- 
 vated at times. It is increased by coughing, and slightly when swal- 
 lowing. A sensation of fulness is also complained of. On examina- 
 tion^ I found the dermoid layer of each membrana tympani to be 
 more opaque than natural, and numerous bloodvessels, especially at 
 the upper part, were observed to be distended with blood. There 
 was but slight diminution in the power of hearing. 
 
 Treatment. — As the pain was not very severe, the ear was ordered 
 to be syringed out with warm water twice daily, a linseed-meal poul- 
 tice to be applied over the ear at night, and a stimulating liquid to 
 be rubbed over the back of the ear. The pain gradually ceased, and 
 the membrane returned to its natural state. 
 
 Case II. Acute inflammation of the dermoid layer of the memhrana 
 tyynpani. — B. S., Esq., a medical man, aged 48, saw me in February, 
 1852. 
 
 History. — When a student, twenty-six years previously, he had 
 an attack of cold, and became suddenly deaf in both ears, but re- 
 covered in the course of two months. Sixteen years ago, had an 
 attack of vertigo, and suddenly lost the use of the left ear ; the 
 hearing partially returned, but still remains dull. A fortnight be- 
 fore consulting me, he had relaxation of the throat, with an uncom- 
 fortable feeling in the left ear, and again became dull of external 
 hearing, though the sound of his own voice Avas like thunder. On 
 examination, the membrana tympani was observed to be swollen and 
 much redder than natural ; its bloodvessels being large and dis- 
 tended. "VVatch heard at a distance of two feet. 
 
 Treatment. — Slight counter-irritation was kept up behind the ear, 
 and a cooling lotion applied to the meatus for ten days ; at the end 
 of that time the patient quite recovered. 
 
 Case III. Acute inflammation of the dermoid layer of the mem- 
 hrana tympani. Discharge of viscid mucus. — Master S., aged 3, 
 was brought to me by his father, a physician in London, on the 19th 
 April, 1853. 
 
 History. — A few days previously, Avlien not feeling very well, com- 
 plained of slight pain in each ear, which continued for two days, 
 and was followed by a discharge of mucus, with slight dulness of 
 
THE MEMBRANA TYMPANI. 1G7 
 
 hearing. The latter symptoms have remained until the present 
 time. 
 
 On examination, each external meatus Avas ohserved to be par- 
 tially filled ■with matter, ■which "was removed by the syringe, and 
 found to be composed of masses of mucus, similar in character to 
 those issuing from the meatus in cases of acute inflammation of the 
 dermis. They Avere more flocculent, whiter, but not so elongated as 
 in the secretion from the mucous membrane of the tympanum. After 
 the meatus had been cleansed, the outer surface of the membrana 
 tympani "was seen to be of a deep red color, and to project out"wards 
 into the cavity of the meatus. More minute inspection sho"\ved that 
 this red appearance depended upon the tumefaction of the dermoid 
 layer of the membrane, which being denuded of epidermis, the pro- 
 cessus brevis of the malleus ■was observed at its uppermost part. 
 The hearing Avas very dull. 
 
 Treatment. — A leech Avas ordered to be applied to the margin of 
 the orifice of each meatus, and hot poultices to be kept over the ears. 
 By these means the pain Avas subdued, and the inflammatory symp- 
 toms abated. In the course of three days a small portion of vesica- 
 ting paper Avas applied behind each ear. The poAver of hearing re- 
 turned by degrees, the discharge disappeared, and the dermoid mem- 
 brane regained its natural appearance. 
 
 Case IV. Acute inflammation of the dermoid layer. Secretion of 
 mucus. — A. Moorman, aged 58, Avas admitted under my care at the 
 St. George's and St. James's Dispensary, on May 24th, 1850. 
 
 History. — During the last five months has felt much debilitated. 
 About seven Aveeks previous to seeing me, pain suddenly attacked 
 the right ear, and Avas folloAved by a "steaming and hissing sound." 
 After this sound had remained for three wrecks, a discharge issued 
 from the ear, Avhicli has continued to the present time, accompanied 
 by a good deal of itching, and by a sensation as of something grind- 
 ing within the ear. On examination, the watch Avas only heard Avhen 
 in contact with the ear ; the dermoid layer of the membrana tym- 
 pani was observed to be flat, red, and very much swollen ; and there 
 was a watery discharge, consisting principally of epidermoid cells. 
 The surface of the meatus was rather redder than natural. 
 
 Treatment. — The ear to be syringed Avith warm Avater twice daily; 
 and vesicating paper to be applied each night behind the car. 
 
 May 31. — Better ; the noise less loud ; the power of hearing in- 
 creased. 
 
168 THE DISEASES OF THE EAR. 
 
 June 7. — Improves daily : the quantity of discharge is much 
 diminished ; and the noises have ceased, with the exception of short 
 occasional attacks. The membrana tympani is recovering its natural 
 aspect. 
 
 [b.) SIMPLE CHRONIC INFLAMMATION OF THE DERMOID LAYER, 
 WITH OR WITHOUT AN ACCUMULATION OF EPIDERMIS. 
 
 This affection is also commonly produced by cold, but is of little 
 importance, excepting when it results in the secretion of large quan- 
 tities of epidermis. A simple tumefaction of the dermoid layer 
 usually aflFects the hearing power too slightly to cause the patient to 
 apply for relief: in many instances where the layer has been hyper- 
 trophied, the patients have suffered no inconvenience. If, hoAvever, 
 it becomes so tumefied as to render the membrana tympani tense, 
 then a perceptible deafness is induced. In the majority of cases of 
 hypertrophy of the dermoid membrane, there coexists a thickening 
 of the mucous membrane of the tympanum, which causes the deaf- 
 ness. The presence of several layers of epidermis on the outside 
 of the dermis, is also a source of considerable deafness, and very 
 frequently of uncomfortable sensations in the ear and head. 
 
 Case I. Simple chronic inflammation of the dermoid layer, with 
 an accumulation of ej)idcrmis on its surface. — Colonel T., aged 45, 
 strong, and in good health, consulted me on July 1st, 1855, on ac- 
 count of a buzzing sensation in both ears, especially in the right, 
 which had lasted for three months, accompanied by a feeling of op- 
 pression in the head and dulness of hearing. On examination, the 
 watch was heard only when in contact with the ear, and a large 
 quantity of epidermis was observed at the bottom of the meatus. 
 By means of the syringe, several layers were extracted, and the 
 surface of the dermis, which was red and thick, exposed. On the 
 removal of the epidermis, the noises and unpleasant sensation in the 
 head vanished, and the hearing Avas much improved; the hearing dis-' 
 tance Avith the Avatch being six inches. 
 
 Case II. Clironic inflammation and hypertrophy of the dermoid 
 layer. — R. J., Esq., aged 25, visited me on March 20, 1853, on ac- 
 count of dulness of hearinj;. 
 
 History. — Five years ago, after a large portion of cerumen had 
 been scooped out, had irritation in the ears^ and remained deaf for 
 some time afterAvards. Three months ago, when suffering from deaf- 
 
THE MEM BR AN A T Y M P A N I. 1G9 
 
 ness, was relieved bj the use of the syringe ; lately the left ear has 
 again become dull, and he has complained of pain in it, and in the 
 left side of the face. On examination, the right ear heard the 
 "watch at a distance of two inches ; the left at the distance of an 
 inch. The dermoid layer of each membrana tympani was hypertro- 
 phied, and that of the left ear was very red. 
 
 Treatment. — A slight discharge was kept up from the surface of 
 each mastoid process, and a weak solution of nitrate of silver (gr. v. 
 ad. 5J) was applied to the surface of thejiffected membrane. 
 
 April 9. — Hearing improved. The watch is heard by the right 
 ear at a distance of three inches ; by the left, at a distance of seven 
 inches. 
 
 {c.) CHRONIC CATARRHAL INFLAMMATION OF THE DERMOID LAYER. 
 
 This form of inflammation is far from being rare. Like the same 
 disease of the dermoid layer of the meatus, it often occurs in chil- 
 dren out of health, and also results from the application of cold to 
 the surface of the membrane. It very frequently takes its origin 
 in an attack of acute inflammation, which, instead of subsiding, be- 
 comes chronic. The discharge usually consists of the epidermoid 
 cells, which are thrown off in conjunction with a quantity of fluid, 
 instead of forming a distinct epidermoid layer. On removal of the 
 discharge, tlie dermis is found to be swollen, and entirely denuded 
 of epidermis ; the color of the surface varying from a deep to a 
 palish red. The cases of this disease require the deepest attention, 
 since they are apt to terminate in the formation of granulations or 
 of polypi on the surface of the membrane, or in ulceration ; the 
 latter process endangering the fibrous lamina;. This affection is 
 also not unfrequently associated with a corresponding one of the 
 dermoid layer of the meatus ; which may be subdued without the 
 disease of the membrana tympani being cured. 
 
 Case I. Chronic catarrhal inflammation of the dermoid layer, with 
 thickening of the mucous membrane of the tympanum. — Rev. W. A., 
 jBt. 32, visited me on the 18th of November, 1854. 
 
 History. — Since childhood the left car has been useless. During 
 the past year the right car has been dull of hearing at times, and 
 he has complained of irritation of the ear, for which he has been in 
 the habit of using an earpick. Lately his deafness has so increased. 
 
170 THE DISEASES OF THE EAR. 
 
 that he has to be loudl}' spoken to Avithin a yard of the head, and 
 also complains of a discharge from the right ear. On examination, 
 the dermis of the meatus in the right ear was observed to be red, 
 while the dermoid layer of the mcmbrana tympani was partly red 
 and partly white : there was also an abundant discharge of mucus. 
 
 Treatment. — The ear to be syringed out with warm water thrice 
 daily, three leeches to be applied to the orifice of the meatus, and 
 vesicating paper to be kept behind the ear. 
 
 Nov. 2G. — Much better : thinks he now hears as Avell as he has 
 done for some years. The dermoid layer of the membrana tympani 
 is less red ; the discharge is less abundant. 
 
 Case II. Catarrhal injlammation of the dermoid layer after bath- 
 ing. — Miss J. G., let 27, consulted me on September 15, 1855, on 
 account of a dulness of hearing in the left car, Avith discharge. 
 
 History. — A year previously, immediately after bathing in the 
 sea, felt a slight pain in the left ear, which continued for three or 
 four days, and was followed by a discharge, which has remained 
 until now, accompanied by a dulness of hearing. On examination., 
 the surface of the dermoid layer of the membrana tympani was found 
 to be covered with discharge, which being removed, the membrane 
 was seen to be red, and its bloodvessels distended. Under the 
 same treatment as in the last case, the patient was cured in two 
 months. 
 
 Case III. Catarrhal inflammation of the dermoid layer after 
 measles. Polypoid groivth from the surface. — Miss M. E. S., aged 
 10, not strong, Avas brought to me on April 2, 1853. 
 
 History. — Three years previously had an attack of measles, fol- 
 lowed by discharge from the left ear, and considerable dulness of 
 hearing in both. Eight months ago had an attack of low fever, 
 Avhich remained for two or three months, and much increased the 
 deafness. At the present time has to be spoken to distinctly within 
 a yard of the right ear. Every night there is discharge, and a cer- 
 tain amount of earache. Is better in warm weather. 
 
 On examination, there was found in the right ear a large quantity 
 of discharge, which being removed, the dermoid layer Avas observed 
 to be much hypertrophicd, and red groAvths covered considerable 
 portions of it, especially posteriorly. Hearing distance four inches. 
 
 Left ear. — Membrana tj'mpani Avhite at the upper part, and the 
 dermis much thickened; discharge abundant: hearing distance half 
 an inch. 
 
THE MEM BR ANA TYMPANI. 
 
 171 
 
 Treatment. — A solution of chloride of zinc, two grains to the 
 ounce, -was injected into each car daily, and a discharge was kept 
 up from the surface of the mastoid process. Under this treatment 
 
 Fig. fil. 
 
 Granulations on the surface of tbe Dermoid Layer of the Membrana Tympani. 
 (Seen through the Speculum.) 
 
 the discharge disappeared, and the poAver of hearing was greatly 
 improved. 
 
 Case IV. Catarrlialinjiammation of the dermoid layer, following 
 measles. — Master M. N., aged 6, pale, thin, and of a scrofulous dia- 
 thesis, was brought to me on the 12th of May, 1851, on account of 
 a discharge from the right ear. 
 
 History. — Since infancy has been subject to attacks of earache : 
 five montlis ago had an attack of measles, followed by a discharge 
 from the right ear, which, though diminishing at times, has never 
 wholly ceased. No dulness of hearing has been perceived. 
 
 On examination, the hearing distance of the right ear was found 
 to be reduced to four inches ; the meatus contained a large quantity 
 of offensive discharge ; the outer surface of the membrana tympani 
 was flat ; the dermis was white, and much thickened. 
 
 Treatment. — Tonic medicines were administered ; the ear syringed 
 out with half a pint of tepid water thrice daily, and afterwards with 
 a solution of tannin, three grains to the ounce ; and a stimulating 
 liniment was rubbed over the mastoid process twice daily. This 
 
172 THE DISEASES OF THE EAR. 
 
 treatment, persevered in for two months, removed the discharge, 
 diminished the hypertrophy of the memhranc, and improved the 
 power of hearing. The patient was brought to me three or four 
 times subsequently, suffering from a recurrence of the attack, but it 
 always yielded to similar treatment. 
 
 (t7.) ULCERATION OF THE DERMOID LAYER OF THE MEMBRANA 
 
 TYMPANI. 
 
 Ulceration of the dermoid layer is an affection only occasionally 
 met with, and is either the result of long-continued catarrli of the 
 dermis, or of the application to its surface of irritating matters, or of 
 cerumen. The symptoms are very similar to those described in the 
 previous section ; there is, however, frequently a discharge of blood, 
 and the pain is more severe. 
 
 Case I. Ulceration of the dermoid layer from the presence of ceru- 
 men. — Mrs. G., aged 40, saw me on May 26th, 1855. 
 
 History. — Fourteen days previously she had a singing in the left 
 ear, which came on suddenly after fatigue, and has remained until 
 the present period ; it is accompanied at times with confusion in 
 the head. 
 
 On examination, the meatus was found to be full of cerumen, and 
 the Avatch was only heard when in contact with the ear. On remov- 
 ing the cerumen by a syringe and warm water, the outer surface of 
 the merabrana tympani was observed to be red. At its anterior 
 part there Avas a small surface, about three-quarters of a line in dia- 
 meter, Avhere the dermis had been wholly destroyed by ulceration ; 
 and there was also a small depression, at the bottom of Avhicli the 
 membrane was red. Hearing distance reduced to eight inches. No 
 applications were made, and the ulcer healed in a few days. 
 
 Case II. Ulceration of the dermoid layer ; fibrous layers exposed. 
 — J. A., Esq., aged 35, was sent to me on March 2G, 1850, by Mr. 
 Mossop, of "Whitehaven. 
 
 History. — Twenty years ago, had a polypus in the right ear, wliieh 
 Avas removed ; but it grcAV again, and Avas a second time removed ; 
 since the last removal has had discharge at times from this ear. 
 Three years previously had a severe cold, Avas very deaf for a Aveek, 
 and then gradually recovered ; but since that attack has been very 
 
THE MEMBRANA TYMPANI. 173 
 
 (leaf during a cold. Is at present suffering from a cold, and is so 
 deaf as to require to be loudly spoken to close to liim. 
 
 Right ear. — On examination, the surface appeared to be red, and 
 at tlie posterior part there was a small depression, from which the 
 dermoid layer had been eroded by ulceration. Wlien the tympanic 
 cavity is distended, there is an outward bulging of the fibrous layers 
 tlirongh the orifice in the dermis. Watcli heard Avhen in contact 
 with the ear. 
 
 Left ear. — Tlie dermoid membrane is white and thick, and dis- 
 charo;e issues from its surface. Ilearino; distance half an inch. 
 
 Treatment. — A discharge was kept up over each mastoid process, 
 and small doses of blue pill were admistered ; by degrees the hear- 
 ing slightly improved. 
 
 Case III. Ulceration of tlie dermoid layer. Discharge of blood. — 
 M. S. Chambers, aged 7, was admitted under my care at the St. 
 George's and St. James's Dispensary, on January 18, 1850. 
 
 JTistori/. — A year and a half ago, suffered from an attack of small- 
 pox, from which she was very ill for six Aveeks. A few months after 
 the attack, discharge suddenly issued from both ears, and has con- 
 tinued ever since, being very offensive, and at times mixed with 
 blood : has lately been also subject to itching in the ears, earache, 
 pains in the forehead, and giddiness. On examining the right ear, 
 its surface was observed to be red and tumefied, and there Avas an 
 orifice, at the anterior part, through the whole of the laminjK. 
 
 Left ear. — The dermis is of a deep red, and its central portion has 
 been destroyed by ulceration : Avhen the tympanic cavity is distended 
 Avith air, the fibrous layers bulge outwards. 
 
 The treatment consisted in the administration of tonics ; in keep- 
 ing up a discharge from the surfoce of the mastoid process ; and in 
 the use of o;entle astrin<Tents. After several Aveeks the discharge 
 gradually diminished, and all pain ceased. 
 
 3. The fibrous lamiiue. — Although the tAvo fibrous lamintxj arc so 
 distinct in their structure and relations, their diseases are so similar, 
 and they are usually so equally affected, that it is desirable to con- 
 sider them together. The diseases to Avhich they are liable are : — 
 Acute inflammation, chronic inflammation, hypertrophy, ulceration, 
 and calcareous defeneration. 
 
174 THE DISEASES OF THE EAR. 
 
 (rt.) ACUTE INFLAMMATION OF THE FIBROUS LAMINA. 
 
 "When the fibrous layers of the membrana tympani are the seat 
 of acute inflammation, the mucous membrane of the tympanum is* 
 usually siniihirly affected, "whicli renders it difficult to define the 
 symptoms of acute inflammation of the fibrous layers. This aff'ec- 
 tion is usually excited by cold air striking the outer surface of the 
 membrane ; hence, the suddenly passing from a heated room into 
 cold air, especially in an easterly wind, often produces it. As in 
 inflammation of the mucous membrane of the tympanum, there is 
 commonly the predisposing cause of debilitated health. The symp- 
 toms of this aff'ection are a tickling sensation deep in the ear, often 
 accompanied by involuntary movements of the membrana tympani, 
 consequent on the irregular action of the tensor tympani muscle. 
 This sensation increases, and a severe lancinating pain ensues, 
 which is increased by the act of deglutition, the use of the hand- 
 kerchief, coughing, or sneezing. On examination, the surface of 
 the membrane is seen to be shiny, its color more leaden than usual, 
 tinged frequently with a reddish hue, from the distention of its 
 vessels with blood. The aff'ection commonly ends in resolution, but 
 sometimes ulceration ensues, which will be afterwards described. 
 
 The treatment of this form of acute inflammation consists in the 
 use of leeches to the margin of the orifice of the meatus, followed 
 by hot fomentations and poultices ; while calomel and opium are 
 administered internally. Cases of this disease will be given under 
 " acute inflammation of the mucous membrane of the tympanum." 
 
 {b.) CHRONIC INFLAMMATION AND HYPERTROPHY OF THE 
 FIBROUS LAYERS. 
 
 In tliis affection, the fibrous layers continue for some time con- 
 gested or become opaque. This disease will be treated of at length 
 under the head of " rigidity of the membrana tj'mpani." 
 
 (r.) ULCERATION OF THE FIBROUS LAMINvE OF THE 
 MEMBRANA TYMPANI. 
 
 This aff'ection commonly originates either in acute or chronic 
 
THE M E M B R A N A T Y M P A N I. 
 
 175 
 
 catarrhal inflammation of the dermoid hiyer ; but sometimes it is 
 the result of primary acute inflammation of the fibrous layers. It 
 usually occurs in persons of debilitated health, and is often attended 
 "with considerable constitutional irritation. When it originates in 
 catarrh of tlie dermoid layer, that membrane becomes destroyed in 
 parts, and the outer surface of the radiate fibrous lamina is exposed 
 to view. If in this state the mcmbrana tympani be examined with a 
 speculum and a strong light, the radiate fibrous layer is seen to 
 form the floor of a depression, the margins of -which are formed by 
 the dermoid layer. In some cases this surface is covered by deep 
 red granulations ; in others, large portions of the fibrous laminte 
 are exposed, which pour out an abundant discharge without the 
 presence of any granulations. After some of the fibres of the 
 
 Fig. 62. 
 
 The Membrnna Tympani fallen in towards the Promontory, from weakness of the fibrous 
 lamina). (Seen in section.) 
 
 fibrous laminae are destroyed by the ulcerative process, the remain- 
 ing fibres are so much Aveakened that the whole lamina falls inwards 
 towards the surface of the promontory, and thus the size of the 
 tympanic cavity is greatly diminished. In other instances, a great 
 portion of the fibrous lamina is entirely destroyed, and the mucous 
 layer alone remains ; or portions of all the laminae are eroded, and a 
 perforation is the result. Upon inspection, a case of perforation of 
 the mcmbrana tympani, produced by ulceration of the fibrous laminae, 
 and advancing from without inwards, can always be distinguished 
 from a case of perforation originating, as it more commonly does, in 
 catarrh of the mucous membrane of the tympanum, and advancing 
 
176 
 
 THE DISEASES OF THE EAK. 
 
 from within outwards. In the hitter chiss of cases, the margin of 
 the orifice is sharp, smooth, and well defined ; its shape is usually 
 round or oval ; and the remaining portion of the membrane, retain- 
 
 FiG. 63. 
 
 The Membrana Tympani fallen in towards the Promontorj-, from weakness of the fibrous 
 lamina\ (Seen from without.) 
 
 ing its natural plane, is smooth : whereas, in cases of perforation 
 from ulceration of the dermoid and fibrous layers, the margins and 
 form of the orifice are irregular ; and the plane of the remnant of 
 
 Fig. 64. 
 
 An Orifice in the Membrana Tj'mpani produced bj' ulceration of the fibrous lnraina\ 
 
 the membrane, deviating from the natural state, is often funnel- 
 shaped, and very concave externally. 
 
 Ulceration of the fibrous layers of the membrana tympani once 
 established is liable to remain during many years, and is one of the 
 diseases hitherto comprised under the term " otorrhoea." Some- 
 times a large part of the substance of the fibrous laj-ers is entirely 
 effaced, and the outer surface of the mucous membrane pours out a 
 secretion. A singular accompaniment of this affection of the fibrous 
 laminae is a contraction of the carotid canal. I have so frequently 
 
THE MEM BR AN A TYMPANI. 177 
 
 found this condition "vvlierc tlie menibrana tympani has been ulce- 
 rated, and so rarely met "with it under other circumstances, that I 
 am induced to consider it as connected with the ulceration. The 
 treatment to be pursued in cases of ulceration of the fibrpus laminae, 
 consists in washing out the meatus frequently with warm water, and 
 in applying, by means of a syringe, a weak solution of the nitrate 
 of silver, or some other astringent, to the part affected. If the 
 membrana tympani has been perforated, the use of an artificial 
 membrana tympani will often be of service. A slight discharge 
 should also be kept up from the surface of the mastoid process. 
 Concurrently with these local aj)plications, measures should be taken 
 to strengthen the general health. 
 
 Case I. Ulceration of the fibrous lamina> of the mcmhrana tym- 
 pani. — AV. AV., aged 50, a medical man, residing in London, con- 
 sulted me, in 1852, on account of a long-standing discharge from 
 the left ear, accompanied by deafness. 
 
 IHstorij. — In early life, after repeated attacks of earache, a dis- 
 charge flowed from the left ear, Avhich has not ceased for more than 
 
 Fig. 65. 
 
 The Fibrous Layers of the Membrana Tympani ulcerated over a small extent at its anterior 
 part. The mucous membrane, remaining, forms a small cul-de-sac, seen externally. 
 This illustration, from a preparation in my museum, gives an idea of the nature of the 
 disease. 
 
 a week or two at a time since that period. Lately there has been 
 at times great deafness, producing extreme inconvenience, as the 
 right ear has been useless during many years. L^pon syringing the 
 left ear, a large quantity of offensive matter was removed, and the 
 menibrana tympani became distinctly vi.<ible. Its circumference 
 was in a natural state, but at the central part the dermoid and 
 fibrous layers had been destroyed by ulceration, so as to disclose 
 the outer .surface of the mucous layer. Instead of forming a sep- 
 tum in the situation of the natural or<]jan, the membrane was nearly 
 
 12 
 
178 THE DISEASES OF THE EAR. 
 
 in contact with the outer surface of the promontory. Upon the 
 patient swallowing with closed nostrils, the mucous membrane was 
 observed to bulge outwards, and form a kind of bubble, which re- 
 mained unti.1 the act of swallowing was repeated witli the nose open, 
 when the membrane again fell inwards. During the time the mem- 
 brane projected outwards, the hearing power was greatly improved ; 
 but diminished as soon as it fell inwards. 
 
 The treatment consisted in syringing out the ear twice daily, so 
 as to remove the discharge, in applying a weak solution of nitrate 
 of silver to the outer surface of the membrane, and in keeping up a 
 slight counter-irritation over the mastoid process. The result was, 
 that the power of hearing improved, and the condition of the mucous 
 membrane became so much strengthened that, instead of falling in- 
 wards towards the promontory, it was able to form a tympanic cavity. 
 So long as that remained, the hearing was excellent ; but if from 
 any cause the mucous membrane fell inwards, the performance of 
 the act of deglutition, during the closure of the nostrils, immediately 
 restored it to its natural position, and improved the hearing. 
 
 Case II. Ulceration of the fibrous la mince of the memhrana tym- 
 pani. — Mrs. E. C, aged 38, consulted me in June, 1850, on account 
 of deafness in both ears, accompanied by giddiness and discharge. 
 
 History. — Twenty years previously she had a bad cold, followed 
 by deafness and a discharge from both ears ; and the latter has con- 
 tinued to the present time. Has been subject to attacks of earache, 
 usually followed by an increase of the discharge, which, during a 
 cold, is much more abundant, often becoming very offensive. During 
 the last year has been much worse, complaining of much singing in 
 the head, and giddiness. She requires to be distinctly spoken to 
 within the distance of a yard. On examination, a quantity of fluid 
 discharge having been removed from each meatus, the right mem- 
 brana tynipani at the posterior and lower part ajipeared white and 
 thick, while the anterior and upper part had fallen inwards, and 
 appeared as if attached to the promontory ; its outer surface was 
 uneven, and poured out the discharge; air passed through the Eusta-' 
 chian tube. Hearing distance two inches. 
 
 Left ear. — Hearing distance one inch. The upper half of the 
 memhrana tympani had fallen inwards, was red, and poured out a 
 discharge. The treatment consisted in keeping up a discharge from 
 the back of the neck, in syringing out the ears twice daily, and in 
 applying a solution of nitrate of silver (gr. xx ad oj) to the surface 
 
THE MEMBRAXA TYMPANI. 
 
 179 
 
 of the membrane. Tliis treatment was pursued during two months: 
 the discharge gradually disappeared ; and the hearing was greatly 
 improved. 
 
 (fZ.) CALCAREOUS DEGENERATION OF THE FIBROUS LAMINiB 
 OF THE MEMBRANA TYMPANI. 
 
 The fibrous laminae of the membrana tympani frequently undergo 
 calcareous degeneration. This change occurs at all periods of life; 
 sometimes taking place when the remaining portion of the membrane 
 
 Fig. 66. 
 
 Calcareous Deposit in the Circular Fibrous Lamina of the Membrana Tympani. 
 
 is healthy, and no other abnormal state can be detected in the organ. 
 In some cases this calcareous condition of the membrane is symp- 
 
 FiG. 67. 
 
 Calcareous Deposit in the ll.i i...i. 1 .uious Lamina of the Membrana Tympani. 
 
 tomatic of calcareous deposit within the tympanic cavity ; in others, 
 it follows, and appears to be produced by, chronic inflammation, 
 with or without catarrh of the dermoid layer. After ulceration and 
 destruction of portions of the membrane, the residue is also at times 
 converted into calcareous matter. Sometimes the calcareous matter 
 is arranged in a circular form, when it will be found to be deposited 
 in the circular fibrous layer ; at other times it assumes a radiate 
 
180 THE DISEASES OF THE EAE. 
 
 form, and tlien the radiate fibrous layer is the seat of the deposit. 
 In other cases the whole mass of the membrane is converted into 
 calcareous matter. Where there is much diminution of the power 
 
 Fic. 68. 
 
 The whole of the Membrana Tyu-j .i... . -ivertetl into Calcareous Matter. 
 
 of hearing in this disease, there is usually partial or complete anchy- 
 losis of the stapes to the fenestra ovalis, and any treatment must 
 have for its object the diminution of the anchylosis. Patients ap- 
 plying for relief in such cases must therefore be treated by counter- 
 irritation over the mastoid process, and by the administration of 
 alteratives. 
 
 Case I. — M. C, aged 32, consulted me in December, 1854. 
 
 nistory. — When a child he had an attack of measles, followed by 
 great diminution of the power of hearing, so that he has ever since 
 been unable to hear unless -the S'peaker's voice is raised higher than 
 natural, and brought near to him. There has been discharge for 
 many years from the right ear. On examination, the meatus of that 
 ear was found full of thick discharge ; when this was removed by 
 the syringe, the upper half of the membrana tympani was seen to 
 be calcareous, the lower half transparent. The Eustachian tube was 
 pervious. "Watch not heard when in contact with the car ; but the 
 crack of the nail Avas heard at the distance of a foot. 
 
 Left ear. — The anterior half of the membrana tympani was calca- 
 reous ; Eustachian tube pervious ; hearing power the same as in the 
 opposite ear. Gentle counter-irritation over the mastoid process was 
 ordered. The patient was not seen a second time. 
 
 Case II.— J. G. T., Esq., aged 18, consulted me in 1855. The 
 general health was good, with no hereditary tendency to deafness. 
 
 History. — Five years previously dulness of hearing slowly ap- 
 peared after an attack of influenza ; two years subsequently suffered 
 from scarlet fever, followed by discharge from each ear, and by a 
 great increase of deafness. The discharge has now ceased ; but 
 
TUE MEM BR AN A TYMPANI. 181 
 
 there is so mucli deafness that he has to be loudly spoken to within 
 three feet. At times, especially during a cold, earache is com- 
 plained of. On examining the right ear, the watch was heard at 
 the distance of half an inch. The greater part of the lower half of 
 the membrana tympani was converted into a mass of crescent-shaped 
 calcareous matter, but the other part of the membrane was healthy. 
 Eustachian tube pervious. 
 
 Left car. — Watch heard on pressure over the ear and over the 
 temple ; the membrana tympani is more concave than natural ; and 
 there is a patch of calcareous matter, similar in shape and size to 
 that of the right ear. Eustachian tube pervious. The same treat- 
 ment was pursued as in the last case, and with some benefit. 
 
 Case III. — Mrs. B., aged 34, in good health, but subject to bilious 
 attacks, consulted me in 1854. 
 
 Ilistory. — Since an attack of earache when a child, the left ear 
 has been useless. Three months ago the right ear became suddenly 
 deaf after a cold ; the deafness was treated by syringing, the opera- 
 tion being followed by slight bleeding, but no immediate improve- 
 ment. After a few days, however, the hearing improved, but the 
 ear was extremely sensitive, and there was a constant feeling of re- 
 verberation in it. When more than one person spoke at a time, con- 
 fusion in the ear was produced, and, during the act of swallowing, a 
 grating sound occurred in the organ. Noise like that of a waterfall 
 is constantly present on the right side. On examining the right 
 ear, the larger part of the membrana tympani was found calcareous ; 
 the Eustachian tube was pervious ; the hearing distance was six 
 inches. The membrana tympani of the left ear had so fallen in as 
 to be in contact with the promontory. The Avatch was not heard, 
 but the crack of the nail was heard at a distance of three inches. 
 The treatment consisted in keeping up a slight discharge from the 
 surface of the mastoid process, which Avas followed by great diminu- 
 tion of the distressing noises in the ears. 
 
 {e.) RELAXATION OF THE FIBROUS LAMINAE OF THE MEMBRANA 
 
 TYMPANI. 
 
 Some writers have doubted the existence of the disease called 
 " relaxation of the membrana tympani." Thus Dr. Kramer^ says: 
 
 ' On the Diseases of the Ear, translated by Bennett, p. 143. 
 
182 THE DISEASES OF THE EAR. 
 
 " I may be allowed to banish relaxation and tension of the mem- 
 brana tympani from the catalogue of diseases met with in practice, 
 in Avhich I have, indeed, been preceded by Itard, who, however, has 
 not adduced his reasons." Although the writers who preceded Dr. 
 Kramer, who had spoken of this disease, had not described the symp- 
 toms nor the appearances by which it could be recognized, they were 
 nevcfthclcss correct in stating that the disease in question existed. 
 Indeed, it appears to me that no disease of the ear can be more dis- 
 tinctly diagnosed than the one under consideration. 
 
 The causes of this disease are : — 1st, the effects of an ordinary 
 cold, producing hypertrophy of the mucous layer ; 2d, inflammation 
 of the fibrous layers. From either of these causes, the membrana 
 tympani may lose its natural degree of resiliency and become flaccid 
 so as to fall inwards, and approach more nearly to the promontory 
 than is natural : a change which ends in great dulness of hearing. 
 This dulness may, however, be temporarily relieved by pressing out 
 the drum to its natural position, either by swallowing Avith closed 
 nostrils, by attempting a forcible expiration, or by forcibly and 
 rapidly inhaling air through the nose. No sooner, however, is the 
 act of swallowing in the natural way repeated, than the air escapes 
 from the tympanic cavity, the membrana tympani falls inwards, and 
 the dulness immediately returns. The treatment depends in a mea- 
 sure upon the cause of the affection. If the mucous membrane 
 lining the tympanum be thickened, counter-irritation over the mas- 
 toid process should be practised ; if the fibrous lamin?e are inflamed, 
 leeches should be applied to the margin of the meatus. "Where the 
 fibrous laminne are Aveakened, a solution of the nitrate of silver ap- 
 plied to the outer surface of the membrane is frequently of great 
 service. There are cases where the deafness is not in the least de- 
 gree relieved by forcing air into the tympanic cavity : when this 
 happens, it is most probable that partial anchylosis of the stapes 
 has taken place. The following cases illustrate fully the symptoms 
 and treatment of this disease. 
 
 Case I. 3Iemhrana tympani relaxed; deafness temporarili/ di- 
 minished after filling the tympanic cavities with air. — S. B., Esq., 
 aged 18, consulted me in November, 1853, on account of dulness of 
 hearing. 
 
 History. — Several years previously, he became dull of hearing, 
 
THE MEMBRANA TYMPANI. 183 
 
 ■vvitliout pain or any assignable cause, and lately the affection has so 
 much increased, that he requires to be loudly spoken to Avithin the 
 distance of a yard. The deafness is greatly aggravated during a 
 cold. The power of hearing is much improved whenever he has 
 blown air into each tympanic cavity ; but as soon as the act of de- 
 glutition is naturally performed, a sensation of weight is felt in the 
 ears, and the deafness returns. On examination of the right ear, 
 the membrana tympani was found to be opaque ; its bright spot 
 elongated ; the form more concave externally than is natural. On 
 swallowing, or forcing the air with the nose closed, the membrana 
 tympani expands to its natural form, and remains so until the act of 
 deglutition is repeated Avith the nose open, when it again fiills in- 
 wards. Hearing distance with watch, half an inch. The left is in 
 the same state as the right ear. The mucous membrane of the 
 fauces is red and thick. 
 
 Treatment. — As there was an evident thickening of the membrana 
 tympani, vesicating paper was applied behind each ear ; the sixteenth 
 of a grain of bichloride of mercury was administered every night ; 
 and a lotion was applied to the outer surface of each membrana 
 tympani, consisting of three grains of nitrate of silver to an ounce 
 of distilled water. This treatment, at the end of a fortnight, so 
 greatly improved the patient's power of hearing, that he could dis- 
 tinctly hear an ordinary voice at three yards' distance. This 
 improvement continued until the patient took a severe cold, when 
 the deafness recurred ; but was subdued again by a repetition of the 
 treatment. 
 
 Case II, Memlrana tympani relaxed and coyigested ; symjjtoms 
 diminished temporarily hy a forcible inspiration through the nose. — 
 J. J., Esq., aged 35, came to consult me in September, 1853. 
 
 History. — Since a child, has been subject to earache in each ear. 
 For a year or two, this pain has occurred in the right ear only, and 
 has lately been very considerable. Complains of a feeling of rum- 
 bling in the ears, and of so great a dulness of hearing that he has to 
 be spoken to distinctly within the distance of a yard. The rumbling 
 sensation and the deafness are both temporarily relieved by suddenly 
 and forcibly drawing in the breath through the nostrils ; but this im- 
 provement disappears immediately the act of swallowing is naturally 
 performed, and if that act is delayed, the symptoms slowly return in 
 in the course of a fcAV minutes. The patient has thus acquired the 
 
184 THE DISEASES OF THE EAR. 
 
 habit of incessantly " sniffing" the air, which is exceedingly unplea- 
 sant to himself and to every one around him. While sitting in my 
 room, he must have performed this act twenty or thirty times. On 
 examination, each 'membrana tympani Avas found red and dull, with 
 the bright spot much larger than natural. 
 
 Treatment. — As there was palpable congestion of the membrana 
 tympani, leeches were applied to the margin of the meatus ; a vesi- 
 cating paper kept on each mastoid process ; and a warm solution of 
 chloride of zinc (gr. ij @ ^j) was dropped into each meatus twice 
 daily. By persevering in this plan of treatment for three months, 
 the patient could hear nearly as well as was natural, and had com- 
 pletely lost the habit of " sniffing." 
 
 Case III. Relaxation of memhraTia tympani from thickening of the 
 tympanic mucous membrane, produced by a cold; deafness improved 
 by forcing air into the tympanum, and by syringing tvith water. — 
 Miss J., aged 50, applied to me in May, 1853. 
 
 History. — Suffered when a child from disease of the left ear, which 
 produced total deafness. For some years the left ear has been dull 
 during a cold, and at times the deafness is very great ; at present 
 the patient has to be spoken to loudly within the distance of two 
 yards ; but after forcing air into the tympanum, the hearing is tem- 
 porarily so improved that she can hear what is said in any part of 
 an ordinary sized room. This improvement can also be produced 
 by syringing water ; but under either treatment, the dulness of hear- 
 ing speedily returns. In order to keep up a tolerable amount of hear- 
 ing, she has fallen into the habit of blowing air into the ear every 
 few minutes. On examination of the right car, tlie hearing distance 
 was found to be two inches. The membrana tympani was Avhite, the 
 surface shiny. Air entered through the Eustachian tube, and when 
 it distended the tympanic cavity, the membrana tympani was seen 
 to move outwards to a much greater extent than natural. This 
 movement was followed by a great improvement in tlie hearing, 
 which, however, very soon disappeared. 
 
 Treatment. — Considering this to be a case of relaxation of the 
 membrana tympani, produced by thickening of the tympanic mucous 
 membrane, slight counter-irritation was excited over each mastoid 
 process, and a solution of nitrate of silver (gr. iij @ oj) was dropped 
 into each ear every night. Tonics were administered. After this 
 treatment had been pursued for a fortnight, a manifest improvement 
 
THE MEMBRANA TYMPANI. 185 
 
 took place, the patient licard better, and had no occasion to force 
 air into the ear ; the habit, too, has been nearly overcome. I have 
 seen this patient once or twice since, — once during the year 1855, — 
 and the result of the treatment has, on the whole, been satisfactory ; 
 the hearing remained much better, except during attacks of cold, 
 when the old habit of "clearing the ears," by forcing air into them, 
 was had recourse to. 
 
CHAPTER X. 
 
 THE MEMBRANA TYMPAXI {concluded). 
 
 PERFORATION, CAUSES — PHYSIOLOGICAL OBSERVATIONS — EXPERIMENTS PREVIOUS TO 
 THE FORMATION OF AN ARTIFICIAL MEMBRANA TVMPANI — ON THE ARTIFICIAL MEM- 
 BRANA TYMPANI — THE MODE OF APPLYING IT — CASES — RUPTURE OP THE MEMBRANA 
 TVMPANI — PHYSIOLOGICAL OBSERVATIONS — PATHOLOGICAL OBSERVATIONS — CASES. 
 
 {a) PERFORATION OF THE MEMBRANA TYMPANI, AND THE USE 
 OF THE ARTIFICIAL MEMBRANE. 
 
 When speaking of ulceration of the fibrous layers of the mem- 
 brana tynipani, I had occasion to point out that perforation of the 
 membrane itself sometimes, thougli rarely, takes place as a result. 
 The usual cause of perforation of the raembrana tympani is catarrh 
 of the tympanic mucous membrane. In the latter case, a large 
 quantity of mucous is excreted, which fills the tympanic cavity, and 
 being too viscid or too abundant to escape through the Eustachian 
 tube into the fauces, it consequently presses against the inner sur- 
 face of the membrana tympani, causing gradual absorption of its 
 substance, and ultimately perforation. That this afiection is not 
 the result of primary ulceration of the mucous membrane lining the 
 inner part of the membrana tympani, is shown, I think, by the fact 
 that in cases of perforation no appearances of ulceration are obser- 
 vable in any other parts of the tympanic cavity ; indeed, as "will be 
 seen, Avhen considering the diseases of the mucous membrane of the 
 tympanum, ulceration is comparatively a rare occurrence. 
 
 The most usual cause of perforation of the membrana tympani is 
 scarlet fever: in other cases it is connected with scrofulous disease, 
 the mucous membrane of the tympanum throwing out large quan- 
 tities of mucus. The result of a perforation of the membrana tym- 
 pani, as all medical men are aware, is a certain diminution of the 
 hearing power. A small orifice, unattended with any other lesion 
 
THE MEM BR AX A TYMPANI. 187 
 
 of the organ, does not produce such a degree of deafness as to be 
 very uncomfortable ; but, if in addition to the small orifice, there is 
 a thickened and relaxed condition of the mucous membrane of the 
 tympanum, or of the remaining portion of the membrana tympani, 
 then very serious diminution of the hearing power occurs. Even a 
 large orifice in the membrana tympani often does not produce any 
 serious amount of deafness ; but if it is accompanied with much 
 thickening of the mucous membrane of the tympanum, the patient is 
 entirely debarred from conversation, except when specially addressed, 
 in a loud tone, Avithin the distance of a yard. What is the cause of 
 deafness in cases of perforation ? There is, it seems to me, no doubt 
 but that one of the functions of the membrana tympani is to con- 
 fine the sonorous undulations to the tympanic cavity, in order that 
 they may be concentrated on the membrana fenestra) rotundiie. In- 
 deed, it is probable that the vibrations only partially pass through 
 the chain of bones to the vestibule, and that the air in the tympanic 
 cavity is one great medium of communication Avith the labyrinth. 
 If the means of communication Avith the labyrinth be the air in the 
 tympanic cavity, it is palpable that an aperture in the membrana 
 tympani is likely to diminish the poAver of hearing, by permitting 
 the vibrations to escape from that cavity into the meatus, and so 
 prevent their concentration upon the membrana fenestras rotundie. 
 This explanation of the diminished power of hearing in cases of 
 perforate membrana tympani, seems confirmed by the result of the 
 treatment adopted for their amelioration. 
 
 Treatment. — Until very recently, the deafness arising from the 
 presence of an aperture in the membrana tympani was regarded as 
 incurable, and no systematic treatment Avas attempted, although 
 several Avriters had alluded to the beneficial consequences folloAving 
 the introduction of foreign bodies, especially of lint and cotton-Avool, 
 Avhere there Avas perforate membrana tympani. Thus Itard cites a 
 case in Avhich the deafness Avas completely relieved by introducing a 
 portion of cotton-Avool to the bottom of the meatus. Deleau, too, 
 speaks of a patient Avho greatly improved his hearing, using in this 
 Avay a piece of avooI or the central part of an onion. Mr. Todd de- 
 scribes " the relief derived from the mere introduction of a little lint 
 into the external meatus in those cases Avhere the membrana tym- 
 pani has been ruptured or destroyed by disease. So great, indeed, 
 is the improvement Avhich takes place from the application of this 
 simple remedy, that patients Avill frequently appear astonished at 
 
188 THE DISEASES OF THE EAR. 
 
 being so easily relieved."' In the year 1848, !Mr. Yearsley pub- 
 lished a pamphlet entitled, " On a New Mode of Treating Deafness 
 when attended by partial or entire Loss of the Membrana Tympani, 
 associated or not with Discharge from the Ear." In this pamphlet 
 he advocates the application of cotton-wool in a moistened state, in 
 cases of partial or entire loss of the membrana tympani ; the object 
 of this substance being, as he has subsequently stated, " to support 
 the remaining portion of the membrana tympani, or the ossicula."^ 
 Respecting the mode of applying the wool, the following are his in- 
 structions : "A small piece of wool, differing in size according to 
 the case, and fully moistened in water, is introduced through the 
 speculum to the bottom of the meatus, and adjusted superiorly, infe- 
 riorly, anteriorly, or posteriorly, according to the situation of the 
 perforation and other circumstances connected with the case ; but 
 care must be taken that the entire opening be not covered, otherwise 
 the experiment will not succeed. It is also indispensable to success 
 that the moisture of the wool should be preserved." 
 
 After having conducted some researches into the functions of the 
 tympanic cavity, which were laid before the Royal Society, and 
 made some experiments upon the ears of patients suffering from per- 
 forate membrana tympani, it appeared to me that an artificial mem- 
 brana tymjiani could be constructed which might confine the vibra- 
 tions to the tympanic cavity, and concentrate them upon the laby- 
 rinth. The course of investigation which has been pursued by me 
 showed that the guttural orifice of the Eustachian tube is closed, 
 except during the momentary action of certain muscles, and that 
 for all purposes relating to the passage of sonorous undulations the 
 tympanum is a shut cavity ; and next, that by a modification of Mr. 
 Wheatstone's experiment with a tuning-fork, suggested to me by 
 Mr. C. Brooke, the sonorous vibrations communicated to the bones 
 of the head appear much louder when the meatus externus is closed 
 than when the orifice is open. 
 
 If, for instance, a tuning-fork be made to vibrate, and then be 
 placed in contact with the head, the sound proceeding from it will, 
 in a few seconds, cease to be heard ; but if directly on this cessation 
 of sound, the experimenter close the entrance of the meatus in one 
 ear so as to convert it into a shut cavity, he will instantly hear a 
 renewal of the sound of the tuning-fork ; from which it appears 
 
 » Anatomy and Phj-siology of the Organ of Hearing. Pp. 105-6. 1852. 
 ' Provincial Medical and Surgical Journal, August 18th, 1852. 
 
THE MEMBllANA TYMPANI. 189 
 
 most prob.ablc tliat the sonorous A'ibrations communicated to the ex- 
 ternal meatus impressed the niembrana tympani much more power- 
 fully Avlien confined "within the meatus than when allowed free com- 
 munication with the external air. Considering the result of this 
 experiment in connection with the other fact of the ordinarily closed 
 state of the tympanic cavity, it appeared to me highly probable that 
 the sonorous vibrations imparted to the cavity of the tympanum, 
 could only make their due impression on the membranes of the laby- 
 rinth when strictly confined to the tympanic cavity, and not allowed 
 to expend themselves in the cavity of the fauces. This conclusion 
 was strengthened by the fact, that all the Avails of the tympanic 
 cavity appear expressly constructed for producing resonance, having 
 an investing membrane of so great tenuity as scarcely to be detected 
 save by the touch or the use of a magnifying glass, and also by the 
 observation, that this peculiar condition of the mucous membrane 
 was restricted to the tympanic cavity itself and to that portion of 
 the Eustachian tube which forms part of the resonant walls of that 
 cavity. 
 
 If the view here advanced be correct, and if for the perfect per- 
 formance of the function of hearing it be necessary to confine the 
 sonorous vibrations to the tympanic cavity, it is clear that the ana- 
 logy usually cited as existing between the kettle-drum and the tym- 
 panum of the human ear, to the eff'ect that in both the air within 
 should be allowed to communicate with that without, is incorrect ; 
 and it is further evident, that an opening in the niembrana tympani 
 must more or less diminish the poAver of hearing. On examining 
 patients affected Avith simple perforation of the niembrana tympani, 
 the impaired inability to hear can, in fact, ahvays be detected ; al- 
 though, as has been stated, if the orifice be small and the organ 
 otherAvise healthy, the difference is but slight. In the greater num- 
 ber of cases, hoAvever, Avliere perforation of the membrana tympani 
 exists, other lesions of a serious character have coexisted, such as 
 thickening of the membrane of the tympanum, pressure on the mem- 
 brane of the fenestra rotunda, derangement of the articulation of 
 the stapes with the fenestra ovalis, or injury to the nervous expan- 
 sion in the labyrinth. Under any of these circumstances it occurred 
 to me, that as an orifice in the membrana tympani, by preventing 
 the sonorous undulations, OAving to their diff'usion in the meatus, 
 from being concentrated upon the membranes of the labyrinth, 
 might be a direct cause of diminution of hearing poAver, so it Avas 
 
190 THE DISEASES OF THE EAK. 
 
 probable that increase of that power wouhl follow an artificial closing 
 of the orifice. 
 
 The preceding train of investigation led me to attempt the con- 
 struction of an artificial membrana tympani, which, it was hoped, 
 might serve as a substitute for the natural membrane, so far, at 
 least, as its function of closing the tympanum, and thus rendering 
 its walls resonant, was concerned. 
 
 These expectations of success Avere strengthened by the result of 
 observations made by me on cases of perforate membrana tympani. 
 When such cases are not complicated with any serious lesion of the 
 organ, it must have been remarked by others as well as by myself, 
 that the patient, from some apparently inexplicable cause, at times 
 suddenly hears perfectly well, or nearly so. This return of the 
 hearing sometimes remains for a few minutes only, at others, for one 
 or more hours. Having found the improvement to follow the use of 
 a syringe and tepid water, or even of the handkerchief, I examined 
 the ear in certain patients after these operations were finished, and 
 found that in the former case a bubble of water, in the latter, of 
 discharge, had filled up the orifice in the membrana tympani. On 
 destroying the bubble, the improvement in the hearing at once dis- 
 appeared. In one patient its stay could be prolonged by the use 
 from time to time of a solution of gum acacia in water. On recon- 
 sidering these facts, since the completion of my observations upon 
 the closed state of the tympanic cavity, I have arrived at the con- 
 viction that the bubble of water, discharge, or mucilage, acted bene- 
 ficially by temporarily reconfining the sonorous imdulations to the 
 tympanum, a conviction which subsequent observations have 
 strengthened. 
 
 After some experiments, I tried vulcanized India-rubber and 
 gutta-percha, making use of the thinnest layers of them that were 
 procurable. With both these substances, I succeeded in making a 
 rude kind of artificial membrana tympani, by cutting a portion 
 about the size of the natural membrane, and passing through it a 
 piece of thread, by means of which it could be conducted through a 
 fine tube to its proper situation. The tube was then withdrawn, 
 and the thread left in the meatus, so that the patient, or the ope- 
 rator, could remove the artificial membrane at pleasure. The dis- 
 advantages of this apparatus Avere — difiiculty of applying it on the 
 part of the patient ; liability of the material to be torn by the 
 thread ; and the unsightliness of the latter hantring doAvn froui the 
 
THE MEMBRANA TYMPANI. 101 
 
 meatus. The experiment, however, was so far satisfactory as to 
 induce me to request Messrs. Weiss to construct one, the centre of 
 which should consist of two very fine plates of silver, having a dia- 
 meter of about three-quarters of a line between which the \njcr of 
 vulcanized india-rubber, or gutta-percha, might be placed, and 
 having a silver wire attached to the surface of the outermost plate. 
 The artificial membrana tympani, made by Messrs. Weiss from 
 these directions, has hitherto been perfectly successful. As sup- 
 plied by them, the portion of vulcanized india-rubber (the only ma- 
 terial now used) is about three-quarters of an inch in diameter, 
 which leaves ample margin for the surgeon to cut out a membrane 
 of any shape that may seem to him desirable ; and to leave the 
 silver plate either in the centre or towards the circumference at his 
 discretion. The silver wire is of sufficient length to admit of the 
 
 Fig. 69. 
 
 The Artificial Membrana Tyuipani. 
 
 membrane being introduced or Avithdrawn by the patient, but is not 
 perceivable externally, except by special observation. A pair of 
 
 Fig. 70. 
 
 Margin of the circumference of the Membrana Tympani remaining after the destruction of 
 the rest of the membrane. 
 
 forceps is made, by which the artificial membrane can be more easily 
 introduced or withdrawn. 
 
192 THE DISEASES OF THE EAR. 
 
 Before describing the method of applying the artificial membrana 
 tympani, a few words are required respecting the state of the re- 
 maining portion of the membrana tympani, after perforation has 
 taken place. The orifice is, in some cases, not larger than a pin's 
 head ; in others, a line in diameter ; Avhile in many, the entire 
 membrane is destroyed, with the exception of a margin at the cir- 
 cumference, about half a line in diameter, which being composed of 
 the combined fibres of the thickest portion of the circular and radiate 
 laminae, generally remains. This margin is deepest at the upper 
 part. In rare cases, the long process of the malleus continues 
 entire, after the complete destruction of the membrane to which 
 it was attached ; but, as a general rule, the whole of this pro- 
 
 FiG. 71. 
 
 Handle of the Malleus remaining aftpr the destruction of the Membrana Tympani. 
 
 cess is gradually absorbed, leaving merely the head of the bone 
 (which articulates with the incus), the neck, and the body, Avhich 
 receives the attachment of the tensor t^-mpani ligament internally. 
 Anteriorly and posteriorly the fibres of the remnant of the mem- 
 brane are attached ; and externally tlie processus brevis remains. 
 It will, therefore, be understood, that in cases of so-called destruc- 
 tion of the membrana tympani, a margin is generally left, to which 
 the body of the malleus remains fixed, and to the inner part of this 
 the tensor tympani ligament and muscle are attached ; affording the 
 means by which the small bones and muscles of the tympanum are 
 still enabled to perform their functions. In cases of general ulce- 
 ration of the mucous membrane of the tympanum, Avhich fortunately 
 seldom occurs, the incus is commonly discharged, and sometimes the 
 malleus also ; but even in these cases, if the attachments of the 
 stapes to the circumference of the fenestra ovalis remain uninjured, 
 the power of hearing may be greatly improved ; should the stapes, 
 however, be removed, total and irremediable deafness ensues. 
 
THE MEM BR AN A TYMPANI. 193 
 
 The artificial mcmbrana tympani is of the greatest benefit in those 
 cases Avhere there is a Avell-defincd aperture in the natural mem- 
 brane, or, if that membrane be entirely absent, Avhere there is 
 
 Fir.. 72. 
 
 
 \ 
 
 V 
 Body of Malleus remnining after destruction of Membrana Tympani. 
 
 simple hypertrophy of the mucous membrane of the tympanum, 
 with or -without discharge from its surface. In these cases, the 
 organ Avill be found to have by no means entirely lost its power of 
 discerning sounds ; for, as a general rule, the human voice is heard 
 when the speaker's mouth is brought within a foot of the patient's 
 ear, and the speech is slow and distinct. This diminished poAver of 
 hearing entirely excludes the sufierer from the advantages of gene- 
 ral conversation ; but the deafness is greatly aggravated when to 
 the affection of the membrana tympani and mucous membrane of 
 the tympanum is added anchylosis of the stapes to the fenestra 
 ovalis, or when the nervous expansions have been injured. In such 
 cases, the patients have to be shouted to close to the ear, and the 
 artificial membrane is useless. 
 
 THE MODE OF APPLYING THE ARTIFICIAL MEMBRANA TYMPANI. 
 
 As in cases of perforation or destruction of the membrana tym- 
 pani, there is so frequently catarrhal inflammation of mucous mem- 
 brane of the tympanum, it is obviously important that no foreign 
 substance should be placed in contact with that membrane ; and as 
 there is always a margin of the membrana tympani remaining, the 
 surgeon should be careful to keep the artificial membrane external 
 to it. After accurately noting the size of the inner extremity of 
 
 13 
 
194 
 
 THE DISEASES OF THE EAR. 
 
 the meatus to which the natural memhrane was attached, the ope- 
 rator should proceed to cut the artificial memhrane as nearly of the 
 size and shape of the natural one as possible, taking care at the 
 same time to keep the margin quite smooth and regular.' The 
 patient should then be placed with the head inclined to the opposite 
 shoulder, while a strong light is thrown into the meatus, which, if 
 liable to discharge, should have been previously syringed. The 
 operator will next take the artificial memhrane, and having moist- 
 ened it with warm water, pass it, by means of the silver wire, gently 
 inwards until it has reached what he considers the natural position. 
 This he will ascertain by the occurrence of a faint bubbling sound, 
 caused by the escape of the slightly compressed air beyond it ; he 
 
 Fig. 73. 
 
 Surgeon introducing the Artificial Membrana Tympani. 
 
 will also feel a slight obstruction ofi'ered to its further passage by 
 the remnant of the natural membrane. Should any attempt be 
 made to pass the artificial membrane beyond this point, the patient 
 
 ' In cases where only a small border of the natural membrane remains, it is often desi- 
 rable to cut the artificial membrane of a size larger than the inner extremity of the tube, 
 so that the edge may turn outwards. 
 
THE MEMBRANA TYMPANI. 195 
 
 will complain of pain, -which up till then had not been felt. The 
 most certain test, however, of the proper placing of the artificial 
 membrane, is the sensation of the patient, who discovers, by the 
 sound of his own voice, or that of the surgeon, or by the movement 
 of his tongue and lips, that his hearing has been suddenly improved. 
 As will be imagined, great care must be taken to cut the mem- 
 brane so that it shall fit the inner extremity of the meatus with ex- 
 actness ; since if too large, it would cause discomfort, and if too 
 small, it would not fulfil its purpose, of rendering the tympanum an 
 air-tight cavity. It is not easy, in all cases, to fit the artificial mem- 
 brane, so as not to allow of any communication between the air in 
 the tympanum, and that in the external meatus ; this, however, is 
 the object which should always be aimed at. The patient, at first, 
 should be told not to use the artificial membrane for more than two 
 hours daily ; and if any uncomfortable feeling is experienced, one 
 hour, or even half an hour, will be sufficient. 
 
 It might, perhaps, be expected, that the contact of a foreign body, 
 like the artificial membrana tympani, with the walls of the external 
 meatus, would soon become intolerable ; such, however, is not the 
 case ; several patients have left my room without being able to say, 
 from the sensation in the ear, whether any foreign body were there ; 
 and many have now worn this apparatus daily, during several years, 
 Avithout suffering the least pain. The explanation of this circum- 
 stance may be found in the fact, that the most sensitive part of the 
 meatus cxternus is about its centre, while the membrane in the im- 
 mediate vicinity of the membrana tympani is less abundantly fur- 
 nished with nerves : to this may be added, that the circumference of 
 the artificial membrane presses with extreme gentleness against the 
 wall of the meatus. 
 
 The results of the application of the artificial membrane have been 
 more satisfactory than there was reason to anticipate. I have al- 
 ready used it beneficially in many hundreds of cases. The substi- 
 tution of a thin layer of vulcanized india-rubber for so exquisitely 
 delicate a structure as the healthy membrana tympani, would be 
 expected to aff'ord but trifling aid ; yet such is not the case ; for 
 among the patients relieved by it, most have heard the human voice 
 perfectly across an ordinary sized room, and in one case, the voices 
 of boys in the open air, were heard at a distance of between one 
 and two fields. Surgeons who have paid careful attention to dis- 
 eases of the ear, will not be surprised at the efficient substitute the 
 
196 THE DISEASES OF THE EAR. 
 
 artificial membrane offers, as they "will call to mind many cases in 
 ■which the natural organ has been greatly hypertrophied, especially 
 in chronic inflammation of its dermoid layer, Avitli but a A'ery slight 
 diminution of the power of hearing. ' 
 
 The surgeon havino; ascertained that the artificial membrane is 
 beneficial to the patient, it may be allowed to remain in the ear for 
 a few hours, and the time gradually increased to a whole day. It 
 is often desirable, that the use of the membrane should be preceded 
 or accompanied by vesication over the mastoid process, whereby the 
 thick mucous membrane of the t^'mpanum may be rendered more 
 healthy. In all cases, the artificial membrane should be removed at 
 night, and when there is any discharge, the ear should be syringed 
 night and morning with tepid water. 
 
 Case I. Deafness for sixteen years ; discharge from each ear for 
 six years ; aperture in each memhrana tympani ; power of hearing 
 restored. — Peter Turnbull, aged 43, formerly in the army, from 
 which he was discharged on account of deafness, was admitted under 
 my care, at St. Mary's Hospital, on the 12th January, 1852. He 
 stated that sixteen years ago, without any other assignable cause 
 than a cold, he became slowly dull of hearing, and five or six years 
 ago, a discharge issued from both ears, which has continued to the 
 present time. The power of hearing has been gradually declining, 
 so that at present he must be loudly addressed close to his head. 
 On exaynination, an aperture, between one and two lines in diameter, 
 was observed in each memhrana tympani, and the mucous membrane 
 of the tympanum, which was the source of the discharge, was thicker 
 and redder than natural. 
 
 The treatment consisted in keeping up counter-irritation over each 
 mastoid process, and in the use of an injection composed of three 
 grains of acetate of zinc to an ounce of water ; and under this he 
 somewhat improved, though the hearing still remained so defective, 
 that he was precluded from following any avocation. In the com- 
 mencement of June I experimented on this patient with the first 
 artificial memhrana tympani, composed of vulcanized india-rubber, 
 and the good effect was at once decided. "When it was placed over 
 the surface of the original membrane, so as wholly to close the ori- 
 fice, the patient made a movement of his lips, and said, " I hear as 
 differently as possible from what I have done for many years ; every- 
 thing sounds clear !" This patient went away with the artificial 
 membrane in his car, hearing conversation perfectly. The follow- 
 
THE MEMBRANA TYMPANI. 197 
 
 ing morning he came to my house, saying, tliat he had accidentally 
 moved what I had left in his ear, and that "he was as dull as ever." 
 I replaced the artificial niemhrane, and ho again heard well ; and 
 being supplied with one which he could introduce or remove at plea- 
 sure, he has worn it during the day ever since, and lias never com- 
 plained of pain or discomfort from it. Latterly, his hearing has so 
 greatly improved, that he has been able to dispense Avitli the use of 
 the artificial membrane for a few hours daily, but he hears much 
 better with than without it. As a proof of the great amelioration 
 that has taken place, this patient told me, that one day, while in the 
 country, and using the membrane, he heard voices at a distance, and 
 upon going to the place whence they appeared to proceed, he found 
 some boys under a hedge, more than a field distant from the spot 
 where he heard them. lie is going back into the army. 
 
 This patient was shown at a meeting of the Pathological Society 
 of London, in February, 1853. The following is the published re- 
 port : — " The artificial membrane having been removed, the mem- 
 bers of the Society had the opportunity of observing the perforate 
 condition of eacli membrana tympani. After the removal of the 
 membranes, he could not hear, imless loudly spoken to ; but Avlien 
 he had replaced them, which he did with apparent readiness, his 
 hearing was excellent." 
 
 Case II. Each memhrana tympani destroyed hy measles, at four 
 years of age; hearing restored hy the artificial membrane ;. great 
 sensibility to sounds. — Miss B., aged 21, consulted me on November 
 9, 1853, on the recommendation of Dr. Grindrod, of Seaforth, near 
 Liverpool. The health was good. 
 
 History. — At four years of age, she suffered from an attack of 
 measles, which Avas followed by discharge from the ears, lasting to 
 the present time ; so that the ears require syringing every day. 
 Since the measles, the power of hearing so greatly deteriorated, 
 that she has to be distinctly spoken to within the distance of a 
 yard. On inspection, it was found that the membrana tympani of 
 each ear had been destroyed, and that the only vestige of it left 
 was a very narrow margin. The mucous membrane lining the tym- 
 panic cavities was very red, much thicker than natural, and covered 
 with a mucous discharge. 
 
 Treatment. — An artificial membrana tympani was introduced into 
 each ear, the immediate effect of whicli was to improve the power of 
 hearing so greatly, that the patient heard my voice perfectly well 
 
198 THE DISEASES OF THE EAR. 
 
 across my room Avith my back towards her. Ordered to wear the 
 artificial membranes during tlie day, to take them out at night, and 
 to syringe tlie ears with Avarm water twice daily. 
 
 13th. — Has been wearing the membranes every alternate day, and 
 lias heard perfectly while they were worn ; indeed, the only drawback 
 to her comfort has been, that her friends still speak loudly to her, 
 which causes considerable uneasiness in the ears from the very great 
 sound. 
 
 16th. — Continues to hear well ; but has been obliged to remove 
 to a quiet street, as the sound of carriages passing the house has 
 been annoying. She complains of the "intolerable rustling of her 
 silk dress," of whicli she was never before conscious. The patient 
 left London after some further Avatching, quite comfortably. I re- 
 ceived a letter from her in the following December, from Avhich I 
 subjoin an extract. 
 
 " I am thankful to say, the improvement in my hearing has in- 
 creased almost daily, and I now hear general conversation easily, 
 and feel quite a different person from what I did a short time since. 
 I am still sensitive to sounds, but not nearly so much distressed with 
 them as I was at first. I found the noise of the organ at church 
 too great the first time I went, and came out almost as soon as the 
 service commenced. I find no pain in ni}^' cars, and am, in all re- 
 spects, in the enjoyment of good health." 
 
 Case III. Deafness of Uocnty years' duration perfectly relieved hy 
 the artificial membrane. — The folloAving particulars of a case, con- 
 cerning which Ave corresponded, Avere sent to me by Dr. Shearman, 
 of Sheffield : — " I tried the false drum in one ear ; the Avhole of 
 the membrana tympani had been destroyed, and the caA'ity of the 
 tympanum so bared to the A'icAV, that it was difficult at first to 
 ascertain Avhether the drum membrane had gone, or Avas obscured 
 by polypoid or other groAvths ; hoAvever the probe came doAvn upon 
 the bone. The false drum gave such relief, that the hearing dis- 
 tance Avas increased from actual contact to tAvelve, and subsequently 
 to eighteen inches : the patient is now able to manage the contri- 
 vance herself. 
 
 " The other membrana tympani of the same patient is yet so 
 covered Avith polypous groAvths, that I cannot make out the precise 
 condition of tlie drum ; hoAvcA'er, inflation of the tympanum shows 
 that the membrana tympani is perforated. The deafness in this 
 case is of nearly tAventy years' duration, is perfectly remoA'cd on 
 
THE MEMBRANA TYMPANI. 199 
 
 the left side, and although the whole of the left membrana tympani 
 is destroyed, the false one acts perfectly." 
 
 Case IV. Destruction of each membrana t7/mpani; stricture of 
 tlie meatus. — Miss S., hgcd 24, not in very good health, states, that 
 at four years of age she suffered from an attack of scarlet fever, 
 subsequently to -Nvhich she became so hard of hearing, as to need to 
 be distinctly spoken to -within the distance of a yard. This hard- 
 ness of hearing is increased during cold and damp weather : has 
 had discharge from both ears, but at present it is only very slight 
 from the left, which is the better ear. Complains of no pain, but of 
 a noise. Lately, from not being in good health, the hearing has 
 been more than usually dull. 
 
 Examination, liigld Ear. — Hearing distance of Avatch, half an 
 inch. The central part of the meatus is contracted to less than half 
 its natural size. A very strong light having been thrown beyond 
 the contracted portion, part of the mucous membrane of the tympa- 
 num could be detected ; but there Avas no appearance of the mem- 
 brana tympani. 
 
 Left ear. — Hearing distance, one inch : meatus contracted as in 
 right ear ; the membrana tympani was not seen, but in its jilace the 
 shining tympanic mucous membrane Avas observed. 
 
 At first sight it appeared as if the presence of the stricture Avould 
 offer an obstacle to the introduction of the artificial membrane. I 
 nevertheless tried a small one to each ear, passing it through the 
 stricture, and then moving it gently to and fro, so as to alloAv it to 
 recover its plane surface. Having done this, I moved it slightly 
 forAvards to the situation of the natural membrane, and immediately 
 the patient heard perfectly all that Avas said at any part of the room. 
 There was little difference between the hearing power of the tAVO ears. 
 Care was required in the management of the case, from a slight ten- 
 dency to irritation of the meatus ; but the patient left me hearing 
 Avell. In the middle of February, 1854, the mother of this lady 
 being in London, called to thank me for the benefit produced in her 
 daughter's case. She said that her daughter " continued to hear 
 perfectly, and that she Avas quite an altered person." 
 
 Case V. Deafness from scarlet fever during five years ; hearing 
 completely restored by the use of the artificial membrane. — Miss G., 
 aged 14, was brought to me, in August, 1853, by Dr. Grindrod. 
 Health good. 
 
 History. — TVhen bctAveen nine and ten years of age, suffered from 
 
200 THE DISEASES OF THE EAR. 
 
 scarlet fever, since wliicli time, has had a discharge from both ears, 
 attended by such a decline of the hearing as to require her to be 
 loudly spoken to very near. She has lately been to a school at 
 Brussels, ^Yhcre her defective hearing had greatly hindered her pro- 
 gress. On inspection, it was found that the mcmbrana tympani of 
 each car was absent, Avhile the mucous membrane of the tympanum 
 ■was thick and red, and poured out a mucous secretion. An artifi- 
 cial mcmbrana tympani was applied to each ear, and produced so 
 complete a restoration of the hearing power, that the patient could 
 detect all that was said in different parts of a large room. This pa- 
 tient returned to school at Brussels, and in about six weeks after- 
 wards, I received a letter from the father, a medical man, from wliich 
 the following is an extract : — 
 
 " We have had the most pleasing intelligence from my little 
 daughter at Brussels, respecting her hearing. I think I cannot 
 do better than to give it in her own words : — ' I have had three 
 German doctors, and one French one, to see me, or rather the arti- 
 ficial membrane. I am quite a new creature, my hearing is so 
 greatly improved.' " The father adds, " This is very satisfactory 
 evidence as to the successful operation of your beautiful invention, 
 after nearly five years' deafness to the extent, that she was unable 
 to hear a w^ord in church the whole of the time." 
 
 Case V. Deafness for twcntu years, from measles and scarlet fever, 
 greatly improved by the artijieial membrane. — Mr. M., aged 23, con- 
 sulted me 20th December, 1853. Health good. No relatives deaf. 
 
 History. — At three years of age had scarlet fever and measles at 
 the same time, accompanied by much discharge from each ear ; was 
 totally deaf for some months after the attack, but slowly improved, 
 so as to hear a loud voice spoken near the left ear ; the right ear 
 nearly useless ; lately has heard better at times with the left ear for 
 two or three hours. To-day requires to be spoken to loudly within 
 two feet of the left car, and is about the same as usual. On exami- 
 nation of the right ear, the meatus was found to contain a collection 
 of mucus and epidermis, Avhich being removed the mcmbrana tym- 
 pani was seen to be white as paper, flat and thick : posterior to the 
 inferior third of the malleus is a small orifice, al)out three-quarters 
 of a line in diameter, through which mucus oozes from the tympanic 
 cavity. "Watch not heard even when pressed against the ear ; but 
 the crack of the nails was distinguishable. 
 
 Left ear. — The meatus contained a shreddy discharge ; the mem- 
 
THE MEM BR AN A TYMPANI. 201 
 
 brana tjmpani was absent ; the mucous membrane of the tympanum 
 red and much tumefied. "Watch heard when in contact with the ear. 
 Although the hearing power of the left ear was somewhat less than 
 in the majority of cases where there is an absence of the membrana 
 tympani uncomplicated with any other disease, I, ncvertlieless, de- 
 termined to try the artificial membrana tympani, the effect of which 
 was to improve the hearing considerably, although not to the same 
 extent as in the majority of cases. 
 
 Dec. 21st. — Ordered to wear the membrane for four hours. 
 
 22d. — Upon using the membrane to-day, heard my voice distinctly 
 half across my room. 
 
 27th. — Says that he never remembers to have heard so well as 
 yesterday ; heard everything that was said at dinner, and his own 
 voice quite distinctly : the sound of the rustling of a lady's silk 
 dress quite astonished him. Towards the latter part of the day did 
 not hear quite so well ; and last night, after removing the drum, was 
 exposed to cold, which caused some pain. Without the drum to-day 
 could not hear my voice, unless I spoke in his left ear ; with it, 
 heard much better, but not so well as yesterday, which arose from 
 the mucous membrane of the tympanum being much tumefied. This 
 tumefaction gradually subsided, and the patient left me a few days 
 afterwards, hearing quite well. lie inserts the artificial membrane 
 himself, which requires some care in its adjustment. On one occa- 
 sion, when he started for a walk in the street, after having inserted 
 the membrane, his hearing was fitr from good ; but as he walked on 
 the pavement, a sudden movement took place in the ear, and he 
 heard perfectly. 
 
 In a letter of February, 1854, this gentleman says : " I have 
 much pleasure in informing you that the artificial membrane con- 
 tinues to be eflFectual ; my friends are much gratified at the improve- 
 ment you have been able to effect." 
 
 (b.) RUPTURE OF THE MEMBRANA TYMPANI. 
 
 Previous to speaking of this affection, it seems to me desirable to 
 make some remarks upon the functions of the membrana tympani 
 and chain of ossicles. 
 
 I. The Articulation of the Stapes. — The stapes is generally de- 
 scribed by anatomists as being connected with the margin of the 
 
202 THE DISEASES OF THE EAR. 
 
 fenestra ovalis by a simple membrane. Sir Anthony Carlisle, in 
 his paper on the Physiology of the Stapes, merely speaks of " a 
 membrane which connects it to the edges of the fenestra vestibuli."* 
 Professors Sharpey and Quain agree -with Sir A. Carlisle. They 
 say, " The annular ligament of the stapes connects the base to the 
 margins of the foramen fenestra ovalis. The fibres of the ligament 
 are covered, on the outer side by the mucous lining of the tympanum, 
 and on the inner side by the membrane of the vestibule."' Mr. 
 "Wharton Jones describes this ligament as springing "from the mar- 
 gin of the vestibular fenestra, and it is inserted into the jutting 
 margin of the base of the stapes all round.'^ Soemmering seems to 
 have had a diiSerent view respecting this articulation. He says, 
 " A thin articular capsule connects the base of the stapes to the 
 fenestra ovalis."^ 
 
 If the circumference of the base of the stapes be carefully exa- 
 mined by means of a lens magnifying between three and four 
 diameters, it will be apparent that, instead of a fine margin only, it 
 presents a distinct surface Avhicli, when in situ, looks towards the 
 border of the fenestra ovalis, and is separated from the inner and 
 outer faces of the base by well-defined margins. The circum- 
 ferential surface of the base varies in breadth : the broadest part 
 has its surface inclined obliquely backwards and outwards ; mea- 
 sures about a third of a line at its centre ; and gradually narrows 
 as it becomes continuous with the superior and inferior surfaces. 
 The anterior extremity of the surface is not so broad as the poste- 
 rior, and, instead of being oblique, is slightly rounded. The upper 
 and lower surfaces of the base of the stapes are narrower than either 
 the anterior or posterior portions, and their middle part is the nar- 
 rowest. AVhen examined in a recent ear the circumferential 
 surface of the base of the stapes is found to be quite smooth, 
 and covered by a very delicate layer of cartilage, which, when 
 touched by a fine probe, communicates a soft sensation to the finger. 
 This cartilage consists of oval corpuscles, very like these in ordinary 
 articular cartilage,- though much smaller, and is most abundant at 
 
 • Philosophical Transactions, p. 201. 1805. 
 " Elementary Anatomy, p. 940. 1848. 
 
 ' CyclopaHlia of Anatomy and Phy-siology, vol. ii, p. 548. 
 
 * De Corporis Iliimani Fabrica, tomus .oecundus, de Ligamentis Ossium, p. 10. Iluschke 
 states, that Soemmering was wrong in regarding this ligament as a capsule. Iluschke 
 speaks of the ligamentum annulare only. 
 
THE MEM BR ANA TYMPANI. 203 
 
 the two extremities, from -wliich portions can often be removed, es- 
 pecially in young persons, for examination by the microscope. The 
 surface of the fenestra ovalis to which the circumferential base of 
 the stapes is applied, is larger than that of the stapes ; nor does its 
 posterior surface quite correspond in direction with that of the stapes, 
 but looks directly forwards, instead of obliquely inwards and for- 
 wards, to face the stapes, which, as stated, inclines backwards and 
 outwards. The articulating surface of the fenestra ovalis is smooth, 
 very compact in appearance, seems to have no cartilage upon it, and 
 is bounded by two well-defined ridges. The circumference of the 
 base of the stapes is attached to that of the fenestra ovalis by means 
 of two membranes or ligaments. The inner, or vestibular ligament, 
 passes from the inner margin of the fenestra ovalis to the inner 
 margin of the circumference of the base of the stapes ; and the 
 outer ligament passes from the outer margin of the one to the outer 
 marffin of the other. These two lio;aments have between them a 
 space Avliich may be called the articular cavity, as it contains enough 
 fluid to lubricate the articulating surfaces of the bones. By the 
 action of the tensor tympani muscle, the base of the stapes is 
 pressed inwards towards the vestibule, as a piston in its cylinder : 
 and as soon as the muscle ceases to act, the ligaments just described 
 being elastic, draAV the base of the stapes out again. 
 
 II. 3Iovements of the Stapes. — The stapes is moved by two mus- 
 cles, the tensor tympani and the stapedius. Anatomists seem agreed 
 that the action of the tensor tympani is to press the stapes directly 
 inwards towards the cavity of the vestibule, and the general opinion 
 appears to be that the stapedius muscle merely assists the tensor 
 tympani. Thus Mr. "Wharton Jones says: "The first action of this 
 muscle (the stapedius) will be to press the posterior part of the base 
 of the stapes against the vestibular fenestra. At the same time, the 
 long branch of the incus will be drawn backwards and inwards ; and 
 the head of the malleus being, by this movement of the incus, pressed 
 forAvards and outwards, its handle w^ill be carried inwards, and the 
 membrana tympani thus put on the stretch. Breschet calls the 
 muscle of the stapes a laxator, but I do not know on what grounds."* 
 Professors Todd and Bowman Avrite : "In contraction it (the stape- 
 dius muscle) would fix the stapes by pulling its neck backwards. 
 It probably compresses the contents of the vestibule."^ Ellis states 
 
 ' Cyclopaedia of Anatomy, vol. ii, p. 549. 
 
 " Physiological Anatomy, 1847. Part III, p. 71. 
 
204 THE DISEASES OF THE EAR. 
 
 that "it assists in retaining the stapes applied to the fenestra 
 ovalis."' Miillcr writes : " The influence of the stapedius muscle 
 in hearing is unknown. . . . Tlie onh' effect which it appears to me 
 could be ascribed to it, would be to render tense the membrane by 
 which the base of the stapes is connected with the margin of the 
 fenestra."^ 
 
 On account of the smallness of the stapedius muscle, and the very 
 slight degree of movement it produces, there is difficulty in deter- 
 mining in Avhat way that muscle influences the contents of the ves- 
 tibule. As the tendon of the stapedius, in its course forwards, 
 passes slightly upwards, there is good reason to infer that it draws 
 the neck of the stapes backwards and slightly downwards, and that 
 it produces a slight rotation of the base. That this rotatory move- 
 ment of the stapes has the effect of somewhat withdrawing its base 
 from the cavity of the vestibule is, I think, shown by the following 
 experiment. The tympanic cavity and stapedius muscle being ex- 
 posed, and the stapes left in situ, by means of a small pair of cut- 
 ting forceps a section is to be made through the cochlea, a portion 
 of which should be left in connection with the vestibule. The scala 
 vestibuli of this portion will be seen filled with fluid as far as the 
 margin of the section ; and this fluid is of course continuous with 
 the perilymph in the cavity of the vestibule. If the stapedius muscle 
 be now pulled, or if the neck of the stapes be gently moved back- 
 ward, the fluid in the exposed sac of the scala vestibuli will be ob- 
 served to recede slightly into the scala vestibuli, and its surface to 
 become concave ; as soon, however, as the stapes is allowed to re- 
 turn to its quiescent state, the fluid repasses into and fills the scala 
 vestibuli, assuming a rounded surface. Independently of thus act- 
 ing on the contents of the vestibule, the stapedius muscle produces 
 a slight relaxation of the membrana tympani. This is effected by 
 the neck of the stapes, in the act of rotation, passing outwards as 
 well as backwards, and thus gently pressing outwards the inferior 
 extremity of the incus ; so that the body of the latter bone passes 
 inwards, carrying with it the head of the malleus, and necessitating 
 the long process of the latter bone and the membrana tympani to 
 pass outwards. It would therefore appear that the stapedius muscle 
 acts as the direct antagonist of the tensor tympani muscle ; the 
 former relaxing the labyrinthine fluid, the membrana fcnestrje 
 
 ' Demonstrations of Anatomy, p. 286. 
 
 'Elements of Physiology, by Baly, vol. ii, p. 12C4, 1842. 
 
THE MEM BR AN A TYMPANI. 205 
 
 rotundjTO, and tlie menibrana tympani ; and the latter rendering 
 tense the labyrinthine fluid and the two membranes. This view is 
 supported by the fact that the stapedius muscle is supplied by a 
 branch from the portio dura nerve, and the tensor tympani from the 
 otic ganglion.' It seems to me fair, therefore, to infer that the 
 function of the tensor tympani muscle is to protect the membrana 
 tympani and the labyrinth from injury by loud sounds, while the 
 stapedius muscle places these structures in a condition to be im- 
 pressed by the most delicate vibrations ; and it Avould appear to be 
 brought into action during the process of listening. Instances are 
 not uncommon in which these two muscles are unable to act promptly, 
 and the unpleasant consequences are manifest. Thus the loud noise 
 produced by suddenly and unexpectedly firing a cannon near a per- 
 son, by not permitting the tensor tympani to contract in time, causes 
 frequently a sensation of singing or buzzing in the ears, produced 
 most probably by a concussion of the expansion of the auditory 
 nerve : sensations which sometimes endure for many years. Cases 
 are not unfrequent in which the mucous membrane of the tympanum 
 is thickened, and a great amount of dulness of hearing is the conse- 
 quence. Many patients thus afiected hear sounds (the human voice 
 for instance) perfectly well Avhen they are listening ; but as soon as 
 the act of volition is su.spendcd, the same voice in the same position 
 is not perceived. In these cases it would appear as if the stapedius 
 muscle had to counteract the pressure upon the stapes, by the thick 
 mucous membrane. The friends of young persons suffering in this 
 
 » In addition to the above description, I may draw attention to a monograpli on the ear 
 by Iluschke, before alluded to, in which he has arrived at similar conclusions respecting 
 the functions of the stapedius muscle to those just advanced. As it is evident, from the 
 quotations from writers on the ear previously cited, that those views have not been enter- 
 tained, I have not scrupled to give my researches at length. The following are lluschke"s 
 words: "While it (the stapedius muscle) presses the posterior extreniitj' of the base of 
 the stapes upon the posterior part of the border of the fenestra ovalis, it lifts the anterior 
 extremity of this bone and covers the fenestra. At the same time, the descending branch 
 of the incus, with the stapes, is drawn backwards, by which the body of this bone presses 
 the malleus forwards, and, as its handle rests upon the membrana tympani, it relaxes it. 
 I have often observed this movement of the malleus when I moved the long branch of the 
 incus in the direction of the tendon of the muscle of the stapes. I thus regard the latter 
 as relaxing the tympanum and opening the labj'rinth ; that is to say, according to the 
 view of Treviranus, it is the antagonist of the tensor tympani muscles. The two have 
 altogether much analogy : they describe an arch looking upwards, pass over a kind of 
 pulley, and are contained in an osseous canal ; but they have also opposite functions : the 
 stapedius muscle passes from behind forwards ; the tensor tympani from before backwards ; 
 the stapedius receives its nerve from the facial, the tensor tympani from the fifth.' — 
 Eiicyclopedie Aiiatomiqne, tome v, pp. 782, 783. 
 
206 THE DISEASES OF THE EAR. 
 
 manner, often imagine that tliere is no real duluess of hearing, but 
 simply a -want of attention ; the fact being that the power of hear- 
 ing certain sounds has ceased to be involuntary with these patients, 
 and can only be exercised by a strong effort of the will. 
 
 The tensor tynipani muscle appears to be of use not merely in pre- 
 venting the menibrana tynipani and la])yrinth from being iiijuiod by 
 powerful sonorous vibrations, but also in protecting these organs 
 from the forcible pressure of air or of a foreign body. Tlius the 
 membrana tynipani offers considerable resistance to the pressure 
 of a foreign substance which has been slowly introduced into the 
 meatus ; though the sudden and unexpected contact of a similar 
 body often produces extensive laceration of it. Again, a violent 
 blow on the ear with the palm of the hand, rarely produces mischief 
 to the membrana tympani when its reception is expected ; whereas 
 a comparatively gentle but unexpected blow, frequentl}^ produces 
 not merely concussion of the nervous labyrinth and serious derange- 
 ment of its functions, but not uncommonly ruptures the membrana 
 tympani itself.^ 
 
 The preceding observations indicate that one function at least of 
 the ossicles and muscles of the tympanum and the membrana tym- 
 pani, is to act as the analogue of the iris in tlie eye, and to regulate 
 the amount of sonorous undulations that are to pass to the labyrinth. 
 This view has already, to a certain exjent, been alluded to by pre- 
 vious writers. M. Savart, in the course of his very interesting re- 
 searches upon the functions of the membrana tympani, arrived at a 
 somewhat similar opinion ; although he omitted to point out the 
 manner in which the muscles acted on the labyrinth and membrana 
 tympani. lie says : " Les osselcts out encore pour fonction de mo- 
 difier Tamplitude des excursions des parties vibrantes des organes 
 contenus dans le labyrinthe."^ Mr. C. Brooke, in a Lecture delivered 
 at the Royal Institution, in the year 1843, says : Tliis osseous ar- 
 rangement may be considered to perform an office in the ear analo- 
 gous to that of the iris in regard to light; namely, tliat of regulating 
 the tension of the various structures tliat are thrown into a state of 
 
 ' I may mention a case illustrative of the above statement. The first that of an eminent 
 physician in London, who, while plajinpj with his children, received a blow on one ear from 
 the head of one of them coming suddenly and rajiidjy in contact with it : from that time to 
 t,he present (an interval of four to five years) there has been a constant ringing in that ear. 
 
 * Rccherches sur les Usages de la Membrane du Tympan et de TOreille E.\terne par M. 
 Feli.x Savart. Lu ;\ TAcademie Royale des Sciences, le 29 Avril, 1S22. Journal de Phy- 
 siologic, par F. JIajendie, tome iv, p. 183. 
 
THE MEM BR AN A TYMPANI. 207 
 
 vibration, according to the pitch and intensity of the sound to be 
 transmitted to the sentient nervous fibres. This is effected by the 
 conjoined action of tlie tensor tympani and stapedius muscles, by 
 "which the tympanum Avouhl be rendered more tense, and a simulta- 
 neous change in the position of the stapes -would alter the tension 
 of the fluid throughout the labyrinth, and therefore also the tension 
 of the membrane of the fenestra rotunda, -which intervenes bet-\veen 
 that fluid and the air in the tympanic cavity."^ Professors Todd 
 and Bowman state that there is " much reason to suppose that the 
 tensor tympani muscle is analogous in its use to the iris, and des- 
 tined to protect the orgafi from too strong impressions."^ 
 
 The first effect of the det^truction of the membrana tympani gives 
 -weight to the opinion liere advocated. Mr. Busk has detailed to me 
 the particulars of a case in Avhich, for a few da^'s after the destruc- 
 tion of the membrana tympani, a patient was unable to endure the 
 whistling of another in an adjoining bed ; and Cheselden says, "that 
 after, destroying the tympanum in both ears of a dog, for some time 
 it received strong sounds with great horror."^ 
 
 Pathological Observations. — There are several modes in which the 
 membrana tympani may be ruptured. The most common is an un- 
 expected blow on the ear. It may also be ruptured by having a 
 foreign body forced through it ; by very loud sounds ; by a fall ; by 
 violently blowing the nose ; or by vomiting. Mr. Wilde relates a 
 case in which the membrana tympani was ruptured by a gentleman, 
 while bathing, thrusting his little finger into the meatus to dislodge 
 some water. 
 
 In cases of simple rupture, as from an unexpected blow on the 
 ear, the margins of the orifice are usually in contact, scarcely any 
 hemorrhage occurs, fibrin is effused, and the rent is speedily re- 
 paired. Where, however, the margins of the membrane are no 
 longer in contact, and Avhere the membrane has been much strained, 
 very great irritation may ensue, requiring active anti-inflammatory 
 measures. The most serious cases arise from the injury inflicted by 
 the introduction of a foreign body, since the dermoid layer usually 
 participates in the disease. 
 
 In cases of simple rupture of the membrana tympani where in- 
 flammatory symptoms are still present, it is not desirable to do more 
 than introduce a portion of cotton-wool into the meatus, to prevent 
 
 ' Lancet, 1843, p. 380. » Physiological Anatomy, Part III, p. 91. 
 
 ' The Anatomy of the Iluman Body (5th edition), 1740, p. 305. 
 
208 THE DISEASES OF THE EAR. 
 
 loud sounds from acting injuriously upon the drum. Where the in- 
 flammation is great, leeches must be applied below the ear, and to 
 the margin of the orifice of the meatus, and evaporating lotions 
 used to the margin of the meatus itself. Should these remedies be 
 unsuccessful, counter-irritation must be applied oyer the mastoid 
 process. 
 
 Case I. Memhrana tympani ruptured hy an unexpected box on the 
 ear. — Master G., aged 14, was brought to me on June 2, 1852, on 
 account of a peculiar sensation in the loft ear whenever he blew his 
 nose. 
 
 History. — Five days ago, as he Avas sitting still, his tutor came 
 quietly behind him, and suddenly and unexpectedly gave him a 
 gentle box on the left ear, which produced instantaneous pain deep 
 in that organ. On using his pocket-handkerchief afterwards, he ex- 
 perienced a tingling and clicking in the ear, in which he has since 
 also had pain at times, and from which occasionally a drop or two 
 of blood have escaped. Inspection showed a small orifice at the 
 
 Fig. 74. 
 
 An Aperture in the lower part of the left Membrana Tympani, from rupture. 
 
 lower part of the membrana tympani, about a line in diameter, with 
 white borders. Air passed through on hohling the nose and blow- 
 ing gently. The Avatch was heard at the distance of a foot. As 
 there was some slight pain, a leech was ordered to be applied below 
 the ear every second night. This Avas continued for ten days, at the 
 end of Avhich time the pain had disappeared, the orifice had closed, 
 and the hearing power had returned. 
 
 Case II. Rupture of the membrana tympani by a blotv on the ear 
 with a bolster. — Master K., aged 14, Avas seen by me in consulta- 
 tion with Mr. Kcal, on December 20, 1855, on account of an un- 
 pleasant sensation in the left ear. 
 
 History. — A Aveck ago was engaged in a "bolstering match" at 
 school, during Avhich he received a blow Avitli a bolster on the left 
 ear, Avhich caused him pain. In the morning, on using his pocket- 
 
THE MEMBRANA TYMPANI. 209 
 
 handkerchief, he found that air rushed out of the left ear, so that 
 he was obliged to place his finger upon the ear while using the hand- 
 kerchief. On examining the ear, a rent was observed in the mem- 
 brana tynipani, running from the lower extremity of the malleus 
 downwards to the inferior parts of the membrane. The margins of 
 the rent were in contact, but the air passed through with the 
 slightest pressure from the fauces. The hearing power was natu- 
 ral. He was ordered a little evaporating lotion to apply on -cotton 
 to the orifice of the meatus. Twelve days afterwards, the margins 
 of the orifice were observed to be sAvollen, and a small coagulum of 
 blood attached to them : air passed into the tympanum from the 
 fauces, but it did not escape through the aperture. When I saw 
 this patient after another fortnight, the orifice was closed, but the 
 cicatrix remained. 
 
 Case III. 3Iemhrana tijmpani ruptured by hloiving the nose 
 forcibly. — Miss S. A. N., aged 16, consulted me on February 5, 
 1850, for pain and discharge from the right ear, accompanied by 
 dulness of hearing in both ears. Her friends stated that she had 
 for a long time the habit of blowing the nose A'ery violently ; and 
 when doing so, four or five months ago, she felt as if something had 
 given way in the right ear, and since that time has had discharge 
 
 Fig. 75. 
 
 An Aperture in the posterior part of the right Membrana Tj-mpani, from nqiture. 
 
 from it. Whenever the nose is blown, air rushes out of the right 
 ear with a loud S({ueaking sound. On examining the right ear, the 
 membrana tympani was observed to be covered with mucus ; and 
 when the nose was blown, air was observed to issue from the tym- 
 panic cavity through a valvular fissure at the posterior part of the 
 membrane. Watch heard at a distance of two inches. The treat- 
 ment consisted in applying leeches to the margin of the meatus, in 
 syringing out the ear with a weak solution of liquor plumbi in water, 
 and in keeping up a slight discharge from the surface of the mastoid 
 process. It was, however, only by slow degrees that the discharge 
 
 14 
 
210 THE DISEASES OF THE EAR. 
 
 diininisliccl, ami the orifice in the membrane closed. The mem- 
 brana tympani did not regain its natural appearance, the part of it 
 posterior to the malleus having fallen inwards towards the promon- 
 tory. 
 
 Case IV. Itupture of the memhrana tympani hy a twig: injury 
 to chorda tymjmni nerve. — J. L., Esq., aged 19, consulted me on 
 September 25, 1856. A week previously, while engaged in shooting, 
 he was endeavoring to force his way through a hedge, and turning 
 sharp round, with the view of picking up a bird, a twig passed 
 into the right meatus, producing a sudden and severe pain at some 
 distance in, followed immediately by deafness and a little bleeding, 
 which has continued to a slight extent every night since. A buz- 
 zing noise in the ear supervened soon after the accident. The pain 
 speedily subsided. On examining the right meatus, a little coagu- 
 lated blood was found ; on removing which by the syringe, the mem- 
 brana tympani presented a rupture extending through the greater 
 part of its diameter, a little posterior to, and parallel with, the 
 
 Fig. 76. 
 
 An Aperture in the right Membrana Tympani (a little posterior to, and parallel with, the 
 handle of the Malleus, nearly its whole length). 
 
 handle of the malleus. The edges of the orifice were red and 
 swollen. Air passed through it when the tympanum was inflated. 
 Watch only heard on contact. A leech was applied to the orifice 
 of the meatus ; and a mildly astringent gargle applied gently by 
 the syringe, twice a day. On October the 4th, the orifice had 
 entirely healed ; the buzzing noise had almost ceased ; the hearing 
 distance was half an inch. This patient returned to India, but 
 intelligence has been received tliat the hearing has greatly im- 
 proved. 
 
 For days after the laceration of the membrane in the above case, 
 there was a feeling on the same side of the tongue as if something 
 cold had been rubbed over it ; the taste on that side also was im- 
 paired. The tongue, however, was quite natural in appearance and 
 movements, and its sensibility to touch was the same on both sides. 
 
THE MEMBRAXA T Y M P A N I. 211 
 
 Case V, Rupture of the memhrana tympani hi/ the bursting of a 
 gun. — W. S., Esq., aged 28, consultcHl me in September, 1856. Six 
 days ago was shooting, when the gun burst in his hand, producing 
 instant deafness in the left ear, followed, two days ago, by a copious 
 discharge of a watery character. Yesterday there was a slight 
 aching pain, and for two or three days every pulsation of the vessels 
 has been heard in the left ear. On examination, the left meatus was 
 found to be red and to contain purulent discharge ; the membrana 
 tympani was also red, and presented an aperture at its upper and 
 posterior part of an oval shape, about a line in length, and nearly a 
 line in breadth, as if a portion of the membrane had been destroyed ; 
 the mucous membrane of the tympanum was red, and the hearing 
 distance four inches. A leech was applied occasionally to the mar- 
 gin of the orifice of the meatus ; the car was kept clean by daily 
 syringing ; and afterwards a lotion, the nitrate of silver (gr. x. ad 
 5j) was applied on cotton-wool, by means of a probe, to the surface 
 of the membrane. The aperture slowly filled up, as if by the de- 
 posit of fibrin on the margins, which, for some time, were thicker 
 than the surrounding portion of the membrane ; and, in the course 
 of six weeks, it was entirely closed, and the hearing power perfectly 
 restored. 
 
 In this case the right membrana tympani was previously ruptured, 
 and the bursting of the gun produced no effect upon the ear. 
 
 The followino; is a tabular view of the condition of the membrana 
 tympani in the dissection of 1013 diseased ears : — 
 
 Opaque, 15 
 
 Vascular, ............. 7 
 
 Vascular and thick, ........... 3 
 
 Belaxed, ............. 4 
 
 Tense, 10 
 
 Tense and atrophied, ........... 2 
 
 Inner surface connected to the promontory by bands of membrane, . . 32 
 
 Inner surface adherent to the incus, ........ 9 
 
 Inner surface adherent to the stapes, ........ 4 
 
 Inner surface adherent to the stapes, by membranous bands, . . .11 
 
 Inner surface adherent to the incus, ....... .1 
 
 Inner surface adherent to all the ossicles, ....... 2 
 
 Inner surface adherent to all the ossicles and the promontory by bands, . 6 
 
 Outer surface more concave than natural, ....... 34 
 
 Outer surface more concave than natural, and thick, . . . ■ . 4 
 
 Outer surface more concave than natural, and opaque. ..... 2 
 
 Outer surface more concave than natural, and thick and opaque, ... 1 
 
 Outer surface more concave than natural, and soft, ..... 2 
 
 Outer surface more concave than natural, and tense, ..... 2 
 
212 
 
 TUE DISEASES OF THE EAR. 
 
 Very concave externally, nnd the inner surface iu contact with the promon- 
 tory 
 
 Very concave externally, and the inner surface connected to tlie promontory 
 by bands, ............. 
 
 Very concave externally, and the whole of the inner surface in contact with 
 the inner wall of the tympanum ; the tympanic cavity being obliterated. 
 
 Very concave externally and thick, and adherent to the promontory. 
 
 Thicker than natural, ..... 
 
 Thick and unyielding, ..... 
 
 Thick and white, ...... 
 
 Thick and soft, - 
 
 Thick and tense, . . • . 
 
 Thick, nnd attached to the incus by membranous bands, 
 
 Thick and vascular, nnd connected to the incus by bands, 
 
 Thick and opacjue, ...... 
 
 Thick, tense, and congested, .... 
 
 Containing deposits of calcareous matter. 
 
 Containing spots of cartilage. 
 
 Flat, externally, ...... 
 
 Flat, thick, and white, ..... 
 
 Epidermoid lamina thick, .... 
 
 Epidermoid lamina absent, .... 
 
 Dermoid lamina very vascular, 
 
 Dermoid lamina very thick, .... 
 
 Dermoid lamina very thick and vascular, 
 
 Dermoid lamina detached from the fibrous lamina?. 
 
 Radiate fibrous lamina absent, entirely destroyed by ulceration. 
 
 Radiate fibrous lamina absent in parts, . 
 
 Dermoid and fibrous lamina? absent in parts, apparently from 
 
 Radiate and circular fibrous laminw destroyed by ulceration in parts, . 
 
 Radiate and circular fibrous lamina) entirely destroyed by ulceration, . 
 
 Radiate and circular fibrous lamina; entirely destroyed by ulceration ; th 
 mucous lamina being attached to the promontory, . 
 
 Radiate and circular fibrous lamina? containing pigment cells. 
 
 Mucous lamina thick, ........ 
 
 All the lamina? destroyed by ulceration except the epidermoid. 
 
 All the lamina? destroyed by ulcerntion exeejjt the mucous, . 
 
 All the laminiv jierforated, ....... 
 
 All the lamina? absent apparently from ulceration, 
 
 All the lamina? jierforated, the remaining i)ortion of the membrane being ad 
 herent to the jiromontory, 
 
 All the lamina< perforated, and very thick, 
 
 All the lamina' perforated, very thick and concave, and adherent 
 to the promontory, ...... 
 
 All the lamina' jierforated by mollu.''cous tumors, . 
 
 Upper part of all the laminw detached from the bone, 
 
 The circular cartilage exposed, .... 
 
 ulcer 
 
 ation, 
 
 internally 
 
 10 
 
 13 
 
 7 
 3 
 
 66 
 5 
 
 12 
 2 
 5 
 1 
 1 
 4 
 2 
 
 14 
 2 
 6 
 4 
 8 
 5 
 1 
 4 
 3 
 1 
 3 
 2 
 3 
 6 
 4 
 
 3 
 2 
 3 
 2 
 47 
 21 
 
CHAPTER XL 
 
 THE EUSTACHIAN TUBE. 
 
 ANATOMICAL OBSERVATIONS — PnVSIOLOGICAL OBSERVATIONS — PATHOLOGICAL OBSER- 
 VATIONS — SEAT OF OBSTRUCTION OP THE EUSTACHIAN TUBE : — 1. THE* FAUCIAL 
 ORIFICE. 2. THE TYMPANIC ORIFICE. 3. MIDDLE PART. CAUSES OF OBSTRUC- 
 TION : 1. THICKENED MUCOUS MEMBRANE. 2. RELAXED MUCOUS MEMBRANE. — «, 
 
 OBSTRUCTION OF THE FAUCIAL ORIFICE FROM THICKENED MDCOUS MEMBRANE — THE 
 
 EXPLORATION OF THE TUBE THE OTOSCOPE — TREATMENT — USE OF THE EUSTACHIAN 
 
 CATHETER AND OF THE EXPLORER — THE EXCISION OF THE TONSILS — CASES. b, 
 OBSTRUCTION OF THE EUSTACHIAN TUBE AT ITS FAUCIAL ORIFICE FROM RELAXED 
 MUCOUS MEMBRANE — SYMPTOMS TREATMENT — CASES. C, OBSTRUCTION OF THE EUS- 
 TACHIAN TUBE AT THE TYMPANIC ORIFICE FROM THICKENED MUCOUS MEMBRANE — 
 
 SYMPTOMS — TREATMENT ON THE OPERATION OF PUNCTURING THE MEMBRANA TYM- 
 
 PAXI. d, OBSTRUCTION OP THE MIDDLE PART OF THE EUSTACHIAN TUBE BY MUCUS, 
 BY STRICTURE, OR BY MEMBRANOUS BANDS. 
 
 Anatomical Observations. — The Eustachian tube, extending be- 
 tween the cavity of tlie fauces and that of the tympanum, is from an 
 inch and a half to two inches in length. At its faucial orifice it is 
 wide and dilatable, but it soon becomes so constricted as barely to 
 admit an ordinary-sized probe. Its direction from the tympanum 
 is obliquely downwards, inwards, and forwards. 
 
 The Eustachian tube consists of two portions, the osseous and 
 fihro-cartilaginous : the osseous portion extends from the tympanic 
 cavity to the fibro-cartilaginous portion ; and is about three-quarters 
 of an inch in length, and about a line in diameter. It is lined by 
 an extremely thin fibro-mucous membrane, very similar to that 
 lining the tympanic cavity. 
 
 The fibro-cartilaginous portion, as its name implies, consists of 
 cartila";e and fibrous tissue, and is about an inch in lenfrth. It is 
 of a conical form, having its apex continuous with the osseous por- 
 tion, while the base extends into the cavity of the fauces in the 
 shape of a rounded tubercle. On examination, the rounded extre- 
 mity of the cartilaginous portion is found to form a superior and 
 
214 THE DISEASES OF THE EAR. 
 
 inferior lip : the former projects sliglitly (loAvnAvartls, and forms the 
 the upper wall or angle of the tube ; the latter turns slightly up- 
 wards, and forms the inferior angle. The fibrous membrane form- 
 ing the outer wall of the tube is attached, above and below, to the 
 two lips just described; forming anteriorly a free boixler, and poste- 
 riorly being attached to the anterior border of the outer part of the 
 osseous portion. The trumpet-shaped fiiucial orifice of the Eusta- 
 chian tube is nearly half an inch long ; and its middle part may be 
 considered to be on a level with the inferior meatus of the nose. 
 
 The use of the Eustachian tube is to allow ingress of air to the 
 tympanum, and egress of mucus from it ; but the point of import- 
 ance which specially claims attention is, whether its guttural orifice 
 remains always open, so that the air in the cavity of the tympanum 
 is constantly continuous Avith that in the fauces. The opinion of 
 physiologists is in favor of this view. Muller says, that the object 
 of its being constantly open is, " that a certain degree of dulness 
 which the sound might acquire from the resonance of the apparatus 
 is avoided :" and adds that, " Henle supposes that the air of the 
 cavity of the mouth and nose are in like manner evolved through 
 the medium of the Eustachian tube, to increase by resonance the 
 intensity of sounds entering the ear by the external meatus."* 
 
 Dr. Todd speaks of one object of the Eustachian tube being to 
 " afford an outlet for the escape of such sonorous undulations as do 
 not impinge upon the labyrinthine Avail of the tympanum."^ 
 
 Other writers differ in some measure from the foregoing view, 
 and some physiologists are not in favor of the constantly patent 
 condition of the Eustachian tube. Thus Mr. Wharton Jones says, 
 " It is to be remarked that the Eustachian tube is not habitually 
 wide open, so that the air can flow freely in and out, but that, 
 on the contrary, in the state of rest its walls are collapsed. By 
 this arrangement, Avhich gives the Eustachian tube the property 
 of a Aveak valve, opening either Avay, the too ready course of the 
 air is opposed."^ 
 
 Ilyrtl agrees in the above statement, and saA's, " The Avails of 
 the convoluted trumpet are disposed to lie upon each other and 
 form mucous adhesions, so that, as any one can easily satisfy 
 himself, a considerable degree of compression of the air in the 
 
 ' Mullen's Physiology, translated by Baly, vol. ii, pp. 1270-1273. 
 
 ' Cyclopaedia of Anatomy and Physiology, article " Hearing," p. 576. 
 
 ' Cyclopaedia of Surgery, p. 23. 1841. 
 
THE EUSTACniAN TUBE. 215 
 
 mouth and nose (by means of the muscles of the cheek, the mouth 
 being shut) is necessary to force air into the cavitas tympani."^ 
 
 In a paper laid before the Royal Society, in 1853, I endeavored 
 to show that, in the state of repose, the faucial orifice is always 
 shut ; that the means by which it is opened are the muscles of the 
 palate; and that it is opened during the act of deglutition. In 
 that paper it was further pointed out, that in man and in most 
 mammalia, the muscles opening the Eustachian tube were tlie tensor 
 and levator palati, which have been long known to be attached to 
 its orifice. In some mammalia the tube is opened by the superior 
 constrictor of the pharynx, and in birds by the internal pterygoid 
 muscles. That the Eustachian tube is usually shut, and the act 
 of swallowing is the process whereby it is opened, is shown by the 
 following experiments : — If the cavity of the tympanum be par- 
 tially distended with air, by making an attempt at a forcible 
 expiration through the nose when the nostrils are held closed, a 
 sensation of fulness or pressure is experienced in the tympanum, 
 arising from the pressure of the air against the inner surface of 
 the membrana tympani : a sensation, however, Avhich does not dis- 
 appear as soon as ordinary respiration is carried on, but remains 
 until the act of swallowing is performed, and the air thereby 
 allowed to escape. Again, if the mouth and nose be held closed 
 during the act of deglutition, the same sensation of pressure in the 
 ears is felt : for during that act the air, which is slightly com- 
 pressed by the muscles of the fauces, passes into the tympanic 
 cavities ; as in the former experiment, the feeling of distention is 
 not relieved until the act of swallowing is repeated Avith the mouth 
 and nostrils open. A third example, proving the Eustachian tubes 
 to be opened during the act of deglutition, and closed when the 
 muscles of the fauces return to a quiescent state, is alForded by a 
 person descending in a diving-bell. It is well known that during 
 the descent the compressed air filling the external meatus produces 
 a sensation of weight, and often of pain, by pressing the membrana 
 tympani inwards. This sensation can, however, be at onced eased 
 by an act of swallowing, whereby the condensed air is allowed to 
 enter the tympanum through the Eustachian tubes, and thus afford 
 support to the inner surface of the membrane. A further proof 
 that air enters the tympanic cavity during deglutition with the 
 
 * Vergleichende Anatomie uber das innere Gehororgan des Menschen und der Saug- 
 thiere, 1845, p. 51. 
 
216 THE DISEASES OF THE EAR. 
 
 nostrils closed, and passes out again during the same act with the 
 nostrils open, is obtained by the inspection of the membrana tym- 
 paiii in the living person, by means of a strong light, during the 
 two operations : in many instances, the membrana tympani is seen 
 to be pressed slightly outwards by the first act, and to return to 
 its previous state during the second. 
 
 ON THE MUSCLES "WHICH OPEN THE EUSTACHIAN TUBE. 
 
 Valsalva,^ in his admirable treatise on the human ear, appears to 
 have been the first anatomist who pointed out the fact, that the 
 tensor and levator palati muscles take an origin from the Eusta- 
 chian tube ; he also gave them the appellation of the muscles of the 
 Eustachian tube ; but he considered that their function is to keep 
 the tube constantly open, as he believed that " if the tube is closed, 
 the hearing is lost at once." 
 
 Most modern anatomists have described the muscles of the soft 
 palate as taking their origin from the Eustachian tube ; but they 
 have not ascribed to them the function of opening or of otherwise 
 aflfecting the tube. 
 
 As stated, the two muscles which open the tube in man are the 
 tensor and levator palati. 
 
 The tensor 2>a^(tti muscle arises from the fossa at the root of the 
 internal pterygoid plate, from the adjacent bone, from the outer sur- 
 face of the superior cartilaginous lip of the Eustachian tube, and 
 from the membrane forming its outer wall ; and the fil)rcs from 
 these several sources pass downwards, form a flat muscle Avhich 
 winds round the hamular process of the sphenoid bone, to be in- 
 serted into the aponeurosis of the palate, and into the ridge of the 
 palate bone. 
 
 The levator jjalati muscle arises from the inferior surface of the 
 petrous bone, near the apex, and from the outer half of the under 
 surface of the cartilaginous portion of the tube ; and the fibres de- 
 scend in contact with the inner half of the under surface of the tube, 
 and are inserted into the aponeurosis of the palate, some of the fibres 
 uniting with those on the opposite side. 
 
 The action of the tensor palati muscle, when it contracts, is to 
 draw slightly outwards, and to keep on the stretch, the membrane 
 
 ' De Aure Humana Trnetatus, 1735. 
 
THE EUSTACHIAN TUBE. 217 
 
 forming the outer wall of the Eustachian tube ; the action of the leva- 
 tor palati muscle is to draw downwards and keep tense the lower 
 wall of the tube : hence it will be seen that the combined action of 
 the two muscles is to keep open the tube by drawing the membrane 
 forming its outer wall apart from the cartilage forming its inner 
 wall. 
 
 As during the act of deglutition the tensor and levator palati 
 muscles contract, it is evident that whenever that act is performed, 
 the Eustachian tube must be opened ; and inasmuch as there is no 
 apparatus by which the faucial orifice of the tube can be kept open, 
 its lips must fall together, and the orifice close as soon as the muscles 
 cease their action. During the few moments that the faucial muscles 
 are brought into play in the process of deglutition, air can either 
 enter or recede from the tympanic cavity, and thus be always of the 
 same density as the outer air. The reasons why the Eustachian 
 tube is closed, save during the momentary act of deglutition, are, 
 first, that the tympanum may be generally a closed cavity, so that 
 the sonorous vibrations reaching it may be concentrated upon the 
 membrane of the fenestra rotunda ; and, second, that, as specially 
 pointed out by Dr. Jago, sounds may be prevented entering the tym- 
 panum from the fauces.^ 
 
 PATHOLOGICAL OBSERVATIONS. 
 Although from the preceding remarks there can remain little doubt 
 
 « An examination of the faucial orifice of the Eustachian tube in other animals is corro- 
 borative of the view above advanced. In inammalia the faucial orifice of the tube pre- 
 sents much variety both in structure and form. In the animals I have dissected belonging 
 to the class ruininantia, there is an entire absence of cartilage at the orifice of the tube, 
 and the aperture is guarded by a thin fold of elastic membrane ; it is opened by the faucial 
 muscles. In the cartiivora the cartilage is prominent, and forms a distinct rounded pro- 
 jection. In the rodentia the orifice consists merely of a fissure in the mucous membrane 
 of the fauces. In some of the mammalia the orifice is opened by the superior constrictor of 
 the pharynx. In all the birds that I have been able to examine, the Eustachian tube was 
 composed of two distinct portions, the membranous and the osseous j and no cartilage en- 
 tered into their composition. The membranous portion consists of a sac, which is common 
 to both ears, the upper extremity of which receives the two osseous tubes, and the lower 
 extremity opens into the cavity of the fauces posterior to the aperture of the nares. The 
 muscles which open the Eustachian tube in the bird are the internal pterygoid, or rather 
 small muscles distinct from the pterygoid, but accessory to them. The common membra- 
 nous tube is situated between the internal pterygoid muscles, and the lateral surfaces of the 
 tube are in contact with, and firmly adherent to, the inner surface of these muscles or their 
 accessories, so that when the fibres are drawn from the median line the walls of the tube are 
 separated, and a free communication exists between the tympanic cavity and the pharynx. 
 
218 ' THE DISEASES OF THE EAR. 
 
 that the faucial orifice of the Eustachian tube is ordinarily closed, 
 except during the act of deglutition, it is requisite to perfect hear- 
 ing that the tube should be pervious, and that there should be a con- 
 stant interchange of air in the cavity of the tympanum. If the 
 Euf^tacliian tube becomes impervious, the air that was in the tym- 
 panum at the time of the closure gradually disappears. It is not 
 easy to decide whether it is absorbed, or whether by a kind of exos- 
 mose it passes through the membrana tympani ; but whatever the 
 cause, in a space of time, varying in different cases from a few hours 
 to a day or two, there is no doubt that the air in the tympanic 
 cavity becomes partially exhausted. The effect is to produce an 
 increased concavity in the external surface of the membrana tym- 
 pani ; a forcing inwards of the chain of ossicles ; pressure on the 
 contents of the labyrinth ; and a very serious diminution of the 
 hearing power. 
 
 The morbid conditions of the Eustachian tube found in 1523 dis- 
 sections were as follows : — 
 
 Containing mucus, ........... 10 
 
 Containing mucus, lining membrane congested, ...... 2 
 
 Containing mucus, lining membrane thick, ....... 2 
 
 Lining membrane congested, .......... 5 
 
 Faucial portion, mucous membrane red and soft, ...... 2 
 
 Bands of adhesion connecting the walls, ..... .3 
 
 Stricture in osseous part, .......... 1 
 
 Stricture in cartilaginous part, ......... 2 
 
 Ver)' large, ............. 2 
 
 The causes of obstruction of the Eustachian tube may be thus 
 classified. 
 
 1. At its faucial orifice ; a thickening or relaxation of the mucous 
 membrane. 
 
 2. At its tympanic orifice ; thickening of the mucous membrane, 
 or a deposit of fibrin. 
 
 3. In the middle ptcirt of the tube; a collection of mucus, a stric- 
 ture of the osseous or cartilaginous portions, or membranous bands 
 connecting the walls. 
 
 1. Obstruction of the Eustachian tube, at its faucial orifice takes 
 place — 
 
 {a.) From thickened mucous membrane. 
 {h.) From relaxed mucous membrane. 
 
THE EUSTACHIAN TUBE. 219 
 
 (a.) OBSTRUCTION OF THE FAUCIAL ORIFICE FROM THICKENED 
 MUCOUS MEMBRANE. 
 
 In these cases there is usually enlargement of the tonsils, or 
 hypertrophy of the mucous membrane of the nose and fauces. If 
 the obstruction occurs in a young person, the mucous membrane of 
 the nose is commonly so thick as to ofter some resistance to the easy 
 passage of air, and to lead to the habit of breathing through the 
 mouth ; a habit which at night is carried out to a marked degree, 
 and the patient often snores loudly. Upon examining the fauces, 
 the tonsils are sometimes found enlarged, and the fiiucial mucous 
 membrane is thicker than natural. In the adult the latter condition 
 is observed, but the tonsils are less frequently affected. The deaf- 
 ness comes on usually rather rapidly, often subsequent to a cold, 
 and, after remaining for a time, suddenly vanishes with a loud crack 
 in the ear. This amelioration often accompanies the acts of yawn- 
 ing, gargling, or other strong muscular effort of the fauces. The 
 improved hearing which thus results rarely continues long ; some- 
 times it lasts for a few hours, in others for a day : a variation which 
 probably depends upon the intervals which elapse before the air dis- 
 appears from the tympanic cavity. The amount of hearing depends 
 upon the quantity of air in the tympanum. Sometimes the patient 
 has to be loudly spoken to close to the ear ; at others a distinct 
 voice is heard at the distance of two or three yards. There is fre- 
 quently complaint of a sensation of weight or pressure in the ears, 
 which often extends to the head, Avhen heaviness and great depres- 
 sion of spirits are experienced. The latter symptom is very marked 
 at times, but entirely vanishes with the removal of the obstruction. 
 
 It possibly may originate from the pressure exerted upon the 
 contents of the labyrinth by the forcing inwards of the membrana 
 tympani and ossicles. A peculiar symptom sometimes met with in 
 this affection, and for Avhich I am unable to account, is the improve- 
 ment which takes place during the temporary position of the head 
 on a pillow, or even if it be turned round and kept looking back- 
 wards. Irritation is often complained of in the external meatus ; 
 sometimes the dermis of the meatus becomes much congested, and 
 eventually pours out a discharge ; and where it happens that the ir- 
 ritation is still greater, a polypus forms, and there is a large quan- 
 tity of mucus secreted. When a patient presents himself for advice, 
 
220 THE DISEASES OF THE EAR. 
 
 with obstruction of tlie Eiistacliian tube coexisting with polypus or 
 the sympathetic discharge from the meatus, unless the case be most 
 carefully examined the real disease is apt to be overlooked, and con- 
 sidered to be an affection of the meatus only. 
 
 On inspecting the membrana fi/mpani, it will be found very con- 
 cave, of a dull leaden hue, and its surface of an unnatural, glassy 
 aspect, the triangular spot being larger than natural. Sometimes 
 the membrana tympani is so much drawn inwards as to approach 
 the stapes, which is distinctly discernible through it ; in other cases, 
 the membrana tympani is somewhat opaque, and its outer surface 
 uneven and irregular. 
 
 The exploration of the Eustachian tube. — The method of doing 
 this is so important to a thorough examination, as to require to be 
 treated in detail. In a paper read before the Medico-Chirurgical 
 Society in 1853, I pointed out a simple mode of ascertaining 
 whether the Eustachian tube was pervious, and one which, as a 
 general rule, is successful, without having recourse to the catheter. 
 It has already been shown, that during the act of deglutition, with 
 the mouth and nose closed, a small quantity of air is passed through 
 the Eustachian tubes into the tympanic cavities ; a process that is 
 attended with a sensation of fulness in the ears. The entrance of 
 air into the tympanum can be distinctly heard by means of an 
 elastic tube about eighteen inches long, each end of which is tipped 
 with ivory or ebony ; an instrument which I have named the Oto- 
 scope. One end of it is to be inserted into the ear of the patient, 
 and the other into that of the medical man, who must take care 
 that no portion of the tube touches any ncighlioring body. When 
 the patient swallows a little saliva, the mouth and nose being closed, 
 if the Eustachian tube be pervious, at the moment that he feels a 
 sensation of fulness in the ear, the surgeon will hear most distinctly 
 a faint crackling sound, produced apparently by a slight movement 
 of the membrana tympani. This crackling sound is that most 
 usually heard ; but in some instances where the mucous membrane 
 of the tympanum is thick, a gentle flapping sound will be detected 
 in its place. If in a case of suspected obstruction of the Eusta- 
 chian tube, the otoscope fail to reveal any sound during the act of 
 deglutition ; if no sound be heard when the patient makes a forcible 
 attempt at expiration with mouth and nose tightly closed ; and if 
 the history of the case, the symptoms and appearances, agree with 
 those already laid down as appertaining to obstruction of the Eusta- 
 
THE EUSTACHIAN TUBE. 221 
 
 cliian tube, I think the surgeon is justified in affirming that the 
 tube is obstructed, and has no need to resort to the use of the 
 Eustachian catheter. Doubtless, in many cases, a person is unable 
 
 Fig. 77. 
 
 The Otoscope. 
 
 to force air into the tympanum, although the pervious condition of 
 the Eustachian tube is shown by the test of the otoscope, and this 
 may depend upon a peculiar arrangement of the lips of the tube 
 which causes them to be pressed together by the compressed air. 
 There are other cases also where the tube may be proved to be 
 pervious by the patient forcing air into it during an attempt at 
 expiration, although the act of deglutition with closed nostrils does 
 not call forth any sound appreciable by the otoscope ; but it is rare 
 indeed for a pervious tube to resist both of these tests. I have, 
 however, met with such cases ; but, as their history, appearances, 
 and symptoms have concurred in showing that no obstruction of 
 the tube existed, it has not appeared necessary to introduce the 
 catheter. In certain cases the membrana tympani may be seen to 
 move during an attempt at expiration, even though no sound could 
 be heard ; the patient, therefore, should always be asked whether 
 he perceives any sensation in the ears during the above-named 
 processes. 
 
 Is the Eustachian catheter then useless as a means of diasnosis ? 
 Notwithstanding its frequent use by surgeons in Germany and in 
 France, I am disposed to think so. By paying attention to the 
 points just laid down, it is my opinion that a case of obstruction of 
 the Eustachian tube can always be diagnosed without the aid of the 
 
222 
 
 THE DISEASES OF THE EAR. 
 
 catheter. Respecting its use as a remedial agent, I shall speak 
 hereafter. 
 
 That the cause of the obstruction of the Eustachian tube at its 
 faucial orifice is the thickening of the mucous membrane, is proved 
 
 Fio. 
 
 The Surgeon using the Otoscope. 
 
 by actual dissection, by the coexistent thickening of the mucous 
 membrane in other parts of the fiiuces, and by the results of the 
 remedial measures adopted for its relief. An opinion formerly ob- 
 tained a certain degree of credence in the medical profession, that 
 enlarged tonsils frequently press upon and close tlie Eustachian 
 tubes. There can be no doubt this opinion is erroneous. To con- 
 vince himself that it is so, the surgeon has only to make an ex- 
 amination of the relative position of the tonsil and of the trumpet- 
 shaped extremity of the tube ; Mhen he will find the tonsil situated 
 from an inch and a quarter to an inch and a half below the tube, and 
 placed between the palato-glossus and palato-pharyngeus muscles, 
 the latter muscle entirely separating the tonsil from the fube : he 
 will also find the Eustachian tube close to the base of the skull, 
 against the basilar process of the occipital bone, and surrounded by 
 the tensor and levator palati muscles, the function of which is, as 
 already shown, to open the tube. Repeated examinations have con- 
 vinced me that even should the tonsil enlarge to its greatest possible 
 
THE EUSTACHIAN TUBE. 223 
 
 known extent, it never reaches the Eustachian tube ; for, together 
 "with the enlargement of the tonsils, the palato-pharyngeus muscle 
 also hypertrophies, and effectually separates the two organs. Nay, 
 further, in the cases seen by me, where the tonsils have been the 
 largest, there has been no deafness ; a fact which must also have 
 been observed by other medical men. Often, in a case of obstructed 
 Eustachian tube in one ear, the tonsil has been comparatively small 
 on the deaf side ; while on the opposite side, Avhere tlierc has been 
 no deafness, the tonsil has been large. There is no doubt that ob- 
 struction from hypertrophy of the mucous membrane of the faucial 
 orifice of the Eustachian tube may coexist with enlarged tonsils ; but 
 the mere coexistence of two affections must not be confounded with 
 cause and effect. 
 
 TREATMENT OF OBSTRUCTION OF THE FAUCIAL ORIFICE OF THE 
 EUSTACHIAN TUBE BY THICKENED MUCOUS MEMBRANE. 
 
 Cases of this disease, when uncomplicated with any affection of 
 the tympanum, ordinarily yield to the use of general remedies and 
 applications to the fauces, without touching the outer ear. The 
 object to be aimed at is the reduction of the congestion and hyper- 
 trophy of the mucous membrane surrounding the orifice of the tube, 
 so as to allow the muscles again to exercise their function of opening 
 it ; and for this purpose considerable patience and perseverance are, 
 doubtless, frequently required ; since in many strumous persons, 
 especially if young, the tendency to congestion and thickening is 
 very great. 
 
 General Remedies. — The most efficient of these are abundant and 
 active exercise in the open air, and warm clothing. Flannel should 
 be worn next to the skin. In youths the flannel jacket, extending 
 from the neck to the ribs, may not only be worn, but, in cold weather, 
 in front, where the chest is exposed, a small additional piece of flan- 
 nel may be worn suspended from the neck. The throat should not 
 be wrapped up with handkerchiefs, comforters, boas, &c., as they 
 only serve to weaken it, by keeping it Avarm for a certain time, and 
 then, on their removal, leaving it exposed frequently to a colder air 
 within doors than had prevailed without, thus bringing on relaxation 
 of the mucous membrane. Where a single tie-handkerchief is worn 
 within doors, no addition is needed on going out ; and where in 
 
224 THE DISEASES OF THE EAR. 
 
 cliilclrcn the throat is left bare •within the house, a small silk hand- 
 kerchief, loosely tied, is all that is required without. I have been 
 thus particular on these points, because experience frequently con- 
 vinces me of their great importance. 
 
 The surface of the body should be daily sponged or rubbed with a 
 coarse towel that has been dipped in cold water, and then wrung 
 out. As the children who suftcr from the affection under conside- 
 ration have usually a languid circulation and deficient nervous 
 energy, the towel bath appears to be a remedy advantageous in 
 both respects. The towel should be very coarse, and only one part 
 of the body should be rubbed at a time. The skin, especially that 
 of the neck, throat, and spine, should be brought to a ruddy glow. 
 This bath may be used either in the morning or the evening, but 
 once daily is sufficient. If the patient be so very delicate that he 
 cannot well bear the slight shock produced by the cold towel, tepid 
 water may be used. In addition to this bath, indeed to supersede 
 it, especially in youths of from fourteen to sixteen, by whom it is 
 not likely to be carried out effectually, the tepid or cold plunge-bath 
 may be resorted to. AVhen it can be practised, sea-bathing should 
 not be neglected; but in all cases of entire immersion it is advisable 
 to wear an oil-skin cap, to keep the head dry: and this, not because 
 the application of water to the head is objectionable, but because 
 there is so great a difficulty in perfectly drying the hair, and the 
 slow evaporation from it is often decidedly injurious. Plunging 
 into a fresh-water river in warm Aveather is not prejudicial. In the 
 treatment of the cases in question, too much stress cannot be laid 
 upon the necessity of exercise, bracing air, and cold bathing. I 
 have known them to overcome the most obstinate cases of obstruc- 
 tion of the faucial orifice of the Eustachian tubes, where all local 
 remedies and medicines had given slight or only temporary relief. 
 Care should also be taken as to the diet of the patient : pastry, 
 sweets, fat, &c., should be avoided ; vegetables may be sparingly 
 partaken of; and the principal food should be bread, especially that 
 containing the bran, meat, and light puddings, as rice, sago, &c. 
 Children should not be overworked in their studies, should retire 
 early, and their sleeping-rooms should be airy and well ventilated 
 (it is a good plan to leave the bedroom door ajar during the whole 
 of the night) ; and, above all, it is important that the head should 
 be kept above the bedclothes. 
 
 To overcome the very prevalent habit of breathing through the 
 
THE EUSTACHIAN TUBE. 225 
 
 mouth, whereby the cokl air keeps up a constant irritation of the 
 faucial mucous membrane, the patient shoukl be directed to sit down 
 quietly for a certain time daily, and practise the habit of nasal 
 respiration. Although it may at first seem difficult, the mucous 
 membrane of the nose soon yields, and the air passes freely.^ 
 
 Medicines. — All medicines that impart tone to the system, may 
 in turn be resorted to. Cod-liver oil, iron in various forms, iodide 
 of iron, iodide of potassium, creasote, and the mineral acids and 
 vegetable bitters, will be found useful. 
 
 Local Treatment. — The most efficient local application is undoubt- 
 edly the nitrate of silver, which may generally be used in a solid 
 form. Messrs. Weiss have made for me a caustic holder, the end 
 of which is capable of being turned at such an angle, that the 
 caustic may be passed behind the soft palate, and applied to the 
 mucous membrane of the orifice of the tube, as well as to that of 
 the fauces. Should the tonsils be enlarged, the solid nitratt of 
 silver may be rubbed over their surface, and over that of the faucial 
 mucous membrane, about once a week ; and it should produce con- 
 siderable irritation and a copious flow of mucus. Stimulating 
 gargles are also to be used ; those combining acids and astringents 
 are of service. Iced or cold water is often beneficial ; and in order 
 to insure the application of the cold Avater to the orifices of the 
 tubes, as well as to improve the condition of the mucous membrane 
 of the nares, the water may be drawn up through the nose, and 
 passed out by the mouth. "When there is much congestion of the 
 faucial raucous membrane, a leech or two, a stimulating liniment, or 
 a vesicating paper, may be applied over the region of the tonsils. 
 
 TJie use of the Eustachian catheter. — It Avas, and is even noWy 
 the custom of some surgeons to pass the Eustachian catheter re- 
 peatedly in cases of obstruction of the Euotachian tube. Now^ 
 what is the effect of this procedure ? If the mucous membrane be 
 not much thickened, air is blown into the tympanic cavity, and the 
 power of hearing is improved. As soon, however, as the catheter 
 is withdrawn, the tube again closes, and its muscles have not the 
 power to reopen it ; while the air which has been forced into the 
 cavity soon disappears, and the deafness returns. The patient 
 again seeks relief from the same process and with the same result ; 
 
 ' Many years ago I pointed out the peculiar erectile tissue of which the nasal mucous 
 membrane is composed, not only in man, but in most mammalia ; this tissue renders it a 
 most eflBcient natural "respirator.'" 
 
 15 
 
226 THE DISEASES OF THE EAR. 
 
 for if the mucous membrane is allowed to remain in its existing 
 state, no permanent relief is to be hoped for ; on the contrary, the 
 repeated use of the catheter tends rather to increase than diminish 
 \he congested state of the membrane. Under certain circum- 
 stances, however, the Eustachian catheter is of great value. The 
 judicious course respecting it, is to use the above-named plans for 
 the purpose of reducing the hypertrophy of the mucous membrane, 
 which will, in the majority of cases, eflFect the cure of the disease. 
 If, after pursuing these measures for ten days or a fortnight, no 
 amelioration ensues, the Eustachian catheter may be introduced and 
 air blown through the tube into the tympanum ; an operation which 
 may at times possibly facilitate a cure by the removal of mucus 
 from the tube, or by liberating the lips of the faucial orifice. Seve- 
 ral days, however, should elapse before the operation, if required, is 
 repeated, and this will seldom be the case. 
 
 The mode of applying the Eustachian catheter. — It has been 
 already stated that the orifice of the Eustachian tube is posterior 
 and external to the posterior aperture of the inferior nasal meatus. 
 The catheter used by me is not quite so large as an ordinary crow- 
 quill ; and as the outer part of the Eustachian tube is oval, it has 
 been recently suggested by me that the extremity of the catheter 
 should be of the same shape. The end of the catheter taken hold 
 of by the surgeon should be rather larger than that which is to 
 enter the tube, in order that the end of the explorer, or the nozzle 
 of a syringe, may be fixed in it. This end having a ring on the 
 side opposite to the concavity of the curved end, is to be taken in 
 the right hand of the surgeon, the patient being seated in the chair 
 before him, and then the instrument, Avith the point downwards, is 
 to be made to glide backwards, by the side of the septum nasi, until 
 the curved end reaches the cavity of the fauces, when it is to be 
 pressed backwards against the mucous membrane of the posterior 
 part of the fauces. It is next to be drawn slightly forwards, and 
 then rotated outwards, so that the extremity may turn upwards and 
 catch the orifice of the Eustachian tube, which can be distinctly felt, 
 and will prevent the further rotation of the instrument. The cathe- 
 ter is now to be pressed slightly outwards and backwards, when the 
 surgeon will feel it to be embraced by the tube. For the purpose 
 of securing the instrument, a frontlet bandage, with a pair of for- 
 ceps attached, has been used ; but it may be dispensed with in all 
 ordinary cases : for the surgeon has only to transfer the catheter to 
 
THE EUSTACHIAN TUBE. 
 
 227 
 
 his left hand, and while holding it lightly, so as not to cause pain to 
 the patient (as the use of the frontlet invariably does), insert into 
 the dilated end of that instrument the small end of the explorer or 
 of the syringe. The explorer, which in my hands has entirely super- 
 
 FiG. 79. 
 
 The Explorer, and the Eustachian Catheter into which it fits. 
 
 seded the use of the air-press, consists of an elastic tube, about 
 eighteeen inches long, one end of which has a flat mouth-piece of 
 ivory, with one or two deep incisions upon it, to enable it to be 
 easily held by the incisor teeth of the operator, Avhile the other end 
 has a small portion of steel tubing attached to it, which fits accu- 
 rately into the further end of the catheter. 
 
 "When the catheter has been properly fixed, as directed in the 
 tube, and held there by the left hand of the surgeon, one end of the 
 explorer is to be placed in his mouth, and the other in the catheter, 
 and held there also by the left hand. With his right hand, thus 
 left at liberty, the surgeon is now to take the otoscope and introduce 
 one end of it into the car of the patient, who may hold it there, the 
 other end being held by the surgeon in his own ear ; or the tube 
 may be made so light as to remain there without being held, leaving 
 the operator's right hand still free. 
 
 The medical man next proceeds to blow air gently through the 
 explorer, at the same time that he listens through the otoscope to 
 ascertain whether the air enters the ear, and if it does, what is the 
 peculiar sound it produces. When the tympanum is unobstructed 
 by mucus, the air is heard to pass in a stream against the inner 
 surface of the membrana tympani, but when mucus is present, a 
 peculiar gurgling is heard ; and if the mucous membrane itself is 
 thickened, a peculiar squeak or bubbling is also perceptible. It is 
 
228 
 
 THE DISEASES OF THE EAR. 
 
 not advisable to blow with force into the ear, but rather to make a 
 few gentle successive puffs, attentively listening during each, to 
 detect the kind of sound that may be heard in the tympanum. 
 
 Fig. 80. 
 
 The Surgeon using the Eustachian Catheter and the Explorer. 
 
 Sometimes no air enters, the mucous membrane being too thick to 
 allow it to pass ; and, under such circumstances, it is unwise to 
 attempt to force the air into the tympanum. Great mischief has, 
 indeed, frequently resulted from such a proceeding; the mucous 
 membrane having been lacerated, and the air been driven into the 
 submucous tissue, causing extensive emphysema. Nay, still more 
 serious results have occurred, the patient having been killed in- 
 stantaneously, perhaps through the effusion of air through the 
 fenestra rotunda (the membrane having been lacerated) into the 
 labyrinth, and the shock upon the nervous system causing instant 
 death. Xor need it be a source of surprise that the effusion of air 
 into the labyrinth should prove fatal, since even the forcible disten- 
 sion of the tympanum, while blowing the nose frequently, produces 
 giddiness by pressure upon the labyrinth. 
 
 Tlie excmon of the tonsils. — On the supposition that the tonsil, 
 when enlarged, pressed against and closed the faucial orifice of the 
 Eustachian tube, the operation for excision, or partial excision, of 
 the tonsils, has long been practised for the relief of deafness. Al- 
 
THE EUSTACHIAN TUBE. 229 
 
 though, as already shown, the tonsil, however hypertrophied, cannot 
 cause occlusion of the Eustachian tuhe, still the removal of a portion, 
 in cases where it is much enlarged, is sometimes of service by dimin- 
 ishing the conjiestion of the mucous membrane at the orifice of the 
 tube ; and it perhaps also operates beneficially by allowing the 
 muscles of the tube to act more freely. This operation is, however, 
 very rarely required ; and the best rule to follow is never to excise 
 a portion of the tonsil, which appears to have important functions, 
 independent of the fauces, unless it evidently interferes with the 
 general health of the patient, or unless the obstruction of the 
 Eustachian tube resists the other measures already indicated. 
 
 CASES OF THE OBSTRUCTION OF THE EUSTACHIAN TUBE BY THICK- 
 ENED MUCOUS MEMBRANE, AT ITS FAUCIAL ORIFICE. 
 
 Case I. — Master M. J., aged 15, was brought to consult me, on 
 December 4, 1852, on account of a very serious diminution of the 
 hearing power, in both ears. He Avas in tolerable health, but pale. 
 About a year previously, after suffering from a bad cold, he became 
 dull of hearing, and since then has been able to hear only when 
 spoken to in a loud voice, within the distance of a yard or two. 
 Occasionally he has felt a sensation as of something bursting in the 
 ears, which has been followed by slight, but only temporary relief. 
 Upon examination, the mucous membrane of the fauces was found 
 very thick and red, and both tonsils greatly enlarged. The right 
 ear. — Watch heard only when in contact with the ear ; the membrana 
 tympani being opaque, of a leaden hue, and more concave externall}'' 
 than natural, while, instead of the usual triangular bright spot, tAvo 
 bright spots Avere perceptible, showing that the membrane was de- 
 prived of its ordinary evenness of surface. Upon listening with the 
 otoscope while the patient swallowed, the mouth and nose being 
 closed, and while he tried to force air into the tympanum, no sound 
 was heard. The left ear was in a very similar state to the right ; 
 the watch, however, could be heard at a distance of two inches from 
 the ear. Feeling assured from the history of the case, the symp- 
 toms, the condition of the throat, the appearances of the ear, and 
 the negative results following the use of the otoscope, that the 
 Eustachian tube Avas closed at the faucial orifice, especially as there 
 Avas no indication of disease in the tympanum, Avhich might lead to 
 
230 THE DISEASES OF THE EAR. 
 
 the supposition of tlie tympanic orifice being affected, I did not use 
 the Eustacliian catlieter, but proceeded at once to apply a solution 
 of nitrate of silver to the mucous membrane of the fauces, and to the 
 orifices of the Eustachian tubes. Three grains of the sulphate of 
 iron -were given daily in combination with ten grains of sulphate of 
 magnesia, and slight counter-irritation was kept up over the region 
 of the tonsils. As a remedial measure, the catheter was not resorted 
 to, as it "Nvas evident that the hypertrophy of the mucous membrane 
 had slowly come on, and it was not probable that it could be other- 
 wise than slowly improved. The first effect of the treatment was a 
 slight improvement of the hearing, although the tube remained 
 impervious ; an improvement which probably depended upon the 
 diminution of the congestion in the mucous membrane of the tym- 
 panum. By the end of January, the hearing power of the right 
 ear had greatly improved ; and in the middle of February, the air 
 passed freely through the Eustachian tubes during the act of deglu- 
 tition, and the patient heard quite well again. 
 
 Case II. OhistriLction at the faucial orifice for two montJis. — W. 
 "W., Esq., aged 52, being strong and in good health, consulted me 
 on July 26, 185-3. He stated that two months previously, after a 
 bad cold, he became slowly deaf in both ears, so as to require per- 
 sons to speak loudly to him Avithin the distance of a yard. On the 
 24th, after yawning, he suddenly experienced a crack in the left 
 car, and as suddenly heard well ; but this improvement only lasted 
 for a day, and then the deafness slowly returned. He has had three 
 similar attacks during the last ten years, but in about a month's 
 time the hearing usually returned after a cracking sound in the 
 ears. At times, on throwing the head back, he has found the hear- 
 ing power in the right ear much improved. On examination^ the 
 mucous membrane of the fauces was red and hypcrtrophied. 
 
 lUglit ear. — Hearing distance three inches ; the meatus was red 
 and hypcrtrophied, the mcmhrana tympani more concave than natu- 
 ral, its surface uneven, and instead of the single triangular bright 
 spot, there were two smaller spots. 
 
 Euatachian tube. — The otoscope did not detect any air entering 
 the tympanic cavity during tlic process of deglutition, or upon an 
 attempt at a forci])le expiration with closed nostrils. 
 
 Left ear. — Watcli heard only when in contact with the ear ; the 
 mcmbrana tympani was in a similar state to that of the right ear, 
 
THE EUSTACHIAN TUBE. 231 
 
 and the long process of the incus coukl be seen through it. The 
 Eustachian tube was impervious. 
 
 By the use of stimuLiting gargles and a liniment over the ears 
 and throat, the patient entirely recovered in the course of a fort- 
 night. 
 
 Case III. Ohstruetion of the faucial orifice : catarrh from meatus : 
 tonnih very large : cure without excision. — Master B., aged 16, was 
 brought to consult me in August, 1850. His general health was 
 not very good, and he was subject to glandular enlargements. 
 
 History. — The right ear has always been slightly dull,, and for 
 two or three years it has been worse. The left ear lately has also 
 become so dull, that he requires to be spoken to distinctly within 
 the distance of a yard from the head. Has had several attacks of 
 earache; after Avhich, and also after a cold, the deafness is increased. 
 Has had discharge from each ear on several occasions, and complains 
 of a singing in them. When asleep he makes a loud snoring sound, 
 and he always breathes through the nose. At times has had a 
 cracking sound in the ears, which has been followed by a tempo- 
 rary improvement. On examination, the tonsils were found to be 
 so greatly enlarged as nearly to touch the median line, while the 
 mucous membrane of the fauces and of the nose was much thicker 
 than natural. 
 
 Right ear. — Hearing distance half an inch ; membrana tympani 
 concave ; bright spot somewhat dull. Eustachian tube impervious. 
 
 Left ear. — Hearing distance two inches ; the bright spot of the 
 membrana tympani subdivided. Eustachian tube obstructed. 
 
 As the tonsils in this case were so much larger than natural, and 
 as they apparently interfered Avith the respiration of the patient, 
 and perhaps with his health, it was thought that the removal of a 
 portion of one or both might be attended with benefit : but the pa- 
 tient's friends so strongly objected to the operation that it was not 
 performed. The treatment consisted in the application of solid 
 nitrate of silver to the fauces ; in the use of an astringent gargle 
 Avith counter-irritants over the ears and throat ; in the administra- 
 tion of tonic medicines ; and in careful diet, with abundant exercise 
 in the open air. On August 21st, a crack took place in the left ear, 
 when he heard perfectly for a short time. After this date, a suc- 
 cession of cracks was heard in each ear, and at last the hearing 
 power entirely returned and remained perfect, except during a cold, 
 the effects of which, however, soon disappeared. 
 
232 THE DISEASES OF THE EAR. 
 
 CaseW. Obstruction from the mucous membrane of the fauces; 
 polypus in meatus externus ; removal by operation; cure. — H. W., 
 Esq., aged 19, was sent to me by Mr. White Cooper, in February, 
 1854, on account of a consitlerable diminution of the power of hear- 
 ing, and of a discharge from the right ear. Ilis health was not very 
 good, and he was subject to enlarged cervical glands. The history 
 of the case was, that about two years ago he found himself becoming 
 gradually dull of hearing. After this dulness had remained some 
 months, accompanied by a feeling of fulness in the ears, a discharge 
 took place from the right ear, the quantity of which has lately con- 
 siderably increased. On examination, the mucous membrane of the 
 fauces was observed to be red and thick. 
 
 Right ear. — The watch heard only when in contact ; a raspberry 
 polypus, the size of a small pea, Avas seen to fill the meatus, close to 
 the membrana tympani. 
 
 Left ear. — Hearing distance six inches ; membrana tympani 
 opaque, and calcareous in parts. Each Eustachian tube was imper- 
 vious to air. The treatment consisted in the removal of the polypus 
 by means of the lever-ring forceps. The membrana tympani was 
 then observed to be white. Astringent and acid gargles were used ; 
 slight counter-irritation was kept up over the cars and the region of 
 the fauces ; tonics were administered ; and daily sponging with cold 
 water was enjoined. In the course of a week a crack took place in 
 the right ear, followed by immediate great improvement of the 
 hearing ; this was succeeded by a crack in the left ear, and a perfect 
 restoration. The discharge also wholly disappeared. On seeing 
 this patient several months afterwards, I found his hearing perfect, 
 and there had been no return of the discharge. 
 
 I have said that the use of the Eustachian catheter is rarely re- 
 quired, because the state of the mucous membrane generally so much 
 improves by means of the other remedies. In the following case, 
 however, wliere there was an additional cause of impediment besides 
 the thickened mucous membrane, the catheter was used with advan- 
 tage. 
 
 Case V. Impervious condition of the tube from hypertrophy of the 
 mucous membrane at the faucial orifice ; fissure of the palate ; ca- 
 theter used ivith advantage. — Dr. P., a medical man, aged 43, con- 
 sulted me in 1853, on account of deafness. 
 
 History. — Several j'ears previously he had a disease of the palate, 
 which terminated in the loss of a considerable portion of the palatal 
 
THE EUSTACHIAN TUBE. 233 
 
 processes of tlie superior maxillary and palatal bones, and caused a 
 large fissure. During tlie last two or three years he has suffered 
 from attacks of deafness during a cold, which, after continuing for 
 some weeks, have disappeared. On cvamination, the mucous mem- 
 brane of the fauces was found to be red and mucli thicker than natu- 
 ral. Towards the posterior part of the palate was a large fissure, 
 exposing the trumpet-shaped extremity of the Eustachian tube ; the 
 mucous membrane of which was much swollen. Each membrana 
 tympani was of a leaden hue and very concave ; and there was an 
 appearance of redness beyond each, as if the mucous meml)rane were 
 congested. The patient had to be spoken to distinctly within the 
 distance of a yard. The Eustachian tubes were impervious. 
 
 Treatment. — A solution of nitrate of silver (5ij @ Sj) was applied 
 to the mucous membrane of the fauces and to the orifices of the 
 tubes ; an astringent gargle was ordered, and gentle counter-irrita- 
 tion over the throat. This treatment produced a slight improve- 
 ment ; but as the deafness soon returned, as the patient Avas espe- 
 cially anxious to hear, and as it appeared probable that the muscles 
 of the tube were partially disabled from performing their function, I 
 passed the Eustachian catheter, and, by means of the explorer, blew 
 air into the tympanic cavities. The good effect was instantaneous, 
 and the patient heard well. The improvement, however, lasted for 
 only about twelve hours, when the deafness gradually returned. At 
 the desire of the patient I passed the catheter on several occasions, 
 while other treatment was being followed. After each operation the 
 hearing improved for about the same space of time ; ultimately the 
 condition of the mucous membrane was so much improved as to allow 
 the muscles to open the tubes, and a cure resulted. 
 
 In some cases after the Eustachian tube has been obstructed for 
 a long time, the patient may almost wholly lose the power of hear- 
 ing. These cases, as will be seen by the following instance, are by 
 no means to be despaired of. 
 
 Case VI. Obstruction by tliichened mucous membrane of the 
 faucial orifice ; duration of many years ; great and jyrolonged hard- 
 ness of hearing ; cure. — Miss J. A. 0., aged 12, was brought to me 
 from Manchester, on the 16th April, 1853. She was strong, but 
 rather pale. The history of the deafness Avas, that during several 
 years she had been dull of hearing during a cold ; on the disap- 
 pearance of which, the power of hearing partially returned, so that 
 she could hear without much difficulty. For some months the deaf- 
 
234 THE DISEASES OF THE EAR. 
 
 ness has been so much •worse, that she cannot hear unless spoken 
 to in a loud voice into the left ear, the right being useless. On 
 examination, the mucous membrane of the fi\uces Avas found to be 
 red, thick, and spongy, but the tonsils -were not larger than natural. 
 The mucous membrane of the nose was very thick and red ; and 
 respiration was usuall}' carried on by means of the mouth. 
 
 Hifjlit ear. — Watch heard on pressure, but indistinctly: membrana 
 tympani concave, surface uneven ; and on that surface three irre- 
 gular-shaped bright spots -were seen. Eustachian tube impervious. 
 
 Left ear. — "Watch heard -when pressed; membrana tympani and 
 Eustachian tube the same as in the opposite ear. 
 
 Treatment. — The solid nitrate of silver was directed to be applied 
 to the mucous membrane of the fauces once a week ; counter-irritation 
 over the ears, and a leech or two at times over the region of the 
 fauces ; the one-thirtieth of a grain of the bichloride of mercury 
 twice daily, and a warm bath once a week : occasionally an emetic 
 was also given. She returned to Manchester, and on the 28th of 
 May her father wrote to me, saying that she was " so much better 
 that she can keep up a conversation across the table."' The child 
 had a relapse in the following January, but a repetition of the 
 treatment again restored her to perfect hearing. 
 
 It is not, hoAvever, only in long-standing cases of obstruction of 
 the Eustachian tube that the deafness is very considerable ; in weak 
 persons almost total deafness may come on in a few hours. A well- 
 marked case of the kind has occurred to me while writing the 
 present chapter. 
 
 Case VII. Sudden ohstruction of each Eustachian tube from con- 
 gestion and tJiickening of the mucous membrane of the fauces, jrro- 
 ducing total deafness in a few hours ; cure. — Dr. B., on the 24th 
 January, 1855, called to ask me to see his wife, of whom he gave 
 the following Idstory. 
 
 For several months she has been much out of health, and confined 
 to her room ; but has never suifered from any deafness or dise:xse of 
 the ear. On the night of the 20th instant she awoke, complaining 
 of a loud singing in her ears ; and when spoken to, it was found 
 that she was so deaf as not to be able to comprehend what was said, 
 although addressed very loudly. If possible, this deafness increased, 
 so that on the 22d no sounds were heard, and all communication had 
 to take place in writing. On examination, on the 24th, I found 
 that the deafness was complete ; each membrana tympani was very 
 
THE EUSTACHIAN TUBE. 235 
 
 concave and dull ; the mucous membrane of the fauces "was very red 
 and thick, the tonsils and uvula much swollen. Each Eustachian 
 tube was impervious. Upon inquiry I learnt that accidentally a 
 part of the window had been left open during the night. The 
 treat)nent recommended was the application of the solid nitrate of 
 silver to the fauces and the orifices of the Eustachian tubes. This 
 was done freely about eleven o'clock on the 2Gth. Dr. B. returned 
 home about two hours after, and found the hearing so improved that 
 he carried on a conversation with his Avife in a loud voice. 
 
 I miirht add to the above a laro-e number of cases in which the 
 treatment was quite successful, but will merely give the leading 
 particulars of another. 
 
 Case VIII. — H. L., Esq., aged 28, consulted me on June 25, 
 1853. Has suffered for several months from sore throat, conse- 
 quent upon an attack of secondary syphilis : for two months has 
 complained of deafness in both ears, so as not to hear any except 
 a loud voice. The deafness is accompanied by constant singing, 
 which is increased when the head is on the pillow, and it varies 
 nuich. On one occasion, after gargling the throat, heard much 
 better with the ri<i;ht ear for twelve hours. On examination of the 
 rigid car, the hearing distance was half an inch ; the membrana 
 tympani was opaque and of a leaden hue ; the surface shone, but 
 the bright spot was nearer the circumference of the membrane 
 than natural. The Eustachian tube impervious. The left ear was 
 in the same condition as the right. The treatment pursued was 
 the use of the nitrate of silver to the fauces, and the administra- 
 tion of steel wine. On July 2d he told me that three or four days 
 previously he heard quite well in the morning, and the improve- 
 ment lasted for two days, since which he has been gradually getting 
 deaf again. By perseverance in the treatment for a month he 
 perfectly recovered. 
 
 (b.) OBSTRUCTION OF THE EUSTACHIAN TUBE AT ITS FAUCIAL 
 ORIFICE FROM RELAXED MUCOUS MEMBRANE. 
 
 This affection is far from being so frequently met Avith as obstruc- 
 tion arising from thickened mucous membrane. In many symptoms 
 the two affections greatly assimilate, but they also present certain 
 decided differences. Obstruction from relaxed mucous membrane 
 
236 THE DISEASES OF THE EAR. 
 
 occurs less frequently in children or in persons subject to glandular 
 enlargements, than in persons -who have no thickening, but simply 
 a relaxed state of the mucous membrane of the fauces. The 
 physical cause of the obstruction appears to be a relaxed condition 
 of the mucous membrane covering the faucial orifice of the tube, 
 so that its muscles are unable to separate the lips sufficiently to 
 admit the air. The predisposing cause is generally some debili- 
 tating influence, as over-work, keeping late hours, indigestion, &c. 
 The exciting cause is often a cold. There is usually no history of 
 any previous affection of the ears, the deafness coming on slowly, 
 and gradually increasing until the patient is unable to hear ordi- 
 nary conversation, and requires to be spoken to in a loud voice. 
 Sometimes the patient impi-oves for a short time, and then the 
 deafness returns ; but frequently the hearing is better when the 
 head is placed in a recumbent position, or when the face is turned 
 and looks backwards. There is often a feeling of weight in the 
 ears, Avith a singing sound, and at times a sensation of confusion 
 in the head. On examination, the patient generally looks pale 
 and out of tone ; the pulse is Aveak ; the mucous membrane of the 
 fauces is either relaxed and red, the bloodvessels bein<::f lar<xe and 
 presenting long streaks ; and the uvula is either hanging down, so 
 as to touch the dorsum of the tongue, or it is of a much paler 
 color than natural from being deprived of its due supply of blood. 
 The membrana tympani is much more concave than natural, fre- 
 quently of a leaden hue, its surface being glassy. Not unfrequently 
 the long process of the incus is seen through it. Upon exploration 
 with the otoscope, the Eustachian tube is found to be impervious. 
 The treatment differs somewhat from that of cases of obstruction 
 from thickened mucous membrane. Instead of nitrate of silver, 
 stimulating gargles are to be used — one composed of whiskey is 
 often very serviceable ; tonic medicine and stimulants are to be 
 administered, generous diet, rest from work, country air, and 
 abundant out-door exercise, should also be prescribed. Similar 
 reasons to those which induce me not to use ordinarily the Eusta- 
 chian catheter in cases of obstruction from thick mucous membrane, 
 have prevented my resorting to it in the cases under consideration. 
 Its use could not, of course, diminish the cause of obstruction, or 
 fticilitate the progress of the treatment ; and unless the patient, 
 from some particular circumstances, was desirous to hear well 
 
THE EUSTACHIAN TUBE. 237 
 
 during a few hours, the introduction of this instrument should be 
 avoided. A cure is always to be effected without it. 
 
 Case I. Obstruction of the left tube from relaxed condition of the 
 mucous membrane ; eonstant beating sound. — J. R. H., Esq., a 
 surgeon, aged 48, consulted me on December 15, 1823. The 
 history was, that about six weeks previously he found himself deaf 
 in the left ear; he felt no pain, but there was a constant sensation 
 of beating in the ear, and a weight on that side of the head, which 
 caused extreme discomfort. He is subject to a relaxed throat. 
 On examination, the mucous membrane of the fauces was observed 
 to be relaxed, though not thicker than natural ; the meatus ex- 
 ternus of the hft ear was dry and smooth, and did not contain 
 any cerumen ; the membrana tympani was very concave and some- 
 what opaque. The processus brevis stood out very prominently ; 
 but the manubrium Avas so much drawn inwards that it could 
 scarcely be seen. The otoscope showed the Eustachian tube to be 
 impervious. The watch heard only in contact with the car. The 
 right ear perfectly natural. 
 
 Treatment. — A whiskey gargle was ordered, afid a mustard 
 plaster to be placed on the region of the fauces ; the outside of the 
 throat to be rubbed Avith a coarse towel dipped in cold water ; simple 
 food, as much rest and as little "night-work" as possible. 
 
 December 24th. — A crack took place in the ear, and the hearing 
 became perfect for a few minutes, but again became gradually dull. 
 The treatment was persevered in, and on the 7th January, 1854, 
 the gentleman wrote, "I am quite well; the air passes into the ear 
 perfectly well." All the unpleasant symptoms had subsided. 
 
 Case II. Obstruction in each tube for ten days after an attack of 
 bronchitis. — S. S., Esq., aged 51, an architect, was brought to rae 
 on June 24, 1853. 
 
 History. — He has had a bad cough and bronchial affection for a 
 month, which came on after having been considerably over-worked. 
 Ten days ago deafness came on slowly in both ears, and has re- 
 mained till now ; so that he has to be spoken to in an elevated tone 
 within a yard. He hears much better in the morning when reclin- 
 ing in bed. Has frequently tested his hearing by means of his 
 watch, and the result is, that when lying down he can hear it at a 
 distance of two feet Avith either ear ; but after being in the erect 
 posture for a minute or two the deafness returns, and he can hear 
 the watch only at two inches from the ears. He has now and then 
 
238 THE DISEASES OF THE EAR. 
 
 had a sliglit crack in each ear, followed by somewhat improved hear- 
 ing. On examination, the pulse was weak and slow, the face pale 
 and flabby, and the raucous membrane of the fauces was seen to be 
 relaxed, with enlarged streaky vessels ramifying in it. 
 
 lliglit ear. — A\ atch heard only when in contact Avith the ear ; the 
 surface of the membrana tympani was dull, had a dark leaden hue, 
 and the membrane was much more concave than natural, having two 
 irregular-shaped bright spots in place of the single one ; the long 
 process of the incus was seen through the membrana tympani, and 
 appeared to be in contact with its inner surface ; the Eustachian 
 tube was impervious. 
 
 Left car. — Similar to the right : hearing distance, a quarter of an 
 inch. 
 
 The treatment consisted in the administration of the citrate of 
 iron, followed by decoction of bark and sulphuric acid ; the use of 
 a tannin gargle and gentle external counter-irritation. He was also 
 advised to sleep in the country, to work as little as possible, and to 
 live generously. On July 2d there Avas a slight improvement, but 
 as yet no free passage for the ear through the tubes. On July 7th 
 a sudden and great improvement took place in the right ear, after 
 blowing the nose. Hearing distance, six inches in the right, and a 
 quarter of an inch in the left ear. Cracks now occurred in both 
 ears from time to time, and were followed by great amelioration in 
 the hearing. At the end of July he had perfectly recovered. 
 
 Case III. Obstruction at the faucial orifice from relaxed mucous 
 membrane for two months after influenza. — Miss. T., aged 16, was 
 brought to me on June 7th, 1853. She was pale, with a weak pulse, 
 and somewhat out of health, having had an attack of influenza for 
 two months. Catamenia irregular. 
 
 History. — AVlien a child, was subject to dulness of hearing during 
 a cold, but recovered as soon as the cold passed away. During the 
 recent attack of influenza has been so dull of hearing as to require 
 to be spoken to distinctly Avithin the distance of a yard ; general 
 conversation is not heard. Sometimes during an entire day hears 
 rather better. Complains of a ticking noise in the ears. 
 
 Results of examination: rigid ear. — Watch only heard on pres- 
 sure ; membrana tympani, surface dull, concave ; Eustachian tube 
 impervious. Left ear. — In the same state as the right. The mucous 
 membrane of the fauces was relaxed. 
 
 Treatment. — Considering that the relaxed condition of the faucial 
 
THE EUSTACHIAN TUBE. 239 
 
 mucous membrane was dependent upon the state of the health, steel 
 was administered, and plans for invigorating the system Avere recom- 
 mended : gentle counter-irritation over the region of the fauces Avas 
 also enjoined. 
 
 July loth. — lias had a " rumbling" sound in the ears, since 
 which she has been better. Hearing distance, tAvo inches. 
 
 July 20th. — Well. Eustachian tubes pervious. 
 
 ScA'cral additional cases might be related, but the three I have 
 mentioned will be sufficient to illustrate the nature of the affection. 
 
 ((?.) OBSTRUCTION OF THE EUSTACHIAN TUBE AT THE TYMPANIC 
 ORIFICE FROM THICKENED MUCOUS MEMBRANE. 
 
 Inasmuch as one of the most common affections of the ear is in- 
 flammation of the tympanic mucous membrane, it will be readily 
 conceived that obstruction of the tympanic orifice of the Eustachian 
 tube is likely to take place from the same cause. It is Avell known 
 tluit the osseous portion of the Eustachian tube, Avhich is about the 
 size of an ordinary probe, is lined by an extremely thin mucous 
 membrane, Avhich, like that covering the osseous Avails of the tym- 
 panum, adheres firmly to the surface of the bone, and appears to 
 act in tlie tAvofold capacity of a periosteum and mucous membrane ; 
 one of the reasons for its extreme tenuity being the fact that the 
 bony part of the Eustachian tube forms part of the cavity Avith re- 
 sonant Avails. The whole of the mucous membrane of the Eusta- 
 chian tube, excepting at the tAvo extremities, is so surrounded by 
 muscles and bone as to be little liable to become the seat of dis- 
 ease. In making dissections, I have rarely found that it has been 
 morbidly affected ; indeed, in some cases of ulceration of the faucial 
 mucous membrane in scarlet fever, accompanied by ulceration of 
 the mucous membrane of the tympanum, the membrane lining the 
 central portion of the tube has been found free froiu disease. It 
 Avould thus appear that the commonly received opinion of the ex- 
 tension of the disease, by direct continuity, from the fauces to the 
 tympanum, is not ahvays correct ; and from observation of Avhat 
 occurs in other cases, there is no difficulty in conceiving the affections 
 of the tAvo parts to originate at the same time Avithout any relation 
 of cause and effect. It cannot be doubted that it is very fortunate 
 the mucous membrane of the central part of the tube is so little 
 liable to become thickened, since it Avould of course be very difficult 
 to act upon it effectually. 
 
240 THE DISEASES OF THE EAR. 
 
 The mucous membrane covering the bone which forms the tym- 
 panic aperture of the tube is, on tlie contrary, liable to congestion 
 and hypertrophy, being, like the mucous membrane of the tympa- 
 num, exposed to the influence of the cold air entering the meatus 
 externus. Symptoms arising from this cause are usually present in 
 the cases under consideration ; but there is generally in addition a 
 great concavity of the membrana tympani, loud noises in the ears, 
 and, upon examination, an impervious state of the Eustachian tube. 
 
 The Jihtory of the two cases differs in the fact, that in cases of 
 obstructed Eustachian tube, the deafness generally comes on rapidly, 
 often disappears, and as rapidly reappears; whereas in those arising 
 from disease in the mucous membrane, the progress is usually slow 
 and regular. It must also be remembered, that in cases of obstruc- 
 tion of the Eustachian tube at the tympanic orifice, there is com- 
 monly a history of previous attacks of inflammation in the tympanic 
 mucous membrane, which is not often the case in instances of ob- 
 struction at the faucial orifice : the membrana tympani also presents 
 appearances indicative of inflammation having occurred in the tym- 
 panic cavity. The most simple cases of obstruction of the Eusta- 
 chian tube at the tympanic orifice are those following an ordinary 
 cold, in Avhich a sense of fulness is felt in the ears, often attended 
 with noises, and with dulness of hearing — S3-raptoms Avhich last for 
 a few days, and then ordinarily disappear with a sensation of some- 
 thing bursting in the ear. 
 
 In the treatment of these cases, all those measures should be re- 
 sorted to which will be described as serviceable in hypertrophy of 
 the mucous membrane of the tympanum. In addition, the opera- 
 tion of puncturing the membrana tympani is sometimes advisable. 
 
 ON THE OPERATION OF PUNCTURING THE MEMBRANA TYMPANI. 
 
 Since Sir Astley Cooper obtained a medal from the Royal Society, 
 on account of the success which, in a few cases, followed the opera- 
 tion of j)uncturing the membrana tympani, this operation has been 
 performed frequently, and in cases of deafness arising from every 
 possible cause. Though, doubtless, in certain cases it may be of 
 great service, it is an operation rarely required, and one which, if 
 not judiciously performed, is liable to produce the most injurious 
 consequences. In Sir Astley Cooper's successful cases, there was 
 
THE EUSTACHIAN TUBE. 241 
 
 simple obstruction of the Eustachian tube ; and there is little doubt 
 that the affection Avould have yielded to simple measures, having for 
 their object the removal of the obstruction, while the cure instead 
 of being temporary would have been permanent. In the great 
 majority of cases where Sir Astley punctured the membrana tym- 
 pani not the slightest benefit accrued, because the deafness was de- 
 pendent upon other causes than obstruction of the Eustachian tube; 
 and in some cases of deafness from debility of the auditory nerve, 
 the shock of the operation greatly aggravated the symptoms. In 
 what cases, then, should the operation be performed ? It will be ob- 
 served that I have not recommended it in cases of obstruction of the 
 faucial orifice of the Eustachian tube, because that obstruction can 
 be otherwise removed; but should the faucial orifice be permanently 
 closed by adhesion of its walls (a case never met with by me), there 
 can be no question that it should be performed. It is also called for 
 in cases of stricture of the osseous portions of the tube, in those of 
 obstruction by fibrinous effusion, and where the thickened mucous 
 membrane of the tympanic orifice will not yield to other treatment. 
 Great and immediate improvement frequently follows the operation ; 
 but there is usually so much difficulty in keeping the aperture open, 
 that the value of it is much diminished. The ordinary instrument 
 for performing the operation is the sharp triangular end of a probe ; 
 and where only temporary effect is required, this is sufficient. Fa- 
 brizzi invented an instrument for drilling out a circular portion of 
 the membrane ; but the extreme sensitiveness of the outer surface 
 of the membrana tympani renders it difficult of application. It con- 
 sists of a silver tube, about four inches long, one end of which, 
 about a line in diameter, is tipped with steel and made to cut ; the 
 opposite end is made to screw on the outer part of a trocar, near its 
 handle ; while the trocar, consisting of a silver rod, has at its end a 
 fine wire shaped like a corkscrew. When used, the trocar is passed 
 through the canula, and the spiral wire which projects beyond it has 
 its point passed through the membrana tympani, and then turned 
 round so as to cause it to enter the tympanic cavity. "When this 
 has been eflfected, and a firm hold of the membrana tympani is se- 
 cured, the canula is to be slightly unscrewed ; an action by which 
 its cutting extremity is pressed through the substance of the mem- 
 brana tympani and removes a circular portion. This instrument 
 may be used, however, in cases where the sensibility of the tym- 
 panic membrane has been impaired by disease. 
 
 16 
 
242 THE DISEASES OF THE EAR. 
 
 The usual method is, as stated, to puncture by the probe : and 
 the part best adapted for this purpose is that between the handle of 
 the malleus and the posterior margin. 
 
 The plan adopted by me for keeping open an orifice in the mem- 
 brana tympani, and the particulars of a case in ■which it was prac- 
 tised, will be found below : it consists in making a triangular flap, 
 by means of a very small scalpel, the blade of which is not more 
 than two lines in breadth. 
 
 Case I. Obstruction by thickened mucous membrane at the tym- 
 p'anic orifice. — Miss K. J., aged 10, was brouglit to me on July 14, 
 1853. 
 
 History. — Between five and six years ago, after a cold, sufi'ered 
 from an attack of earache, followed by dulness of hearing, so that 
 she has been obliged to listen, in order to hear conversation. 
 During attacks of cold, she has been so much worse as to require 
 to be spoken to distinctly, within tlie distance of a yard or two. 
 Is now subject to occasional attacks of earache, and has had a 
 slight discharge from the right ear. On examination of the right 
 ear, the dermoid layer of the membrana tympani was white and 
 thick, and covered with a small quantity of discharge ; the mem- 
 brana itself was more concave than natural ; and the Eustachian 
 tube was obstructed. 
 
 Left ear. — The surface of the meatus was covered with cerumen, 
 having a natural appearance ; the membrana tympani was white 
 and concave ; the Eustachian tube was obstructed ; and the mucous 
 membrane of the fauces Avas in a natural state. 
 
 Treatment. — Leeches were applied below each ear, twice a Aveek, 
 followed by blisters ; and the one-thirtieth of a grain of the bichlo- 
 ride of mercury was given twice daily ; a course of treatment which 
 was pursued for six weeks. At first, there was no improvement ; 
 after three weeks, however, a slight diminution of the deafness took 
 place ; and on the 1st of September, the hearing was quite restored, 
 and the Eustachian tubes were pervious. 
 
 Case II. Obstruction by thickened mucous membrane at the tym- 
 panic orifice, after influenza; jyolypus in one ear, a collection of 
 cerumen in the other ; great improvement. — Master J. P. M., aged 
 14, in good health, was brought from Lincolnshire, July 27, 18")3. 
 
 History. — Four years ago he had an attack of influenza, followed 
 by so conspicuous a hardness of hearing, that he required persons 
 to speak to him in a loud voice. During a cold the deafness is much 
 
THE EUSTACHIAN TUBE. 243 
 
 increased ; at times, after a feeling of cracking in the ear, has heard 
 much better. This crack occurred once in the right ear, after bath- 
 ing, and was followed by perfect hearing for a few hours. The right 
 ear has discharged blood for several months, and been affected with 
 earache. Previous treatment. — Glycerine has been dropped into 
 both ears without any benefit ; slight improvement followed the use 
 of a blister behind each ear ; tonics have been administered. 
 
 On examination: rigid ear. — Hearing distance, half an inch; the 
 meatus contained a discharge, and at its inner part, concealing the 
 membrana tympani, Avas a red, globular polypus. Eustachian tube 
 obstructed. Left ear. — Hearing distance, half an inch ; the meatus 
 contained a collection of cerumen ; on removal of which, the mem- 
 brana tympani was seen to be very concave and white : Eustachian 
 tube obstructed. 
 
 Treatment. — The polypus was extracted from the right ear by the 
 lever-ring forceps ; vesication was kept up over the mastoid pro- 
 cesses ; small doses of the iodide of potassium Avere administered. 
 In the course of three months the hearing returned, and he remained 
 well. 
 
 Case III. Obstruction of the tympanic orifice of the tube; polypus 
 in the right ear ; cured. — Miss M., aged 14, saw me on the 14th of 
 February, 1854. Her health was good, but she complained of head- 
 ache. 
 
 History. — During the last seven years has been, at times, dull of 
 hearing, and has had attacks of earache. During a cold is much 
 worse. Has not had any discharge. Occasionally, after feeling as 
 if something had burst in the right ear, had heard quite well for a 
 short time. She now has to be loudly spoken to close to the right 
 ear ; the left is useless. On examination., the hearing distance of 
 the right ear was found to be two inches ; the membrana tympani 
 was concave and white ; the Eustachian tube obstructed. With the 
 left ear, the crack of the nails Avas heard ; the membrana tympani 
 was thick ; the Eustachian tube obstructed. 
 
 Treatment. — Brown's vesicating paper Avas ordered to be applied 
 behind both ears every night, and three grains of hydrargyrum cum 
 creta Avere to be taken every night. 
 
 March 7th. — The same : has not been pursuing the treatment Avitli 
 regularity : to take an emetic once a Aveek, and the one-thirtieth of 
 a grain of the bichloride of mercury, twice daily ; the vesicating 
 paper to be continued. 
 
244 THE DISEASES OF THE EAR. 
 
 April 0th. — Has heard well for a week, and hears better to-day 
 than on March 7th. A small vascular polypus is seen in the right 
 meatus near the membrana tympani. 
 
 Mav 11th. — The right ear has greatly improved ; hearing distance 
 nine inches. Left ear : watch heard on pressure. 
 
 June 14th. — Right ear cured : the polypus has disappeared. 
 
 Case IV. Obstruction of the tympanic orifice of the tube ; tempo- 
 rary relief by puncturing the membj'ana tympani ; cured by removing 
 the obstruction. — J. R., Esq., aged 53, strong, and in good health, 
 was sent to me by Mr. Cock, on May 7th, 1853. 
 
 History. — When a boy, was deaf, and was taken to Sir Astley 
 Cooper, who punctured the drum of each ear ; which operation was 
 followed by complete relief until eight years ago, when, after a vio- 
 lent cold, deafness gradually came on in both cars ; and has remained 
 till now, with the exception of a day or two's improvement, at times, 
 after violent sneezing. At present, he has to be loudly spoken to 
 within a foot of his head, in which there is a feeling of constriction 
 and of pressure on the top part. On examination of right ear, the 
 crack of the nails only is heard ; the membrana tympani is very 
 opar^ue, uneven, and concave ; Eustachian tube obstructed. Left 
 ear. — Watch heard on pressure. Membrana tympani and Eusta- 
 chian tube in the same state as in the right ear. 
 
 There was no doubt in my mind that the cause of the deafness 
 was a thickened state of the mucous membrane at the tympanic ori- 
 fice of the tube ; and I prescribed the application of leeches below 
 the ear, to be followed by blisters, while small doses of mercury 
 were to be administered. The patient, however, implored me, if 
 possible, to render him some immediate relief, as he was a candi- 
 date for a public appointment ; for, although my assurance that he 
 would recover might favorably influence the committee, before whom 
 he was to appear the following day, still he greatly feared that, 
 should he not hear what was said, he might be rejected. I, there- 
 fore, but unsuccessfully, attempted to pass air into the tympanum 
 through the catheter. I then punctured each membrana tympani 
 with an ordinary probe, which, as it passed, conveyed the feeling of 
 the membrane being soft and flaccid. The result Avas an instanta- 
 neous return of the hearing power, and the total disappearance of 
 the weight in the head : to use his own words, he " felt free again." 
 The hearing distance of each ear was six inches." 
 
 May 30th. — After the operation, continued to hear well until a 
 
THE EUSTACHIAN TUBE. 245 
 
 few (lays ago, when the deafness slowly returned, and he is now 
 nearly as deaf as on the 14th. The orifice in each niembrana tym- 
 pani had closed. As he was unable to wait until the remedies for 
 opening the tube could be tried, I made a triangular flap, about two 
 lines long, and a line broad below, in each membrane, by means of 
 a scalpel, the blade of Avhich was about two lines in breadth : the 
 apex of the flap was above, and it was turned down. The result 
 was as instantaneously favorable as in the previous operation : and 
 as it was considered probable that the aperture would close, active 
 treatment for the purpose of opening the tube was at once carried 
 out. The consequence was, that in a fortnight, although the orifice 
 in each membrana tympani had closed, the air passed freely through 
 the Eustachian tube, and the patient heard well. 
 
 Closure of the tympanic orifice of the Eustachian tube by the effu- 
 sion of fibrine will be spoken of when describing cases of the effusion 
 of fibrine into the tympanic cavity. 
 
 {d.) OBSTRUCTION OF THE MIDDLE PART OF THE EUSTACHIAN TUBE; 
 BY A COLLECTION OF MUCUS, BY A STRICTURE OF ITS CARTILA- 
 GINOUS OR OSSEOUS PORTIONS, OR BY BANDS OF ADHESION CON- 
 NECTING THE WALLS. 
 
 In the tabular view giving the result of 1523 dissections, it will 
 have been observed that in thirteen instances the Eustachian tube 
 contained mucus. In my opinion, however, a collection of mucus 
 rarely offers insuperable resistance to the action of the muscles of 
 the tube, to the pressure of the air in the fauces during the act of 
 deglutition, or to an attempt at a forcible respiration, with closed 
 nostrils, &c. It is nevertheless possible that in some of the cases 
 where the tympanic orifice of the tube is closed by thick mucous 
 membrane, there may be also an accumulation of mucus : but as its 
 presence would not require any alteration in the treatment, it is un- 
 necessary to dilate upon the subject. 
 
 Stricture of the osseous j^ortion of the Eustachian tube is very 
 rare. Only one case has fallen under ray observation ; .but as I had 
 the opportunity of seeing the patient during life, and afterwards of 
 making a dissection of the ear, it is of sufficient interest to be de- 
 tailed at length. 
 
 Casel. Stricture of the osseous portion of the Eustachian tube; 
 
246 THE DISEASES OF THE EAR. 
 
 dissect I on. — C. J., aged 45, was visited by me in the month of 
 November, 1840. He was dying from tubercular disease, so that I 
 was precluded from making so minute an examination as would have 
 been desirable. The history of the origin and progress of the deaf- 
 ness, as far as could be ascertained, was as follows : — About twenty 
 years ago, the patient suffered from a violent inflammation in the 
 right ear, followed by a discharge from the external meatus, which 
 had continued almost without intermission up to the time he was 
 seen by me. For a considerable period this ear had been unable to 
 distinguish sounds, and the left ear had been gradually growing less 
 and less sensitive to sonorous vibrations during the preceding six or 
 seven years. No pain had been felt in it, however, and there had 
 been no discharge from the external meatus. 
 
 Upon inspection by means of a speculum and lamp, the membrana 
 tympani of the right ear was observed to be absent, while the mucous 
 membrane lining the tympanic cavity was very thick, and covered 
 by a large quantity of purulent matter. In the left ear, the lining 
 membrane of the external ear was slightly reddened, and the mem- 
 brana tympani Avas as white as writing paper ; while the handle of 
 the malleus, usually so distinctly seen, could not be distinguished 
 from the surrounding membrane. Towards its centre, the surface 
 of the mem])rana tympani had lost the natural shining appearance ; 
 but a small portion of its surface, on each side of the handle of the 
 malleus, although perfectly white, was so smooth as to reflect the 
 light of the lamp. As the patient was in a state of great debility, 
 the otoscope was not applied to either ear to test the condition of 
 the Eustachian tube. The patient died a few days after the exami- 
 nation. 
 
 Post-mortem inspection. liight car. — The mucous membrane 
 lining the tympanic cavity was thick and in parts ulcerated ; wliile 
 the bone forming the upper wall of the cavity, with which the ulcer- 
 ated membrane was in contact, was carious. The Eustachian tube 
 was healthy. 
 
 Left ear. — The central portion of the membrana tympani was 
 found to be white and thick ; but those parts of it whicii lie ante- 
 riorly and ]K)steriorly to the handle of the malleus, were soft and 
 attenuated, and the white appearance was due to the presence of 
 mucus in the tympanic cavity, in immediate contact with the inner 
 surface of the membrana tympani. So softened Avas this portion of 
 that membrane, that on applying the slightest pressure, the fibres 
 
THE EUSTACHIAN TUBE. 
 
 247 
 
 composing it gave way, and three small orifices were produced. 
 The cavity of the tympanum and the mastoid cells were filled with 
 thick, white mucus, and no air was discoverable. The mucous 
 membrane lining the cavity was also thicker than natural. 
 
 Tlic Eustacliian tube. — The internal portion for the length of 
 half an inch was healthy ; but at about that distance from the cavity 
 of the tympanum, there was a sudden constriction, and for the 
 length of about a line and a half tlie tube was so contracted, that, 
 even when its superior wall was removed, it was with difficulty that 
 an ordinary sized bristle could be introduced into the opening. 
 
 Fig. 81. 
 
 stricture of the Eustachian Tube. The black bristle is seen passing from the tympanic 
 cavity through the strictured portion. 
 
 This stricture resulted from the external and internal walls of the 
 tube pressing against each other ; the small space still permeable 
 being at the upper part. The more remote cause of the stricture 
 would appear, however, to have been an enlargement of portions of 
 the bone constituting the external and internal osseous walls of the 
 tube : the former being at this part twice its natural thickness, and 
 somcAvhat rough, Avhile the latter was forced outwards by the dilata- 
 tion of the carotid canal, which, pressing thus upon the cartilaginous 
 portion of the Eustachian tube with -which it was in contact, pro- 
 duced a flattening of the natural concavit}^ of the internal wall. 
 The mucous membrane lining the Eustachian tube was in a natural 
 state. 
 
 Although three dissections are recorded' of adhesion between the 
 walls of the tube by means of membranous bands, I have not hitherto 
 met with a case during; life. In such an instance the treatment 
 would consist in puncturing the membrana tympani, and establish- 
 ing an orifice in it. 
 
CHAPTER XII. 
 
 THE CAVITY OF THE TYMPANUM. 
 
 ANATOMICAL OBSERVATIONS — PATHOLOGICAL OBSERVATIONS — DISEASES OF THE 
 IIUCOUS MEMBRANE : — a, CONGESTION. b, ACUTE INFLAMMATION — AFFECTING THE 
 PORTIA DURA NERVE — EXTENDING TO THE BRAIN — SCROFULOUS MATTER IN THE 
 TYMPANIC CAVITY. C, CHRONIC INFLAMMATION. fl, CHRONIC CATARRHAL INFLAM- 
 MATION, e, CHRONIC CATARRHAL INFLAMMATION EXTENDING TO THE BONE, DURA 
 MATEU, on BRAIN. /, ULCERATION OF THE MUCOUS MEMBRANE. 
 
 Anatomical Observations. — The tympanic cavity is lined through- 
 out by a fine membrane, -which forms the internal layer of the 
 membrana tympani, and from which it can sometimes be detached 
 without difficulty. Internally it covers the surface of the pro- 
 montory and the membrana propria of the fenestra rotunda ; it is 
 reflected from the promontory at the circumference of the fenestra 
 ovalis upon the surface of the stapes, and it envelopes the incus 
 and malleus, by means of which it is continuous with the inner 
 layer of the membrana tympani ; above and below that membrane 
 it covers the osseous walls of the tympanum, and is prolonged 
 posteriorly into the mastoid cells, while anteriorly it is con- 
 tinuous with the lininji membrane of the Eustachian tube. The 
 mucous meml)rane of the tympanic cavity, in a healthy ear, is 
 so extremely thin as to be (^uite transparent ; and its presence 
 upon the surface of the osseous walls and ossicles of the tympanum, 
 can often only be detected by the use of a magnifying-glass and by 
 the touch. In a natural state the nervous filaments upon the sur- 
 face of the promontory are very distinctly seen, the margin of the 
 fenestra rotunda is defined and regular, and the membrane which 
 occupies it is thin and transparent. The crura of the stapes, as 
 well as their point of connection with the base, are clearly seen, 
 and a distinct fissure is observable between the inferior surface of 
 the crura and the ])romontory. The quantity of mucus covering 
 
THE CAVITY OF THE TYMPANUM. 
 
 249 
 
 this membrane in :i healthy ear is so small as to be scarcely per- 
 ceptible. The membrane itself is composed of extremely fine and 
 delicate fibres, and it has a strong analogy "with the serous mem- 
 branes : first, in respect to its extreme tenuity and great smoothness ; 
 second, in the frequency "vvith Avhich membranous bands connect 
 together various parts of the tympanic cavity. Over its surface 
 extends a layer of very minute epithelial cells, some of -which are 
 ciliated. The supply of bloodvessels is abundant, though they are 
 so minute as not to be discernible, except when distended with 
 blood : this happens in disease, and then they are often very much 
 dilated and surcharged. In young persons the membrane is highly 
 vascular, and, when successfully injected, is found to be pervaded 
 by plexiform ramifications. Beneath the mucous membrane lie 
 the branches of the tympanic nerve from the glosso-pharyngeal. 
 
 The upper wall of the tympanum is formed by a layer of bone 
 Avhich separates the tympanic cavity from that of the cerebrum, 
 and which deserves special attention, inasmuch as the diseases of 
 the tympanum, Avhich affect the brain, usually advances through 
 that bone. Its form is an elongated oval, and it measures about 
 
 Fig. 82. 
 
 An antero-posterior vertical section of the Temporal Bone through the Tympanic Cavity 
 
 and Mastoid Cells. 
 
 three-quarters of an inch long and from a quarter to half an inch 
 in breadth. Its direction is obliquely inwards and forwards, like 
 that of the petrous bone. Externally it is attached to the lower 
 part of the scjuamous, and internally to the outer part of the 
 petrous, bone : anteriorly it is continuous with the roof of the 
 
250 
 
 THE DISEASES OF THE EAR. 
 
 Eustachian tul)c, ami posteriorly with the roof of the horizontal 
 portion of tlic mastoid cells. This osseous lamina, forming the 
 upper wall of the tympanum, varies iinuli in thickness, being in 
 some instances from half to an entire line thick, though more 
 frequently it is very thin, presenting a mere shell of translucent 
 bone. In many specimens this lamina is deficient in parts, and 
 the mucous membrane of the tympanum is in contact with the dura 
 mater covering the petrous bone. In some specimens in my pos- 
 session, the head of the malleus projects through an orifice in this 
 portion of the bone, and was directly covered by the dura mater. 
 This defect in the upper wall of the tympanum is not usually the 
 result of disease, but of the process of development. In the 
 specimen, of which the following is a representation, the hori- 
 
 FiG. 83. 
 
 The upper Osseous Wall of the Tympanum defective. 
 
 zontal lamina alone is absent, wliilc' the vertical septa extend 
 upwards, even above the surrounding surface. 
 
 It has been thought desirable to be thus particular in the descrip- 
 tion of the relations of the tyinpannm, because fre([uent reference 
 
THE CAVITY OF THE TYMPANUM. 251 
 
 is made to the description in the pathological details subsequently 
 entered into. 
 
 Pathological observations. — Tlie diseases of the tympanic cavity 
 are numerous and important. Perhaps the most common affection 
 to which the organ of hearing is subject, is a greater or less degree 
 of thickening of the tympanic mucous membrane, with or without 
 catarrh through the membrani tympani. Besides this affection, a 
 simple accumulation of mucus in the tympanic cavity is of great 
 frequency; and, finally, anchylosis of the stapes to the fenestra 
 ovalis is a most common disease. 
 
 The diseases of the tympanic cavity, as revealed by the dissection 
 of 1013 diseased ears, are as follow : — 
 
 CONTEXTS. 
 
 Mucus, .............. 65 
 
 Blood, 6 
 
 Blood and niucu.s, ........... 1 
 
 Blood, mucus, and lymph, 1 
 
 Serum, ............. 10 
 
 Serum and mucus, 3 
 
 Serum and lymph, ........... 1 
 
 Lymph, ............. 6 
 
 Epithelium, ............. 2 
 
 Epithelium and oil, . . ........ 1 
 
 Scrofulous matter, ........... 20 
 
 Calcareous matter, ........... 8 
 
 Cerumen, ..,,,.......• 1 
 
 Cholesterine, , ........... 1 
 
 Cholesterine and mucus, .......... 5 
 
 Cellular tissue, ............ 2 
 
 Oily matter, ............. 1 
 
 Pus, 17 
 
 STATE OF THK MUCOUS MEMBKAXK. 
 
 More vascular than natural, .......... 75 
 
 Thicker than natural, ........... 211 
 
 Thick and very vascular, .......... 16 
 
 So thick as to conceal the stapes, ......... 27 
 
 So thick as to fill the tympanic cavity, ........ 6 
 
 Ulcerated 24 
 
 Pulpy 5 
 
 Containing black pigment cells, ......... 2 
 
 Having serum beneath it, .......... 1 
 
 MEMBRANOUS HANDS BETWEEN. 
 
 Malleus and promontory, .......... 6 
 
 Malleus, incus, and promontory, ......... 1 
 
252 
 
 THE DISEASES OF THE EAR. 
 
 Malleus and stapes, 
 
 Malleus, stapes, and promontory, ..... 
 
 Incus and promontory, 
 
 Incus, stapes, and promontory, ..... 
 
 Incus and malleus, ....... 
 
 Stapes and promontory, the mucous membrane being healthy 
 Stapes and promontory, the mucous membrane being thick. 
 Stapes and promontory, the mucous membrane being vascula 
 Stapes, promontory, and pyramid, ..... 
 
 All the ossicles, ........ 
 
 All the ossicles and the promontory, .... 
 
 Tensor tyrapani muscle (the tendon) and the stapes, 
 Chorda tympani nerve, incus, stapes, and promontory, . 
 Chorda tympani nerve and upper wall of tympanum, 
 
 3 
 
 1 
 
 79 
 
 48 
 
 6 
 
 1 
 
 30 
 
 9 
 
 3 
 
 2 
 
 1 
 
 MALLEUS. 
 
 Adherent to the promontory, ........ 
 
 Absent, apparently from caries or ulceration, .... 
 
 Partly removed by caries, ........ 
 
 Malleus and incus lying in the mastoid cells, ..... 
 
 Fi.xed by ligamentous anchylosis to the upper wall of the tympanum, 
 Fixed by osseous anchylosis to the upper wall of the tympanum, . 
 The body anchylosed to the incus, ..... 
 
 The long process detached from the membrana typipani. 
 The long process fractured, .... 
 
 The long process in contact with the promontory, 
 The long process adherent to the incus, . 
 The long process detached from the body, 
 The long process absent, .... 
 
 The long process carious, .... 
 
 The long process exostosed, . . . . 
 
 Absent, 4 
 
 Long process absent, ........... 2 
 
 Partly removed by caries, .......... 8 
 
 Disconnected from stapes, .......... 14 
 
 Disconnected from stapes and malleus, ........ 1 
 
 Fixed by membranous anchylosis to the orifice of the mastoid cells, . . 2 
 
 The base anchylosed by bone to the fenestra ovalis, . . . . .49 
 
 The base anchylosed by bone to the fenestra ovalis, the base being expanded, 6 
 
 The base anchylosed by membrane to the margin of the fenestra ovalis, . 36 
 The base anchylosed by membrane to the margin of the fenestra ovalis, the 
 
 base being exjianded, .......... 6 
 
 The base anchylosed by membrane to the margin of the fenestra ovalis, an 
 
 exostosis surrounding the fenestra, ........ 2 
 
 The base of the stapes attached to the fenestra ovalis more rigidly than natu- 
 ral 06 
 
THE CAVITY OF THE TYMPANUM. 
 
 253 
 
 The base projecting into the cavity of the vestibule, 
 The base expanded and more fixed than natural, . 
 The base expanded and projecting into the vestibule, 
 Detached from incus and attached to the membrana tynipani 
 Anchylosed to incus, ....... 
 
 Detached from the fenestra ovalis and the incus, . 
 Disconnected from the fenestra ovalis, .... 
 
 Partially absorbed, ....... 
 
 Atrophied, ......... 
 
 Absent, apparently from ulceration, .... 
 
 A1,I, THE OS.SICLES. 
 
 Less movable than natural, .......... 4- 
 
 Absent, apparently from ulceration, ........ 2 
 
 Disconnected from each other, ......... 1 
 
 Carious, ............. 2 
 
 OSSKOUS WALLS. 
 
 Thickened, 
 Carious, . 
 
 Upper wall partly deficient, .......... 54 
 
 Lower wall partly deficient, .......... 25 
 
 Osseous lamina between mastoid cells and lateral sinus incomplete, . . 2 
 
 Osseous lamina between mastoid cells and cavitas cerebelli incomplete, . . 1 
 
 Canal for portio dura nerve incomplete, ....... 2 
 
 Carotid canal contracted, .......... 7 
 
 Upon reference to Mr. Hinton's valuable paper on the Pathology 
 of the Ear, published in the thirty-ninth volume of the " Medico- 
 Chirurgical Transactions," it will be found that the results at which 
 he has arrived agree with those quoted above. 
 
 The plan I purpose to follow in investigating the subject will be 
 to consider successively the affections of the mucous membranes, 
 and those of the ossicles. 
 
 (a.) CONGESTION OF THE MUCOUS MEMBRANE OF THE TYMPANUM. 
 
 Congestion of the tympanic mucous membrane usually follows a 
 cold, or an attack of influenza. The symptoms are a feeling of dead- 
 ness in the ears, sounds like the ringing of bells, dulness of hearing, 
 and not unfrequently slight pain. If neglected, this affection is 
 liable to advance to acute inflammation. It frequently accompanies 
 conjrestion of the mucous membrane of the fauces and of the Eusta- 
 chian tubes. On examination, the surface of the membrana tympani 
 is sometimes observed to be very shining, and in other cases opaque. 
 
254 THE DISEASES OF THE EAR. 
 
 The hearing power is but slightly Jiminished. The treatment con- 
 sists in applying leeches below the ears, and using gentle counter- 
 irritation over the mastoid processes. The symptoms commonly 
 yield in a few days. 
 
 Case I. — Mrs. B., ?et. 40, was sent to me by a medical man in 
 1853. She enjoyed good health. 
 
 History. — Has not suffered from any affection of the ears imtil a 
 fortnight since, when,, subsequently to an attack of cold, a feeling 
 of numbness, and a sound as of the ringing of bells, supervened in 
 both ears. There was also, at times, a shooting pain in the right 
 ear. On examination^ the mucous membrane of the fauces was ob- 
 served to be red. 
 
 Riglit ear. — The membrana tympani was rather more opaque than 
 natural ; the hearing power natural ; the Eustachian tube pervious. 
 
 Left ear. — Membrana tymjjani opaque ; hearing distance three 
 inches ; Eustachian tube pervious. 
 
 Treatment. — Slight counter-irritation, by means of a stimulating 
 liniment, was kept up over and around each ear, and in the course 
 of ten days the symptoms were wholly removed. 
 
 Case II. — Mrs. P., iet. 73, consulted me in July, 1853. 
 
 History. — Six weeks previously had an attack of influenza, which 
 was succeeded by considerable pain in the right ear, followed by a 
 sensation of "pumping" in the ear, which has continued to the pre- 
 sent time : recently deafness of that ear has been complained of, 
 and the voice appears to come out of the ear. 
 
 On examination, the membrana tympani and Eustachian tube 
 appeared to be normal ; but the hearing power was so diminished 
 that the watch was heard only when pressed upon the car. 
 
 Treatment. — A leech was applied below the ear, and the symp- 
 toms abated; counter-irritation was then resorted to, and by degrees 
 all unpleasant sensations vanished. 
 
 {b.) ACUTE INFLAMMATION OF THE MUCOUS MEMBRANE OF THE 
 
 TYMPANUM. 
 
 I have not hitherto been enabled to distinguish between acute in- 
 flammation of the mucous membrane of the tympanum and that of 
 its fibrous membrane, the periosteum, which is subjacent to it. 
 Wlien the delicacy of these membranes is taken into consideration, 
 
THE CAVITY OF THE TYMPANUM. 255 
 
 and tlieir intimate union so as to form one membrane of sucli ex- 
 treme tenuity that its presence in the healthy ear can only be de- 
 tected by the closest examination, it ■would be a source of surprise 
 if acute inflammation were to attack either of these structures Avith- 
 out involving the otlicr ; although in many cases doubtless one of 
 them is more specially implicated. In the description of acute in- 
 flammation of the mucous membrane of the tympanum, the perios- 
 teum -will therefore be included by me, especially as the symptoms 
 to be detailed appear to indicate that the view just advanced is cor- 
 rect. If the mucous membrane of the tympanum be examine<l 
 during an attack of acute inflammation, an opportunity for •which is 
 sometimes afforded when a patient suffering from this affection dies 
 of some other disease, the bloodvessels are so large and so nume- 
 rous, that upon a cursory inspection the membrane seems as if it 
 were covered by a layer of dark-colored blood. On more accurate 
 inspection, however, it is observed that this blood is confined to the 
 cavity of the vessels, and that the latter are completely distended 
 in every part. 
 
 The exciting cause is usually exposure to a draught of cold air, 
 or sudden change of temperature. In its milder form this affection 
 is met with in children, and known as earache ; for although the 
 paroxysms of pain are often very severe, the symptoms are generally 
 confined to the ear, and do not produce much constitutional disturb- 
 ance. In children it is evident that the mucous membrane is more 
 affected than the periosteum ; and perhaps one cause of the compa- 
 rative mildness of the affection in the young, is, that the tympanic 
 fibro-mucous membrane is laxer and more extensible than in the 
 adult. 
 
 In children attacks of acute inflammation of the mucous mem- 
 brane of the tympanum are apt to be greatly neglected, and conse- 
 quently they frequently recur in the same child ; and even if they 
 do not at the time produce a serious lesion of the membrana tym- 
 pani or obstruction of the Eustachian tube, they prol)al)ly lay the 
 foundation of deafness in after life, by causing a permanent thicken- 
 ing and rigidity of the membrane : membranous anchylosis of the 
 stapes seems also to originate in this manner. When called to see 
 a child suffering from inflammation of this membrane, a medical 
 man will generally find that the membrana tympani is very smooth 
 and shining, and more or less red in color, according to the degree 
 of distension with blood of the vessels of the mucous membrane 
 
256 THE DISEASES OFTUE EAR. 
 
 forming its inner layer. Sometimes this latter membrane lias be- 
 come thickened, giving a sodden appearance to the membrana tym- 
 pani ; a condition liable to occur also when the tympanic cavity 
 contains an accumulation of mucus. It commonly happens that in 
 children the chief pain is felt at night, when the recumbent position 
 and the heat of the pillow favor the congestion of the membrane. 
 Although the child may not complain of pain in the daytime, and 
 when seen by the surgeon may even be cheerful, still, should any 
 appearance of congestion remain, or, tested by the watch, any dul- 
 ness of hearing, it is important to apply one or two leeches below 
 the ear, and to keep up a slight discharge behind it. 
 
 Ill the adult, this affection is usually of a much more formidable 
 nature, and it sometimes has a rheumatic or gouty character. The 
 first symptom is a sense of uneasiness in the ear, Avhich becomes pain 
 during motion, pressure on the organ, the act of deglutition, or the 
 use of the pocket-handkerchief. This uneasiness soon amounts to 
 continuous pain, which, in severe cases, rapidly increases until it be- 
 comes so intense as to be scarcely endurable ; and extends over the 
 mastoid process, the whole of the affected side of the head, down the 
 neck, and into the fauces. The power of hearing rapidly diminishes, 
 and a variety of the most horrible sounds are experienced ; some- 
 times described as like the hissing and puffing of a steam-engine, 
 varied by others like a series of explosions in the ear, or the ringing 
 of bells. A symptom of this affection Avhich adds greatly to the suf- 
 fering of the patient, is the impairment of the functions of the brain ; 
 sometimes amounting only to a confusion of ideas, frequently accom- 
 panied by extreme fear and depression of the nervous system, caus- 
 ing the worst forebodings as to the result of the attack ; in other 
 cases delirium supervenes, and in the most formidable cases death 
 takes place, from the inflammation extending to the membranes of 
 the brain. Where only some of these symptoms, and those of a less 
 violent character are present, the surgeon may doubt whether the 
 affection is in the tympanic cavity or in the meatus. An examina- 
 tion of the ear with the speculum and lamp will decide the ques- 
 tion ; for in the affection under consideration, there is no appear- 
 ance of inflammation in the dermoid meatus or in the membrana 
 t3'mpani. The modes in which this affection terminates are the for- 
 mation of lymph ; the effusion of serum into the tympanic cavity, 
 which escapes through the Eustachian tube into the fauces ; or a 
 copious secretion of pus or mucus, which distends the tympanum. 
 
THE CAVITY OF THE TYMPANUM. 257 
 
 causes ulceration and perforation of all the lamina; of the membrana 
 tympani, and ends in abundant discharge. In some cases there is 
 no indication of any secretion occurring in the tympanum, and the 
 affection seems to terminate by resolution ; in others, the dermoid 
 meatus pours out a sympathetic discharge without the presence of 
 any orifice in the membrana tympani. The prognosis in cases of 
 this disease is favorable, and it is a great consolation to the patient 
 to be assured, amidst the very distressing symptoms from which he 
 suffers, that no permanent injury need be apprehended. It would 
 appear that a single attack of inflammation of the fibro-mucous mem- 
 brane of the tympanum, however violent it may be, does not leave 
 behind it that rigidity and duhiess of hearing Avhich is a sequence of 
 the attacks of a milder cliaracter occurring in children. When an 
 orifice forms in the membrana tympani, it usually closes without 
 difiiculty ; and the power of hearing is in two or three weeks com- 
 pletely restored. In some, but fortunately rare cases, the inflam- 
 mation extends to the petrous bone, and thence to the membrane of 
 the brain, causing death. It not unfrequently happens, however, 
 that the inflammation extends to the portio dura nerve in the aque- 
 duct of Fallopius, and partial or complete paralysis of that nerve is 
 the result ; which is removed as soon as the inflammation has wholly 
 subsided. 
 
 The treatment of this affection consists, in the first place, of the 
 local abstraction of blood by leeches or cupping ; the leeches being 
 applied at the orifice or behind the ear, and the cupping practised 
 directly below it. Leeches may also be applied to the nostrils. 
 Vapor baths should frequently be applied to the ear, so as to allow 
 the steam to penetrate as far as the membrana tympani. The throat 
 should be repeatedly gargled with hot water. The patient is to be 
 kept perfectly quiet, as the least excitement or exercise is apt to 
 aggravate the symptoms materially ; the room should also be dark- 
 ened, and every sound excluded as much as possible. The use of 
 mercury will be found very efficacious, especially when combined 
 with full doses of opium or morphia. When the pain is very in- 
 tense, it is desirable to keep tlic patient for several hours under the 
 influence of opium. In the early stages of the affection tartar emetic 
 proves advantageous. As soon as the discharge appears, the meatus 
 should be gently syringed with a copious supply of warm Avater 
 thrice daily. 
 
 In children the treatment may usually be less active ; but it is 
 
 17 
 
258 THE DISEASES OF THE EAR. 
 
 important to try the application of leeches and counter-irritants, 
 thoroughly to subdue the inflammation as rapidly as possible. 
 
 Case I. Acute inflammation of the mucous membrane of the tym- 
 panum ; perforation of the memhrana tympani. — C. C, aged 40, 
 sent for me in Kovember, 1852, on account of a severe attack of 
 pain in the right ear. 
 
 History. — Two days previously he had been exposed to a cold 
 wind, which was followed towards night by pain in the ear. During 
 the night the pain became much aggravated, and seemed not only to 
 be in the ear, but to extend over the whole of the side of the head, 
 and especially over the region of the mastoid process. There was 
 also great constitutional disturbance, confusion in the head, and the 
 most extraordinary noises. " At the same moment," said the pa- 
 tient, "I seemed to be standing at the side of a steam-engine, snort- 
 ing, puffing, and hissing, and yet hearing the sound of a church-bell 
 tolling at a distance." 
 
 On examining the ear, the membranous meatus was observed to 
 be red, the membrana tympani dull and opaque. The patient was 
 very excitable ; pulse quick ; skin hot. Leeches were ordered to 
 be applied immediately below and at the back of the ear, to be fol- 
 lowed by hot fomentations and poultices. Calomel and opium were 
 administered. Under this treatment, Avith the addition of a blister 
 to the nape of the neck, in three days the symptoms gradually sub- 
 sided. At the end of the third day, while, the head was on the 
 pillow, a feeling as of something bursting in the ear was expe- 
 rienced. This was followed by a discharge from the ear, and a con- 
 siderable additional relief to the pain. On further examination, a 
 small orifice was detected in the lower part of the membrana tym- 
 pani, through which viscid mucus escaped from the tympanum. 
 There was also great dulness of hearing, Avhich was the more dis- 
 tressing to the patient from his having lost the use of the other ear 
 during childhood. The perforation was regarded by me as a favor- 
 able symptom, being likely to prevent the formation of membranous 
 bands in the tympanic cavity. The inflammation slowly subsided ; 
 the aperture in the membrana tympani closed ; and, in the course of 
 ten days, the patient heard as well as before the attack. His hear- 
 ing has since continued good. 
 
 In some cases of acute inflammation of the mucous membrane of 
 the tympanum, the pain in the ear is not so violent as in the case 
 just detailed ; but the symptoms of cerebral disturbance are more 
 
THE CAVITY OF THE TYMPANUM. 259 
 
 distressing and continuous. One reason for the cases of less active 
 inflammation assuming the chronic form, seems to me to be, that a 
 much smaller quantity of mucus being secreted, the membrana tym- 
 pani does not give way. The consequence is, the mucus collects by 
 degrees in the tympanic cavity, and thus keeps up a constant, though 
 slight, irritation. In these chronic cases the symptoms often dis- 
 appear after a discharge from the ear ; and careful inspection shows 
 that there is no perforation of the membrana tympani, and that the 
 discharge does not originate from the tympanic cavity, but has its 
 source in the dermoid meatus ; being the result simply of the irrita- 
 tion of the tympanic mucous membrane. 
 
 The following case will illustrate the preceding remarks. 
 
 Case II. Acute inflammation of the mucous membrane of the tym- 
 panum ; prolonged pain in the head ; discharge from the meatus ; 
 relief. — M. A. K., aged 26, was admitted under my care in St. 
 Mary's Hospital on October 6th, 1854. 
 
 History. — About a month ago she complained of pain in the face 
 and soreness of the throat, together with pain in the right side of 
 the head. These symptoms were followed by deafness in the right 
 ear. At the time of admission she complained of pain and throb- 
 bing in the right ear, extending inwards down the throat. On exa- 
 mination, the tongue was found slightly furred, the pulse 84 and 
 small. The surface of the meatus was red, and the vessels of the 
 dermoid layer of the membrana tympani were distended. The crack 
 of the nail was heard when made close to the ear. Air passed into 
 the tympanic cavity. 
 
 Treatment. — Leeches were applied below the ear ; and an evapo- 
 rating lotion around it. 
 
 October 12th. — Pain much the same. To repeat the leeches and 
 take half a grain of the chloride of mercury, and a quarter of a 
 grain of opium every night. 
 
 October 16th. — Pain somewhat less, but still severely felt deep in 
 the ear. 
 
 October 20th. — To repeat the leeches. 
 
 October 24th. — Much better ; has had an abundant discharge 
 from the ear, followed by immediate cessation of the pain. On in- 
 spection, it was seen that the discharge had issued from the surface 
 of the meatus ; and there was no perforation of the membrana 
 tympani. 
 
 October 28th. — The pain has totally disappeared. 
 
260 THE DISEASES OF THE EAR. 
 
 1. Acute injlammation affecting the portio dura nerve. — It is well 
 known that the portio dura nerve passes through the aqueduct of 
 Fallopius along the upper and posterior wall of the tympanum ; but 
 
 Fig. 84. 
 
 The Canal for the Portio Dura Nerve at tlic upper part of the tympanic cavity incomplete. 
 A dark bristle is passed through the canal. 
 
 it not unfrequently happens that the inner osseous wall of this canal 
 is incomplete, and thus the mucous membrane of the tympanum is 
 in contact with the outer surface of the nerve. In cases of acute 
 inflammation of the tympanic mucous membrane, therefore, the 
 nerve often becomes aflfected, either by the prolongation of the in- 
 flammation from the mucous membrane directly to the nerve, or 
 through the wall of the canal. In some of these cases the mem- 
 brana tympani ulcerates, and there is a copious- discharge from the 
 tympanic cavity ; in others it remains intact. 
 
 Case III. Acute injiammation of the mucous memhrane of the 
 tympanum ; ulceration of the memhrana tympani; iJaraJysis of the 
 portio dura nerve ; cure. — E. I., aged 23, was admitted under my 
 care at the St. George's and St. James's Dispensary, on February 
 28th, 1843. 
 
 History. — He stated that three months previously he was suddenly 
 seized with a violent attack of pain in the right ear, which extended 
 over the side of the head. After the pain had lasted for about 
 twenty-four hours, he experienced a sensation of something burst- 
 ing in the ear, followed by an abundant thick and offensive-smelling 
 discharge. During the attack of pain he had much giddiness, lost 
 the use of the right side of the face, and could not shut his right 
 eye, while the mouth was drawn to tlic loft side. On examination, 
 an orifice was observed in the right mcml)rana tympani; the mucous 
 membrane of the tympanum was red and thick, and poured out a 
 mucous discharge. He was ordered to apply a blister behind the 
 car, and became better, having no return of the pain till March 
 
THE CAVITY OF THE TY.MPANUM. 261 
 
 lltli, when it suddenly reappeared in great violence, accompanied 
 bj a singing and bj sensations of pumping and throbbing in the 
 ear. These symptoms were much aggravated by coughing. The 
 discharge was abundant, and the mucous membrane of the tym- 
 panum very red. Leeches -were applied below the ear, which was 
 often syringed with warm water ; and after the pain was somewhat 
 subdued, a blister was applied behind the ear. Calomel and opium 
 were administered until the gums were rendered tender. The symp- 
 toms gradually subsided. 
 
 April 11th. — Improved, and complains of but little pain. 
 
 April 16th. — The discharge is much diminished ; the orifice in the 
 membrana tympani is smaller ; and the singing noise not so loud. He 
 cannot yet close the right eye or use the mouth freely, but the power 
 over the muscles of the f^ice is certainly greater. Ordered to rub the 
 ointment of tartarized antimony behind the car. From this time the 
 patient gradually improved, and on the 3d of July the portio dura 
 nerre had regained its power, and the quantity of discharge had 
 much diminished. 
 
 The following case of the same kind occurred in a younger per- 
 son : — 
 
 Case IV. Acute inflammation of the mucous membrane of the right 
 tympanum ; great pain in the head ; temporary paralysis of the right 
 portio dura nerve. — Master S., aged 5, pale and weakly, was brought 
 to me on the 10th of February, 1850. 
 
 History. — Three months previously, the right ear had been pulled 
 rather violently. Fourteen days ago, he complained of pain deep 
 in the right ear, which in two days Avas followed by discharge and 
 relief. Lately he has so suffered from pain on the riglit side of the 
 head, that he constantly presses it with his hand ; and for a week 
 he had paralysis of the right side of the face : but perfectly re- 
 covered. To-day he again complains of pain in the ear. On exa- 
 mination of the right ear, the surface of the meatus was observed to 
 be red and swollen, denuded of epidermis, and covered by a thick 
 white discharge ; the membrana tympani, which was in the same 
 state, bulged outwards. Leeches below the ear, the use, of warm 
 fomentations, and the administration of tonic medicines, speedily 
 reduced the pain in the car and head, and he was sent to the sea- 
 side. On March 7th, about a month after I had first seen him, I 
 found that the matter had made its way through a small orifice in 
 the lower part of the membrana tympani. 
 
262 THE DISEASES OF THE EAR. 
 
 In some cases, the portio dura nerve becomes aifected -wliile the 
 patient is under treatment for secondary syphilis. Two instances 
 of this kind have occurred to me. In one, the patient was a man of 
 twenty-three, who stated, that six months previous to his consulting 
 me, he had complained of pain in his left ear for two or three days, 
 when he suddenly lost the use of the left side of the face, and found 
 that he could not close the left eye. On examination., the left mem- 
 brana tympani was rather opaque, although its surface was smooth. 
 On swallowing with closed nostrils, and in forcing the air, it passed 
 freely into the right tympanic cavity, but not so freely into the left. 
 The patient was treated with small doses of iodide of potassium, and 
 by the application of ointment of tartarized antimony behind the 
 ear. After six weeks of this treatment, there was scarcely any trace 
 of the paralysis of the muscles of the face, and the hissing sound had 
 greatly diminished ; but the deafness remained as before. 
 
 2. Acute injlammation extending to the brain. — In some cases, 
 the inflamniiation advances from the tympanic cavity to the brain, 
 and death is the consequence. The following illustrative case is 
 taken, in an abridged form, from Itard.' 
 
 Case V. Acute inflammation of the mucous membrane of the tympa- 
 num; inflammation of dura mater ; death. — J. B., aged 26, of a san- 
 guine temperament and robust constitution, was received into the 
 military hospital of Val de Grace, on account of an inflammation of 
 the pleura. On the fifth day of the attack, he was seized with vio- 
 lent pain in both ears, but especially in the left, and the pain was 
 accompanied by a rushing noise like that of a torrent. On the sixth 
 day the pain increased so as to become intolerable, with throbbing 
 in the ears ; pain in the head violent, pulse hard and full. These 
 symptoms increased, with great excitement, delirium, and stupor, 
 and the patient died on the seventh day. 
 
 On dissection of the right oar, the mucous membrane of the tym- 
 panum was red, swollen, velvety, and covered by puriform mucus, of 
 "which the cavity was full. The membrana tympani was entire, but 
 its inner layer very thick and red. The mastoid cells were full of 
 mucus. In the left ear, where the pain had been the most acute, the 
 mucous membrane of the tympanum and mastoid cells was of a deep 
 red color, but there was no secretion of mucus. The dura mater 
 covering the anterior and posterior surfaces of the petrous bone was 
 
 ' Traite des Maladies de rOreille. Vol. i, p. 193, et seq. 
 
THE CAVITY OF THE TYMPANUM. 263 
 
 adherent to the adjacent cerebral substance ; it was red and thick, 
 and separated from the bone. Between the bone and the dura 
 mater, there was nearly half an ounce of a transparent gelatinous 
 fluid. 
 
 A case somewhat similar to the foregoing, I liad an opportunity 
 of inspecting, after death, with Dr. Blakely Brown. 
 
 Case VI. Acute injlammation of the tympanic mucous membrane 
 after whooping-cough; dura mater inflamed: effusion of serum he- 
 ttveen it and the jJetrous bone, and in the lateral ventricles. — The 
 child was three years old, and shortly before the fatal seizure had 
 gone through an attack of whooping-cough. A year and a half pre- 
 vious to her death, she had a discharge from the left ear, at first un- 
 accompanied with pain, but subsequently, at times, she suiFered from 
 acute attacks of pain in the ear and side of the head, previous to, and 
 during which, the discharge subsided. A few days before her death, 
 one of these attacks of intense pain in the ear and head came on, and 
 resisted every remedial measure prescribed, until the child died in 
 the greatest sufferino;. 
 
 On inspection, it was found that the whole of the membrana tym- 
 pani had been destroyed, with the exception of a small semilunar 
 margin at the upper and posterior part. The mucous membrane 
 lining the tympanic cavity was of a deep red color, from its blood- 
 vessels beincr enlarged and distended with blood. The dura mater 
 was much congested ; serum was effused between it and the petrous 
 bone, and its inner surface was adherent to the arachnoid. Serum 
 was also effused beneath the arachnoid, and in the lateral ventricles. 
 
 In cases of typhus fever, I have found the dura mater partaking 
 of the inflammation of the tympanic mucous membrane. One case 
 of this kind was that of a girl, aged IG, who died of typhus fever, 
 after seven weeks' illness. She was, to a certain degree, dull of 
 hearing from the commencement of the attack, but not previously. 
 
 Dissection. Right ear. — The meatus externus contained a large 
 quantity of thick matter, and the dermis and periosteum were so 
 soft as to be easily detached from the bone. The membrana tym- 
 pani had been removed by ulceration. The tympanic mucous mem- 
 brane was thick and soft, and, although the ossicles were in their 
 natural position, the long process of the malleus had been absorbed. 
 The cavity contained thick mucus ; and the dura mater was detached 
 from the upper part of the tympanum. 
 
 Left ear. — The meatus was full of pus ; its lining membrane was 
 
264 THE DISEASES OF THE EAR. 
 
 soft, and a small strip only of the membrana tympani remained. 
 The tympanum and mastoid cells were full of thick muco-purulent 
 matter ; the lining membrane being thick, soft, and disconnected 
 from the bone. The dura mater adhered so slightly to the upper 
 ■wall of the tympanum, that it was disengaged by the gentlest trac- 
 tion. 
 
 In other cases of death from typlius fever, I found the dura mater 
 inflamed, and separated from the upper surface of the petrous bone 
 by serum. In one case, that of a patient aged 17, during the attack 
 of fever, but not previous to it, there was great dulness of hearing 
 for nine days, and discharge from the left ear four or five days prior 
 to death. On dissection, the dura mater was found to partake of 
 the inflammation of the mucous membrane ; the bone was also very 
 vascular, and it was separated from the dura mater by a small quan- 
 tity of serum. 
 
 The presence of scrofulous matter in the tympanic cavity some- 
 times gives origin to the most formidable cerebral symptoms, and, 
 in some cases, without leaving any traces of inflammation of the 
 brain after death. In the following case, which occurred under the 
 care of Dr. Chambers, in St. Mary's Hospital, and Mliich I had the 
 opportunity of seeing during life, I think there is no doubt but that 
 the cerebral symptoms arose from the afiection of the ear. 
 
 Case VII. Accumulation of scrofulous matter in the tympanum; 
 acute inflammation of the mucous membrane ; severe cerebral symp- 
 toms; death. — S. B., aged 10, was admitted into St. Mary's Hos- 
 pital on the 21st April, 1854, with the following history : — A'^omit- 
 ing, heat of skin, headache ; occasional shrill screaming had com- 
 menced on the 18th, and continued to the time of admission. The 
 bowels had not acted since the 19th. She had formerly a discharge 
 from the right ear ; but that had latterly ceased, though deafness 
 remained. 
 
 On examination, the pulse was rapid and regular ; the skin hot 
 and dry ; the face flushed ; the eyes heavy but shiny ; the pupils 
 naturally afi'ected by light. There was a tendency to a sort of coma- 
 tose sleep, but she was easily roused by speaking to her. 
 
 April 21st. — Ten leeches to be applied to the head ; also ice ; 
 one and a half grain of calomel every hour, and a purgative in the 
 morning. 
 
 22d. — Urine albuminous, probably from the calomel. No more 
 vomiting. Bowels opened several times. Complains of pain in the 
 
THE CAVITY OF THE TYMPANUM. 265 
 
 cardiac region. Keeps boring her head into the pillow, and occa- 
 sionally screaming. No pain in the head. Tongue white and furred ; 
 pulse 108, regular ; one of the evacuations was mucous and bloody, 
 the rest dark. Ordered the calomel every three hours, and a blister 
 to the nape of the neck. 
 
 23d. — The same symptoms exaggerated, with violent delirium 
 occasionally and screaming, alternating with a half-comatose state. 
 This continued till her death, at two in the morning of the 25th, 
 the face and lips remaining flushed till the time of decease. 
 
 Post-mortem Inspection. — The tympanic cavity contained scrofu- 
 lous matter. The mucous membrane lining the tympanic cavity 
 was very red, and its bloodvessels very distended. The Avhole of 
 the petrous bone and the dura mater covering it, was also of a deep 
 red color, from the distention of the vessels. 
 
 [c.) CHRONIC INFLAMMATION AND HYPERTROPHY OF THE TYMPANIC 
 MUCOUS MEMBRANE. 
 
 I am not sure that the above designation is perfectly correct, 
 because it appears probable that hypertrophy of the mucous mem- 
 brane sometimes takes place without the occurrence of any appre- 
 ciable inflammatory symptoms ; indeed, in children having a ten- 
 dency to glandular enlargements, the mucous membrane appears to 
 become thickened without the slightest sign of inflammation. In 
 some cases, however, chronic inflammation undoubtedly precedes 
 the hypertrophy. 
 
 Pathological Observations. — The mucous membrane lining the 
 tympanic cavity frequently undergoes the process of hypertrophy. 
 This delicately thin mucous membrane, so fine in its natural state 
 as often to require the aid of touch as well as sight to determine its 
 presence, may nevertheless become so thickened as to fill the whole, 
 or nearly the Avhole of the tympanic cavity. From being like a 
 piece of the finest silver paper, it becomes more like velvet. Instead 
 of throwing out just so much mucus as suitices to lubricate the sur- 
 face of the membrane, it pours forth a thick and viscid secretion 
 which often fills up the entire cavity unoccupied by the hypertro- 
 phied lining. In some cases where the Eustachian tube is partially 
 or wholly closed by the hypertrophied membrane, the mucus presses 
 upon the inner surface of the membrana tympani ; gradually by its 
 
266 THE DISEASES OF THE EAR. 
 
 pressure causing absorption, and ultimately produces an orifice 
 through which the mucus escapes into the meatus, giving rise to 
 what Avas formerly called a case of otorrhoea. This discharge 
 througli an orifice in the membrana tympani, in the "way just de- 
 scribed, is one of the common results of scarlet fever ; and though 
 it does not appear probable that the mucous membrane should 
 become hypertrophicd in so short a space of time as that in Avhich a 
 case of scarlet fever is developed, yet it is still possible that it may 
 be so. My belief, however, is, that in these cases of catarrh of the 
 mucous membrane, hypertrophy has usually preceded the attack of 
 fever ; and that this condition of the tympanum and other organs 
 are evidence of a -weakened state of the system. Sometimes this 
 condition of chronic inflammation of the mucous membrane extends 
 upwards through the osseous Avail, and affects the dura mater. The 
 constant attacks of earache in some children are due to this afi"ec- 
 tion. 
 
 The predispositu/ cause is the most essential point to ascertain in 
 respect to this affection, since it almost invariably occurs in those 
 whose vital power has been lowered by disease, or some other debili- 
 tating influence. Improper food or clothing, insufficient ventilation 
 or exercise, or some analogous cause, may almost ahvays be detected ; 
 and when detected, should be at once removed, if possible, or at least 
 diminished by the skill of the surgeon ; after which, the next step is 
 to assist in remedying the effects. It will usually be observed, on 
 general examination, that the child is pale, flabby, deficient in bodily 
 strength and spirit, Avith the submaxillary, or cervical glands, often 
 hypertrophicd, and tlie heart weak. On inspecting the ear, the 
 dermis of the meatus is commonly thicker than natural, so that the 
 calibre of the meatus is diminished, and there is some difficulty in 
 obtaining a distinct vicAv of the membrana tympani ; but when the 
 latter organ, or a portion of it, is seen, its surface is found to be 
 less shiny than natural, and not unfrequently of a AAhitish color, 
 resembling the appearance of parchment more or less sodden. 
 Sometimes, Avhile the long process of the malleus is unseen, the 
 processus brevis stands out prominently. When the Eustachian 
 tube is also obstructed, the membrana tympani is externally much 
 more concave than natural. On exploring tlie tympanic caA'ity by the 
 otoscope, air is not unfrequently heard most distinctly to enter the 
 cavity, although the sounds developed by its entrance are abnormal. 
 Instead of the normal crackling, a flap, as of air suddenly bloAA-n 
 
THE CAVITY OF THE TYMPANUM. 267 
 
 into a wet bladder, is heard. At times, during the act of swallow- 
 ing with closed nostrils, the air does not enter the tympanum, and 
 a forcible expiration with closed nostrils is requisite to insure its 
 admission ; but when the air is forced in, a sound similar to the last 
 described is produced, but of a louder and more defined character. 
 In certain cases there is an accumulation of mucus in the tympanic 
 cavity, so that when air is forcibly injected a gurgling or bubbling 
 sound is heard. 
 
 Treatment. — As before stated, the first step is to discover what has 
 been done or is doing in violation of nature's laws, and to insist, as far 
 as possible, on a proper mode of living. This having been attended 
 to, remedial medical measures may be hopefully applied. These are, 
 gentle counter-irritation over the mastoid processes by means of vesi- 
 cating plaster or solution ; and, where there is much congestion, with 
 frequent attacks of pain, a leech or two may be applied beneath each 
 ear ; a stimulating gargle may be prescribed, and cold Avater freely 
 used outside the throat. The tonsils, often much enlarged, may 
 be washed with a solution of nitrate of silver (twenty grains to an 
 ounce), and tonics administered. In very advanced cases, where 
 the health is much deranged, the child amcmic, and its physical 
 powers greatly depressed, it may be requisite at once to insist upon 
 sea air, or at least change of air. The prognosis in these cases is 
 usually favorable ; by careful management, the mucous membrane is 
 gradually restored to a more natural state ; the mucus disappears 
 from the tympanic cavity, and the patient regains his hearing in a 
 month or two. Cases of a less favorable character occasionally 
 occur, where the earache has been violent, the inflammation acute, 
 and rigid bands of adhesion have formed in the tympanic cavity, or 
 the membranes of the articulations of the ossicles have become rigid : 
 these, of course, demand longer perseverance and greater attention, 
 but are usually eventually cured. 
 
 [d.) CHRONIC CATARRHAL INFLAMMATION OF THE MUCOUS MEM- 
 BRANE LININCf THE TYMPANIC CAVITY. 
 
 This affection differs from the last in the circumstance that mucus 
 has collected in so large a quantity as to distend the tympanic 
 cavity, and press upon the inner surface of the membrana tympani, 
 so that this structure, becoming gradually atrophied and yielding to 
 
268 THE DISEASES OF THE EAR. 
 
 the pressure of the mucus "within, has given way, and the discharge 
 issues through the orifice thus made. 
 
 The treatment of this cLass of cases diflfers from that of the pre- 
 ceding in the use of the syringe and warm water twice, or oftener, 
 daily, to effect a complete removal of the secretion. The great 
 desire of the friends to stop the discharge must be earnestly con- 
 tended against, since that discharge is simply an effect and not a 
 cause ; and it is the latter which requires to be removed. Among 
 the causes to Avhich attention is frequently called, is the admission of 
 cold air to the delicate mucous membrane of the tympanum through 
 the external meatus. In these cases, the artificial membrana tym- 
 pani is to be used where the age of the child will permit it, and re- 
 ference must be made to the chapter where it is described, together 
 with its mode of application. 
 
 ie.) CHRONIC CATARRHAL INFLAMMATION OP THE TYMPANIC MUCOUS 
 MEMBRANE AFFECTING THE BONE, DURA MATER, OR BRAIN. 
 
 The first effect upon the tympanic mucous membrane produced by 
 scarlet fever and other predisposing diseases, is usually a simple ca- 
 tarrhal inflammation, i. e., the ciliated mucous membrane, which is 
 naturally extremely thin, and pours out a very small quantity of 
 thin mucus, becomes hypertrophied, and secretes copiously a viscid 
 matter, which, being too abundant and thick to escape through the 
 natural excretory passage, — the Eustachian tube, — gradually fills the 
 tympanic cavity, and presses against the inner surface of the mem- 
 brana tympani, causing the partial or entire destruction of that 
 organ ; the mucus then freely escapes into the meatus, and forms 
 one of the class of cases usually comprised under the term otorrlioea, 
 it being in reality a case of simple catarrh of the mucous membrane 
 of the t^niipanura. So long as there is a free exit for the discharge, 
 I believe that the disease rarely extends to the cerebrum ; and for- 
 tunately, in a large proportion of cases where the ear is injured by 
 scarlet fever or other diseases, so large a section of the membrana 
 tympani is removed, that the viscid mucus secreted has free egress 
 from the tympanum. But, as stated, the membrana tympani some- 
 times remains entire, or has only a small aperture, or a part falls in- 
 wards and becomes attached to the promontory, thus making a sep- 
 tum, shutting off the tympanic cavity from the meatus. Sometimes 
 
THE CAVITY OF THE TYMPANUM. 269 
 
 membranous bands stretch across the tympanum, or scrofulous de- 
 posits accumulate. Bj one or other of the above circumstances, the 
 secretion of the tympanic mucous membrane is prevented passing out- 
 wards ; and it gradually distends the tympanic cavity till it affects 
 the osseous ^valls ; and tlius disease of the membranes of the brain, 
 or of the brain itself, is originated. 
 
 Although, as just stated, simple chronic catarrh of the tympanic 
 mucous membrane, when there is free egress for the discharge, rarely 
 extends to the brain, the dura mater may, nevertheless, become 
 diseased. In chronic catarrhal inflammation the tympanic mucous 
 membrane becomes much hypertroj^hied and its vessels enlarged; 
 and as these vessels are, through the medium of the bone, directly 
 continuous Avith those of the dura mater, it is not surprising that the 
 latter membrane should be affected, and we find it accordingly un- 
 dergoing slight changes. One of these is hypertrophy; another is 
 detachment from the petrous bone; and the third is atrophy and 
 extremely firm adhesion to the bone. The bone is also liable to be 
 slightly affected. 
 
 The following case illustrates the effects of simple catarrh of the 
 tympanic mucous membrane, with free egress for the secretion. 
 
 Case I. Catarrh of the tympanic mucous membrane ; hone soft. — 
 A woman who had been deaf in both ears during many years, died 
 of apoplexy, at the age of 64. On dissection of the right ear, nearly 
 the whole of the membrana tympani was found to have been de- 
 stroyed ; the small portion which remains is thick and soft, and is 
 in contact with the promontory. The malleus has disappeared, but 
 the incus remains, and is attached to the stapes ; the latter bone 
 being Avholly concealed by the thick mucous membrane. The upper 
 osseous wall is soft. 
 
 Chronic catarrhal inflammation of the mucous membrane of the 
 tympanum, 2vhere the memhrana tympani is entire, and where there 
 has been but sliglit catarrh from the mucous membrane, may also 
 produce disease in the dura mater ; but so far as my experience 
 extends, no cases have occurred in which the disease has advanced 
 to the injury of the brain, so long as there is not more discharge 
 than can pass away through the Eustachian tube. Cases of this class 
 have come before me when making dissections of the ears of patients 
 who have died of other diseases ; and the following brief notices 
 indicate the state of incipient disease that may be present ; and 
 farther consideration will show that it is likely to assume a very 
 
270 THE DISEASES OF THE EAR. 
 
 serious character, when, under the influence of exciting causes, the 
 quantity of the secretion is much increased. 
 
 Dissection. Mucous memhrane of the tympanum thick ; memhrana 
 tympani entire ; hone carious ; dura mater ulcerated ; the arachnoid 
 in contact ivith the tympanic mucous memhrane. — A man Avho had 
 been many years deaf, died of consumption at the age of 50. 
 Right Uar. — The memhrana tympani is Avhite, concave, and very 
 thick, and the whole of its inner surface adheres to the inner "wall of 
 the tympanum, "while the ossicula are firmly hound together by hands. 
 The membrane lining the mastoid cells is thick, and the cells contain 
 a viscid fluid. I/cft ear. — In much the same state as the right, but 
 there was a carious orifice in the upper wall of the tympanum. The 
 dura mater was thin in some parts, and ulcerated in others, so that 
 the outer surface of the visceral arachnoid was in contact with the 
 mucous membrane of the tymjianum. 
 
 Dissection. 3Iucou8 memhrane of the tympanum thick ; memhrana 
 tympani entire; hone carious; dura mater atrophied, uJeerated. — 
 A woman, aged Qb, died of paralysis. Many years previous to her 
 death, deafness slowly came on in the right ear, after repeated at- 
 tacks of earache. Dissection of right ear. — Memhrana tympani 
 white and thick, and a large membranous band connects the incus 
 with the inner wall of the tympanum, so as nearly to conceal the 
 stapes. The tympanic mucous membrane is four or five times its 
 natural thickness, and adheres firmly to the bone. The upper os- 
 seous wall of the tympanum is cribriform, so that at various points 
 the thickened mucous membrane is in contact with the outer surface 
 of the dura mater. The dura mater is very thin, and presents two 
 or three small orifices. 
 
 In another woman, aged 70, who died of apoplexy, and who had 
 been many years deaf, the following was the condition of the left 
 ear. The memhrana tympani was thick and opaque, more especially 
 at its posterior part ; and its inner surface firmly adhered to the 
 inner wall of the tympanum and to the stapes, Avhich bone is con- 
 cealed by bands of adhesion. The upper osseous wall of the tympa- 
 num is carious, and presents several large orifices, which allow the 
 dura mater to be in contact with the thickened mucous membrane. 
 
 Treatment. — Chronic catarrhal inflammation of the mucous mem- 
 brane lining the tympanum is usually attended by so extensive a 
 destruction of the memhrana tympani, that fortunately the discharge 
 finds a free outlet, however viscid it may be. The cfi"ects, therefore, 
 
THE CAVITY OF THE TYMPANUM. 271 
 
 are confined to a certain amount of congestion of the dura mater 
 covering the petrous bone. In cases of this simple kind, it is there- 
 fore not uncommon to meet Avith symptoms of slight cerebral irrita- 
 tion, -which gradually yield to treatment by local depletion and 
 gentle counter-irritation. The majority of these cases result from 
 an attack of scarlet fever. The following is an instance : — 
 
 Case II. Catarrh from the tympanic mucous membrane after 
 scarlet fever; destruction of eacli memhrana tymiKini ; attacks of 
 giddiness. — Miss A. H., aged 15, consulted me in November, 1845, 
 on account of a discharge from each ear, accompanied by dulness of 
 hearing and frec^uent giddiness. She stated that seven years pre- 
 viously she had an attack of scarlet fever, for -which she -was con- 
 fined to her bed. During the fever a copious discharge issued from 
 each ear, and the hearing Avas greatly diminished. For the last 
 three years there has been so much less discharge, that it has not 
 reached the orifice of the car for two or three weeks at a time ; but 
 with this diminution of the discharge the deafness has been aggra- 
 vated. She now complains of frequent attacks of giddiness. 
 
 Upon examination, each membrana tympani was discovered to be 
 entirely absent, and the mucous membrane, which was thick and 
 red, was the source of the secretion. Watch heard at one inch from 
 the right ear, and at two inches from the left. The treatment con- 
 sisted in the application of leeches below the ears ; the use of a 
 very weak solution of the diacetate of lead as an injection after 
 tepid water ; and the administration of the twentieth of a grain of 
 the bichloride of mercury twice daily. Under this treatment the 
 congestion of the mucous membrane of the tympanum greatly 
 diminished, the discharge gradually decreased in quantity, and the 
 giddiness disappeared. 
 
 Other cases might be cited in which catarrhal inflammation of 
 the tympanic mucous membrane had been accompanied by symptoms 
 of giddiness ; some resulted, as in the last case, from scarlet fever ; 
 others from measles. The treatment in each case was very similar; 
 and although in some instances the pain extended over a great part 
 of the head, and "was even accompanied at times by vomiting, all 
 ultimately recovered. 
 
 In the case above cited the entire membrana tympani was absent, 
 so that the whole of the discharge could be removed by syringing. 
 In those which follow, part only of the membrana tympani was 
 destroyed, and the remainder prevented the egress of the matter ; 
 
272 THE DISEASES OF THE EAR. 
 
 additional care had therefore to be exercised to insure the complete 
 removal of the dischai'ge. 
 
 Case III. Catarrh from the mucous membrane of the left tym- 
 panum ; perforation of the memhrana tympani ; pain in the left side 
 of the head. — F. 11., an architect, aged 44, consulted me in 1852, 
 respecting a discharge from the left ear, accompanied by pain and 
 tenderness over the left side of the head. He stated that since 
 childhood he had been subject to a discharge from the left ear, 
 which had never ceased for more than a few days. During the last 
 five or six years he has also complained of pain in the loft side of 
 the head, extending in front as far as the temple, and behind over 
 the region of the mastoid process. Slight excitement or fatigue 
 produces considerable aggravation of the symptoms. At times, 
 the pain in the ear comes on suddenly, and is followed by very 
 abundant secretion. About a month ago, during a cold, he had an 
 attack of pain in the ear, attended by a loud whizzing sound and 
 great additional tenderness over the left side of the head. On 
 exa77iinatio7i, an ulcerated orifice, about two lines in diameter, was 
 observed in the posterior part of the left membrana tympani, 
 through which oozed a large quantity of thick tenacious discharge, 
 havino; an offensive odor. On removing; this, the mucous membrane 
 of the tympanmn was seen to be red and much thicker than natural, 
 so as to project towards the orifice in tlie membrana tympani, and 
 in some degree prevent the free passage of the secretion through 
 the orifice. The treatment in this case consisted in keeping up a 
 discharge from the mastoid process, and in administering small 
 doses of the bichloride of mercury in conjunction with sarsaparilla. 
 The ear was also syringed twice daily with warm Avater, care being 
 taken that the stream was directed to the orifice in the membrana 
 tympani, so that the water might be made to enter the tympanic 
 cavity, and, by mixing with the mucous secretion, so soften it as to 
 facilitate its discharge through the orifice of the membrane. This 
 treatment was very successful, for the pain around the car dimin- 
 ished greatly by degrees, and the attacks of pain within the ear 
 became less frequent. The quantity of the discharge, however, 
 remained much the same until a weak solution of the diacetate of 
 lead was injected. This treatment was pursued for four months, 
 at the end of which time the patient no longer complained of any 
 pain in the ear or head, and the quantity of discharge had greatly 
 decreased. 
 
I 
 
 THE CAVITY OF THE TYMPANUM. 273 
 
 Cases similar to the above being frequently met with in practice, 
 the following brief particulars of a very similar instance are sub- 
 joined. 
 
 Case IV. Catarrlial injiiwimation of the tympanic mucous mem- 
 hrane ; perforation of the memhrana tyrnpani; pain in the head, and 
 giddiness ; irritation of the portio dura nerve. — Miss M. S., aged 
 30, says, that since childhood, with exception of an interval of two 
 years' duration, she has had a discharge from the right ear, follow- 
 ing an eruption on the head. For eight or nine years has com- 
 plained of pain at the top of the head, with heat and a sense of 
 weight. This pain sometimes suddenly shoots across the head from 
 the right ear. She suffers at times from giddiness, and for the last 
 fcAV months has had a feeling of confusion in the head ; six months 
 ago had twitchings of the muscles on the right side of the face. On 
 examination, the memhrana tympani of the right ear was seen to be 
 perforated at its upper and anterior part, the aperture measuring 
 about a line and a half in diameter. Mucus oozed through the 
 aperture, and having been removed, the mucous membrane of the 
 tympanum was observed to be^ thick and red. The treatment was 
 the same as in the last case, except that leeches were applied below 
 the ears once a week. After three months all the symptoms were 
 much diminished, and the patient was ordered to continue the counter- 
 irritation and the injection with warm water. 
 
 From the situation of the orifice in the memhrana tympani in the 
 above case, it will be observed that in tlie usual position of the head 
 during the day, a portion of the mucus must have been confined to 
 that part of the tympanic cavity which Avas beneath the orifice ; 
 there was, however, a free escape of the mucus during the recum- 
 bent position, as there was then an opportunity for the complete 
 evacuation of the contents of the tympanic cavity ; and as the symp- 
 toms were not very urgent, it appeared advisable to try the effect of 
 counter-irritation, instead of enlarging the orifice in the memhrana 
 tympani. 
 
 In treating the class of cases now under consideration, it is of 
 great importance to be able to decide when the memhrana tympani 
 should be perforated by artificial means, or when an orifice in it 
 should he enlarged. To the perforation of the memhrana tympani, 
 much objection exists on account of the difficulty of keeping the 
 aperture open. It is seldom that a punctured aperture, even of 
 large size, docs not close in the course of two or three days. I have 
 
274 THE DISEASES OF THE EAR. 
 
 found, even after making a triangular flap and turning it down, that 
 the orifice thus produced sometimes closed in a few days by the 
 effusion of fibrine. It is, however, not always possible to make a 
 triangular aperture of this kind, either on account of the small 
 calibre of the meatus, or the extreme sensibility of the surface of 
 the membrana tympani. The only sure wa}^ of keeping open an 
 aperture in this membrana with which I am acquainted, consists in 
 applying to it the point of a fine stick of potassa cum calce. Such 
 a proceeding appears, at first sight, to be attended with danger to 
 the adjacent parts ; but, in reality, the action of this substance is 
 wholly under coiitrol ; for the injection of warm Avater at once 
 entirely stops its escharotic properties. During and after the appli- 
 cation of this remedy, to which I have resorted in the destruction 
 of polypoid groAvths, I have never known any inflammation to arise. 
 At the same time there is no doubt, that in cases such as Ave are 
 noAV considering, Avhen there are symptoms of cerebral irritation, 
 extreme caution should be used, and every other possible measure 
 adopted before having recourse to this, or indeed any other opera- 
 tive proceeding ; and as remedial measures of a different kind are 
 generally sufficient to alleviate or cure the disease, the operation of 
 perforating the membrane is rarely required. The potassa cum 
 calce has been used by me in only one case. 
 
 In those cases of catarrhal inflammation where the quantity of 
 discharge from the tympanic mucous membrane has not been suffi- 
 cient to cause ulceration of the membrana tympani, but Avhere the 
 superabundant quantity has passed away through the Eustachian 
 tube, it seems to me that, as a general rule, unless the disease has 
 made great progress and threatens the life of the patient, the ordi- 
 nary remedial measures already adverted to Avill be found sufficient 
 to arrest its progress and produce considerable iraproA'ement. The 
 folloAving cases will illustrate this branch of the subject, and it Avill 
 be seen that they differ from those last quoted in the circumstance 
 of the membrana tympani being still entire. 
 
 Case V. Chronic injlammation of the mucous membrane of the 
 tympanum, without j^eff oration of the membrana tympani; giddi- 
 ness, ^c. — M. C, aged 27, consulted me on the 15th of February, 
 1857. She said that for four months she has had at times a sensa- 
 tion of pricking in the right ear, accompanied by a humming noise, 
 deafness, giddiness, a sensation of swimming in the head, and pain 
 over the right side. During the last fcAV days has complained of a 
 
THE CAVITY OF THE TYMPANUM. 275 
 
 throbbing in the ear, attended with great pain, and followed by dis- 
 charge : has also been "light-headed" at night. Every time she 
 draws in breath through the nose, she states there is a rattling sound 
 in the ear, and for a minute or two she hears better. The hearing 
 is also better after a copious discharge. On inspection^ the surface 
 of the meatus was found to be red, denuded of epidermis, and secret- 
 ing a muco-purulent fluid. The membrana tympani was opaque, es- 
 pecially at its lower part ; the Eustachian tube pervious, and the 
 poAver of hearing much diminished. Considering tiie case to be one 
 of chronic inflammation of the mucous membrane of the tympanum, 
 Avith a collection of mucus in the lower part of the tympanic cavity, 
 and that the irritation of the meatus was only a symptom of this in- 
 flammation, the treatment adopted consisted in the application of 
 leeches below the ear, and of blisters behind it ; under this treat- 
 ment the head-symptoms greatly diminished, while the hearing was 
 much improved. On the 12th of May, the patient was again seized 
 with violent pain in the right ear, extending across the head and 
 towards the forehead. On the 17th she became much worse, and 
 was insensible for some hours. Blisters were applied to the nape of 
 the neck, and a constant discharge was kept up through them for 
 some weeks ; small doses of calomel were also administered until the 
 gums became tender. The acute symptoms were soon abated, but 
 counter-irritation was kept up for a long period, and iodide of potas- 
 sium and sarsaparilla were afterwards administered. Treated in 
 this way the symptoms of cerebral irritation wholly subsided, and 
 the power of hearing greatly improved. 
 
 Although it is difficult to determine positively whether there is a 
 collection of mucus in the tympanic cavity, the history and symp- 
 toms of the case, and the peculiar sodden condition of the mem- 
 brana tympani, such as was presented in this case, especially at the 
 lower part, left little doubt in my mind that mucus had collected ; 
 and the second attack was probably the result of a collection of this 
 fluid, causing irritation and pressure on the labyrinth. It is pos- 
 sible that more speedy relief might have been effected, by allowing 
 an escape of the mucus through an orifice in the membrana tym- 
 pani ; but I was quite aware, from previous operations, of the great 
 difficulty of keeping open the aperture, even if the means employed 
 did not cause a serious increase of the inflammation. The impor- 
 tant rule to bear in mind, is to keep up counter-irritation long 
 
276 THE DISEASES OF THE EAR. 
 
 enough to cause absorption of the fluid, and the arrest of the inflam- 
 mator}^ action Avhich produces the secretion. 
 
 As stated, there is some diflSculty in ascertaining positively whe- 
 ther there is a collection of mucus in the tympanic cavity. Some- 
 times the opacity and sodden appearance of the membrana tympani 
 is the chief indication ; but often the gurgling sound, produced by 
 the entrance of air into the tympanum, or the peculiar flap, result- 
 ing from the air striking against a soft flaccid membrane, shows, at 
 least, that there is a considerable quantity of mucus in the cavity. 
 The following case will further elucidate the subject : — 
 
 Case yi. Chronic catarrh of the mucous mcmhrane of the tym- 
 panum ; giddiness, and symptoms of cerebral invitation. — E. Mid- 
 dleton, aged 14, Avas admitted under my care, at the St. George's 
 and St. James's Dispensary, in December, 1849. She had an at- 
 tack of measles at four years of age ; since which she has com- 
 plained of much pain in both ears and in the front of the head, at- 
 tended by throbbing and frequent attacks of giddiness, especially 
 when walking quickly. At tjmes, also, she has been delirious and very 
 violent. The head-symptoms have much increased in severity since 
 the cessation of the discharge, which took place nine months pre- 
 vious to her consulting me. 
 
 On examination, the membrana tympani of the right ear was seen 
 to be very white, and parts of it had fallen in. Hearing distance, 
 with watch, half an inch. Left ear. — The membrana tympani is 
 milky white : hearing distance same as right ear. Air passes into 
 each tympanum during an expiration with closed nostrils, producing 
 a gurgling sound. The treatment consisted in the use of a blister- 
 ing ointment to the nape of the neck, by Avliich a constant discharge 
 Avas kept up for more than a month, and in giA'ing tonic medicines. 
 By sloAv degrees the head-symptoms abated ; she avus free from 
 giddiness for days, and the occasional attacks Avere in a mitigated 
 form, and for short intervals only. At the end of tAvo months, she 
 had so far improved, as to be able to enter service as a housemaid. 
 
 Althoujzh the n;ci^tiral cause of this kind of inflammation is most 
 usually an attack of scarlet fever, measles, or common cold, this 
 affection may folloAV a bloAv on the ear or head ; and it is probable 
 that in the folloAving case a bloAV was the })rimary cause of the 
 disease. 
 
 J. S., aged 35, Avas admitted under my care, in the Hospital, on 
 May 1st. 1853, complaining of pain in the riglit ear and doAvn the 
 
THE CAVITY OF THE TYMPANUM. 277 
 
 back, accompanied by faintncss when the nose Avas blown, or the ear 
 was pressed. She stated that when she was ten years old, she 
 received a blow on the right car, since which that car has been deaf. 
 Tavo years ago, discharge took place from the right ear, and has 
 continued. On examination, the menibrana tympani was observed 
 to have fiillen in, and there was a valvular opening at the lower part, 
 through which discharge was forced upon blowing the nose. Regard- 
 ing the case as one of long standing disease of the tympanic mucous 
 membrane, causing irritation of the brain, I at once ordered a seton 
 to be placed in the back of the neck, the effect of Avhich was slowly, 
 but entirely, to remove pain from the ears, the head, and the spine. 
 
 The general opinion respecting the mode in which disease pro- 
 gresses from the ear to the brain, appears to be that the bone 
 becomes carious, the dura mater ulcerates, the arachnoid and the 
 pia mater, and ultimately the substance of the brain, participate in 
 the disease, as the result of direct extension from the ear. A care- 
 ful examination of the post-mortem appearances found in some of 
 the fsital cases, shows that the disease does not always advance from 
 the ear to the brain as the result of continuity ; indeed, in some 
 instances, an abscess is developed in the brain without ulceration of 
 the mucous membrane of the tympanum, or caries of the bone. It 
 would appear that constant irritation in the tympanic cavity, pro- 
 duced by chronic inflammation of the mucous membrane, with the 
 absence of a free outlet for the matter, is sufficient to produce 
 an abscess in the substance of the cerebrum. Dr. Abercrombie 
 states : There is reason to believe that extensive suppuration within 
 the cavity of the tympanum is capable of producing symptoms of 
 great urgency, especially if there should be any difficulty of finding 
 "an outlet;" but the evidence derived from dissection shows that 
 these symptoms of great urgency are associated with disease of the 
 cerebral substance, without the existence of caries of the petrous 
 bone. Thus in a case published by Dr. Joseph Williams,* of which 
 the following is an abstract, there was no caries of the petrous bone. 
 
 Case VII. Ulceration of the tympanic mucous membrane ; abscess 
 in the substance of the brain ; petrous bone not carious. — E. B., 
 aged 23, not strong, but her health, till about a fortnight before her 
 death, had been uniformly good : she was then suddenly seized with 
 violent headache, and most severe pain in the right ear ; chilliness 
 
 * Treatise on the Ear. London, 1840. 
 
278 THE DISEASES OF THE EAR. 
 
 next came on, -svliicli in a short time amounted to actual rigors. The 
 pain in the ear now increased, and for several hours there was an 
 oozing of blood from the meatus. The next day the discharge be- 
 came thin and ichorous ; the febrile symptoms rapidly increased ; 
 she fell into a state of semi-stupor, and the discharge became thick, 
 fetid, and purulent. She died on the third day after the appearance 
 of the acute symptoms. 
 
 Autopsy. — The dura mater was softened, and easily broken down 
 over the petrous bone. In the substance of the middle cerebral 
 lobe was an abscess containing an ounce of pus, which had a fetid 
 odor, was of a dark yellow appearance, and was mixed with serum. 
 The abscess itself appeared to be about the size of a five-shilling 
 piece. It had penetrated deeply into the substance of the brain, 
 and its contents were mixed with blood. The portion of the brain 
 surrounding the abscess was soft and very vascular. The surface 
 of the petrous bone was of a somewhat dark color, and on sawing 
 into it, the inner portion of the petrous bone Avas found increased in 
 vascularity, and even in some parts ulcerated ; the secretion was 
 fetid and puriform, and the mucous membrane completely destroyed. 
 The niembrana tympani was ulcerated nearly through, and some of 
 the bones of the external ear were destroyed. Dr. Williams adds : 
 " Dr. Alison has communicated to me a case where abscess was 
 found in the brain, consequent upon disease attended with discharge. 
 The petrous bone was sound, consequently there was no communica- 
 tion between the matter of the ear and that of the brain." 
 
 In other cases, a considerable portion of healthy brain is found 
 to exist between the abscess and the petrous bone. For the particu- 
 lars of the following case, and for the opportunity of making the dis- 
 section, I am indebted to Dr. Merriman. 
 
 Case VIII. Catarrh of the mucous membrane of the tympanum, 
 since measles; attack of arachnitis; death; petrous hone not cai-ious ; 
 abscess in the substance of the brain; adjacent cerebral matter healthy. 
 — M. K., a widow, aged 26, of a scrofulous diathesis, and much con- 
 fined to the house as a maker of military caps, came under the care 
 of Dr. Merriman, at the Westminster General Dispensary, for a 
 cough, on the 7th January, 1846. On the 26th, she complained of 
 earache on the right side, and then said that she had been subject 
 to a discharge from the right ear since an attack of measles when a 
 child : the discharge was at times very offensive. Previous to the 
 present attack, no pain had ever been felt ; but she is said, for 
 
THE CAVITY OF THE TYMPANUM. 
 
 279 
 
 twelve or sixteen months to have suffered much from headaches, 
 being at times forgetful and very giddy. She has also fallen a.vay 
 very much. At first, only fomentations were ordered, which were 
 followed by leeches; but without any benefit. The pani greatly 
 increased, and was described as if, at times, a knife were being 
 thrust into the ear ; and then, as if there was a sawing outside the 
 ear at its ed<re. During paroxysms of pain the patient screamed 
 out suddenly" and then could not open her mouth. On two occa- 
 sions a small quantity of discharge was observed, but its appearance 
 afforded no relief. When the pain at all relaxed she lay m a partial 
 sleep On the 17th of February she became insensible, but put out 
 her tongue when loudly told to do so, and then relapsed into a 
 comatose state. She died on the evening of the 17th, twenty-three 
 days after the attack of pain had commenced. 
 
 Autops>/.—^Yhen the skull was sawn' through, pus flowed trom 
 within the dura mater; and upon examination it was found to come 
 from an abscess which occupied the whole of the upper part of the 
 riaht cerebral hemisphere. The substance of the surrounding brain 
 was healthy. The dura mater above the part cut off by the saw 
 presented a patch of coagulable lymph, about the size of a four- 
 penny piece; lymph was also effused on the surface of the dura 
 mater, covering the petrous bone, and a portion of it was detached 
 from the bone. Upon dissection of the ear, the membrana tympani 
 was absent; the tympanic mucous membrane, and that of the 
 mastoid cells, was thick and soft, and covered by a large quantity 
 of caseous, scrofulous matter. The upper tympanic wall was of a 
 dark color, extremely thin, and perforated by numerous blood- 
 ve^^sels. The dura mater covering the upper part of the petrous 
 bone an<l that lining the squamous bone, was very thick and 
 detached from the bone, and a large quantity of purulent matter 
 was deposited between the dura mater and the arachfioid. Ihe 
 arachnoid membrane was highly congested. In some parts the 
 purulent matter had passed through the dura mater, and was in 
 contact with the bone. The outer surface of the dura mater, 
 forming the lateral sinus, was rough where in contact with the in- 
 flamed bone; and the internal surface of the sinus had portions of 
 
 fibrin adhering to it. 
 
 The presence of a portion of healthy brain between the abscess 
 and the petrous bone, has induced some observers to conclude that 
 abscess in the cerebrum is the primary disease, and affection of the 
 
280 THE DISEASES OF THE EAR. 
 
 ear the result. The objections to this opinion are : Firstly, that 
 the cases of abscess- in the cerebrum are usually preceded by a long 
 standing affection of the ear. Secondly, that the portion of bone 
 which becomes carious is far from being the most dependent part 
 of the cerebral fossa. And, thirdly, that although the abscess may 
 be very large, the walls of the tympanum only are the real seat of 
 disease in the bone. 
 
 The very insidious progress of the disease in its course towards 
 the brain has been already adverted to. In some cases no symp- 
 tom indicates to the patient that the brain has become affected until 
 the sudden appearance of the acute stage ; the presence of a dis- 
 charge from the ear and a certain amount of deafness are, as they 
 assure the medical man, the only unpleasant symptoms. Never- 
 theless, it does seem to me that, by a careful professional exa- 
 mination of the patient, the early stages of the disease might be 
 detected ; for in cases where my suspicions have been aroused by 
 the condition of the ear and the inward progress of the disease, I 
 have not unfrequently found an unnatural sensibility of the brain 
 upon percussing the suspected side of the head. In some cases the 
 discharge may take place for a month or two, and then disappear 
 for a similar period ; Avliere this cessation occurs, however, there is 
 usually tenderness in or about the ear. The simple fact of discharge 
 occasionally issuing from the ear should induce the medical man to 
 make a careful investigation. 
 
 The exciting causes of the acute cerebral symptoms are various : 
 a blow upon the head, violent exercise, a cold, stimulating applica- 
 tions, or any dppressing influence, may bring them on. Sometimes 
 no exciting cause can be detected beyond the progress of the chronic 
 affection of the ear. 
 
 One of the first symptoms of the disease assuming an acute form 
 is the cessation of the discharge ; this is the result of inflammatory 
 action, and it is so commonly associated with the origin of acute 
 symptoms, that the stoppage of the discharge has been considered 
 as the cause instead of the effect of acute inflammation ; and medi- 
 cal men have been afraid to stop a discharge from the ear, lest in- 
 flammation of the brain should be induced. If this fear were confined 
 to the exclusion of all irritating astringents in these cases, it would 
 be salutary ; but when it gives rise to a belief that it is injudicious 
 to interfere in any way with a disease of the ear which is slowly 
 progressing, and which, if neglected, would probably terminate in 
 
THE CAVITY OF THE TYMPANUM. 281 
 
 the deatli of the patient, it may act very prejudicially. Mr. Wilde, 
 in his work on " Aural Surgery," before alluded to, has some inte- 
 resting observations on this subject. 
 
 Two cases of abscess in the substance of the cerebrum, arising 
 from catarrhal inflammation of the mucous membrane of the tym- 
 panum, have been already described. In that which follows, the 
 ^lost-mortcm examination was attended by me with the late Mr. 
 Farish. Death took place from arachnitis, and an abscess was found 
 in the middle cerebral lobe ; but the cause of the irritation appeared 
 to be the presence of scrofulous matter in the tympanum. 
 
 Case IX. Scrofulous matter in the tympanic cavity ; caries of the 
 upper ivall of the tympanum ; arachnitis; abscess in the middle 
 cerebral lobe. — Miss H. G., aged 9i, fair and delicate, but not un- 
 healthy, had measles when quite a child, though not severely ; since 
 the measles, has had an offensive discharge from the left ear, at- 
 tended by occasional attacks of pain. On tlic 5th May, 1845, she 
 was seized with symptoms of active fever. She did not complain of 
 headache, but Avhen questioned, said there Avas some uneasiness 
 about the vertex. The discharge had ceased. There was constant 
 vomiting. Calomel and opening medicines were administered, fol- 
 lowed by effervescent salines. On the 7th, she seemed well ; every 
 unpleasant symptom had vanished ; her pulse was natural, her 
 tongue clean, food was relished, and there was no pain. On the 8th, 
 the bad symptoms reappeared. On the 10th, she complained of pain 
 in the left ear, which, by degrees, became excruciating to the last 
 degree ; she, however, retained her faculties till from tAvelve to twenty 
 hours previous to her death. The only symptoms of derangement 
 of the nervous system were, some vomiting and a slight degree of 
 paralysis of the muscles on the left side of the face. The remedial 
 means em])loyed Avere leeches, calomel, James's powder, and a little 
 opium ; and these were employed freely from the 11th. In spite 
 of all efforts, she gradually became comatose ; but even then fre- 
 quently shrieked out from pain on the left side of the head. She 
 died at midnight, on the 15th, tAvelve days after the occurrence of 
 the first symptoms. 
 
 Autopsy. — Upon removing the calvaria, the dura mater was 
 observed to be red, and its bloodvessels distended. The cavity of 
 the arachnoid on the left side contained nearly half an ounce of 
 yellow purulent matter; lymph was deposited upon the inferior sur- 
 face of the posterior lobe of the left hemisphere. The arachnoid 
 
282 THE DISEASES OF THE EAR. 
 
 and pia mater covering the inferior surface of the middle lobe on 
 the left side, Avere thick and dark colored over a superficies about 
 the size of a sixpence. This thickened portion corresponded Avith 
 an orifice in the dura mater covering the upper surface of the 
 petrous bone. In the interior of the left middle cerebral lobe, 
 there "svas an abscess as large as a small hen's egg, in which a 
 quantity of dark-colored fetid matter, of a watery consistence, was 
 contained. There was no communication between the abscess and 
 the cavity of the arachnoid. The dura mater covering the upper 
 surface of the petrous bone Avas three or four times its usual thick- 
 ness, and its inner surfiice darker colored than natural and rough ; 
 being in some parts firmly adherent to the bone, and in others 
 detached from it. About the centre of the upper surface of the 
 petrous bone, the dura mater presented an orifice about a line in 
 diameter, directly beneath which was another and smaller one in 
 the petrous bone, measuring about a quarter of a line in diameter. 
 The latter orifice, and several smaller ones about the size of pin- 
 holes, were filled by concrete scrofulous matter, which projected 
 from the tympanic cavity. The superior Avail of the cerebellar 
 corner of the tympanum presented two carious orifices. The tym- 
 panic cavity and mastoid cells Avere completely full of scrofulous 
 matter, having the consistence of soft cheese, by which the mastoid 
 cells appeared to be much dilated ; the mucous membrane of the 
 tympanum Avas but slightly thicker than natural, and, where orifices 
 existed, they appeared to have been produced by atrophy, resulting 
 from the pressure of the scrofulous matter rather than from the pro- 
 cess of ulceration. The greater part of the substance of the mem- 
 brana tympani had been destroyed, and the remaining fibres Avere 
 adherent to the inner Avail of the tympanum. 
 
 (/.) ULCERATION OF THE MUCOUS MEMBRANE OF THE TYMPANUM. 
 
 This disease is rarely met Avith, and its treatment is the same as 
 that of chronic catarrhal inflammation. 
 
 The folloAving case, belonging to this class, AA^as supplied to me by 
 Mr. Obre, together Avith the preparation. 
 
 Case I. Scrofulous ulceration of the tympanic mucous membrane; 
 destruction of the upper wall of tympanum ; purulent degeneration 
 of the middle cerebral lobe. — A young lady, aged 18, of scrofulous 
 
THE CAVITY OF THE TYMPANUM. 
 
 283 
 
 diathesis, imd avIio was treated by a medical friend, was attacked, 
 on November 20th, 184G, witli fever and hysterical symptoms, un- 
 accompanied by any pain. The following day symptoms of pleuritis 
 appeared, accompanied by severe pain in the right side of the head. 
 It was noAv ascertained that she had been deaf in the right ear for 
 two years, and that tlie deafness was preceded by a fetid discharge. 
 Notwithstanding the most active treatment, the symptoms of cere- 
 bral irritation grew worse daily, and death occurred on the ninth 
 day of the attack. The patient's memory and intellect were perfect 
 up to the hour of her death, which was preceded by epileptic fits. 
 There was a very fetid odor about the ear, but no discharge. On 
 dissection, the periosteum was found detached from the exterior, 
 and the dura mater from the interior, of the squamous bone, and 
 separated by dark-colored pus. The dura mater on the right side 
 of the head was gangrenous over a large surface ; and the middle 
 
 Fig. 85. 
 
 The internal surface of the Temporal Bone, showing the Tympanic Cavitj' in a state of 
 disease ; the entire upper osseous wall of the Tympanum having been destroyed by 
 caries. 
 
 lobe of the right hemisphere was in a state of suppuration, being 
 principally composed of pus. On careful inspection of tlie petrous 
 bone, the whole of the upper wall of the tympanum was found to 
 have been destroyed by caries ; and the tympanic cavity communi- 
 
284 THE DISEASES OF THE EAR. 
 
 cated "with that of the cerebrum by an aperture, measuring three- 
 quarters of an inch in length, and a third of an inch in breadth. 
 
 It thus appears that in some cases the disease of the ear, instead 
 of an abscess, produces 2^ftrii(e7it degeneration of the substance of the 
 brain. 
 
 Case 11, Ulceration of the mucous membrane of the tympanum; 
 caries of the bone; partial destruction of the portio dura nerve, and 
 softening of the dura mater. — John Cochrane, a laborer, aged 44, 
 ■was admitted nnder the care of Dr. Kingston, at the Westminster 
 Hospital, for consumption, in October, 1849. His history is, that 
 twenty-four years previously, discharge took place from the right 
 ear, and has continued ever since. He has long been deaf in that 
 ear, but has not complained of any head-symptoms. On examining 
 the ear the membrana tympani "was absent, and the tympanic mucous 
 membrane was covered by an opaque discharge like cream. When 
 that was removed, the mucous membrane Avas seen to be thick and 
 its surface rugose. The patient died of consumption about a month 
 after his admission into the hospital. Some days previous to his 
 death, there was a paralytic condition of the muscles of the right 
 side of the face ; but there was a partial recovery of their action a 
 short time previous to death. On dissection, the mucous membrane 
 lining the tympanic cavity was found very thick and dark colored, 
 excepting at the anterior part, where it had been destroyed by ulce- 
 ration. The stapes was absent. At the upper part of the tympanum 
 the bone was carious ; the aqueduct of Fallopius was exposed for a 
 space of more than a line and a quarter in length, and the portio 
 dura nerve, in a soft and ulcerated state, protruded from it. The 
 part of the nerve towards the tympanum was gelatiniform in its 
 consistence, and extended downwards so as to cover the fenestra 
 ovalis. The posterior half of the nerve was healthy. The dura 
 mater covering the petrous bone was thicker than natural ; and a 
 small circular portion, about a line and a quarter in diameter, was 
 of a dark brown color, and of a pulpy consistence. It was slightly 
 raised above the surface of the surrounding membrane, and on being 
 touched broke up, and exposed a carious orifice in the bone below 
 it. The bone around tlie orifice was ver}' thin. The brain Avas not 
 diseased. 
 
 In this case there appeared no obstacle to the free escape of the 
 discharge, excepting its tenacity and its concretion in the tympanic 
 cavity ; and it is worthy of observation in a practical point of vicAV, 
 
THE CAVITY OF THE TYMPANUM. 285 
 
 that unless the syringe ^vith warm water be frequently used, the 
 matter secreted by the mucous membrane of the tympanum is apt 
 to accumulate and solidify, and so cause a certain degree of irrita- 
 tion in the adjacent parts. 
 
 In the following, which is the last case I shall cite in reference to 
 this class of diseases of the tympanum, the disease was evidently of 
 a scrofulous character. The mucous membrane of the tympanum 
 had ulcerated, and its place was occupied by scrofulous matter. 
 The substance of the brain had also undergone scrofulous degenera- 
 tion. 
 
 Case III. Ulceration of the mucous memhrane of the left tympa- 
 num ; softening and tubercular deposit in the corresponding cerebral 
 lobe. — AVni. K., aged 4, was admitted under my care, at the St. 
 George's and St. James's Dispensary, in March, 1849. He was de- 
 scribed as never having had good health, his bowels having always 
 been irregular, and his abdomen tumid. In earliest infancy dis- 
 charge of offensive matter took place from the left ear, and has 
 never disappeared for more than a few days at a time. The ear 
 appeared tender to the touch, although no pain had been complained 
 of. _ Has suffered from pain in the forehead and eyes for some 
 months. 
 
 Three days before my seeing him, he fell down at school in what 
 appeared to be a fit, and remained insensible for some minutes. 
 Upon his recovery he was found to have lost the use of the muscles 
 on the right side of the fi\ce and body. "When seen by me he Avas 
 in a state of extreme exhaustion, speechless and hemiplegic. On 
 the following day he complained of great pain in the left ear and 
 the left side of the head, anil there Avas an abundant, creamy, offen- 
 sive discharge from the ear. 
 
 On examination, the Avhole of the membrana tympani Avas found 
 to have been destroyed, the tympanic mucous membrane had disap- 
 peared, and the cavity contained thick, caseous, scrofulous matter. 
 The pain in the head and the convulsive fits increased in intensity ; 
 he often remained insensible for hours together ; his strength gra- 
 dually declined ; and, in spite of tlie most active treatment Avith 
 leeches and mercury, he died on the 21st of May. 
 
 Autopsif, sixteen hours after death. — The dura mater covering the 
 upper surface of the cerebral hemispheres Avas healthy ; but In the 
 substance of the left cerebral hemisphere, above the middle cerebral 
 lobe, was a space measuring three inches from behind forwards, an 
 
286 THE DISEASES OF THE EAR. 
 
 inch and a half from without inwards, and an inch from above down- 
 wards, which was much harder than natural, and studded with tuber- 
 cles ; and between this mass and the lateral ventricle the brain was 
 pulpy. In the left lateral ventricles was a small quantity of turbid 
 serum. The dura mater covering the upper surface of the petrous 
 bone Avas more vascular than natural, and on its free surface was a 
 patch of blood. The upper Avail of the tympanum was dark colored, 
 
 Fig. 86. 
 
 The lower osseous wall of the Tympanum incomplete, so as to allow of a communication 
 between the Tympanic Cavity and the Fossa Jugularis. 
 
 and the thick mucous membrane Avas seen beneath it. The tympa- 
 nic mucous membrane was very thick, and of a dark purple color, 
 its vessels being distended. The upper part of the tympanum was 
 so filled by this thick membrane, that the scrofulous matter and pus 
 were retained by it. The scrofulous matter itself Avas composed of 
 fine granules of epithelial cells, and of very fine crystals, which latter 
 were stated by Dr. Garrod to consist of phosphate of ammonia and 
 magnesia. The stapes was disarticulated from the incus, and the 
 ossicles were concealed by the thick mucous membrane. The loAver 
 
 Fig. 87. 
 
 The orifice seen from the Jugular Fossa. 
 
 osseous Avail also Avas thin and of a red color, and presented an orifice 
 which allowed of a communication between the tympanum and the 
 fossa jugularis. 
 
THE CAVITY OF THE TYMPANUM. 287 
 
 This case is especially interesting, from the fact that the disease 
 had extended downwards to the lower osseous wall, as Avell as up- 
 wards. The lower wall of the tympanum is frequently formed by a 
 thin layer of bone, Avliich separates it from the fossa jugularis. In 
 many instances this osseous lamina is deficient in parts, and the 
 outer surface of the mucous membrane of the tympanum is in con- 
 tact with the jugular vein. Disease may thus be propagated from 
 the tympanic cavity to the jugular vein. 
 
CHAPTER XIII. 
 
 THE CAVITY OF THE TYMPANUM [concluded). 
 
 a. RIGIDITY OP THE MUCOUS MEMBRANK — CAUSE OF DEAFNESS IX ADVANCING YEARS — 
 TREATMENT — CASES. b. THE FORMATION OF BANDS OF ADHESION. C. ANCHYLOSIS OF 
 THE STAPES TO THE FENESTRA OVALIS — PATHOLOGICAL OBSERVATIONS — TREATMENT 
 CASES. (L DISCONNECTION OF THE INCUS AND STAPES — PHYSIOLOGICAL OBSER- 
 VATIONS — PATHOLOGICAL OBSERVATIONS — CASES. 
 
 The mucous membrane of the tympanum may be subject to 
 chronic inflammation, complicated or not with rheumatism, at any 
 period of life, and, if neglected, this is liable to terminate in a rigid 
 state of the membrane ; so that the ossicles become bound together 
 more firmly than is natural. In advanced years, this rigid condition 
 seems to take place without any symptom of inflammation. The 
 membrana tympani also partakes of this rigid condition, and, what 
 is of far greater importance, the base of the stapes may become 
 much more firmly fixed to the border of the fenestra ovalis than is 
 natural. As a consequence, the membrane of the fenestra rotunda 
 and the fluid of the labyrinth participate in this fixed condition. 
 This afiection is less prevalent in the young than in the adult, in 
 Avhom it is liable to occur after repeated attacks of cold, whether 
 with pain or not. It is, however, most frequent in persons ad- 
 vancing in life, and may, in fact, be considered as the disease which 
 causes deafness in advancing years. The generally received opinion 
 that in this kind of deafness tlie nervous system is at ftiult, is mani- 
 festly incorrect, as proved by the symptoms, and by the mode of 
 relief found beneficial. 
 
 The diagnosis of this aifection is far from being diflicult ; although, 
 as will be seen, it offers very little to guide the medical man, except 
 the history of the case. Thus, there is very often little or no 
 opacity, or even dulness, of the membrana tympani ; the Eustachian 
 tube too is pervious, and the air enters naturally. Not unfrequently, 
 
THE CAVITY OF THE TYMPANUM. 289 
 
 ho-\vever, the membrana tympani shows signs of chronic inflam- 
 mation, in hypertrophy and a greater concavity than natural ; -while 
 the air, when forced into the tympanum, enters it with a dull flap- 
 ping sound instead of the normal crackling. Sometimes on forcing 
 the air into the cavity very suddenly, a greatly louder crackling 
 than is natural is heard ; and the patient occasionally hears better 
 for a short time subsequent to the operation. A symptom of con- 
 siderable importance in forming a diagnosis, is the peculiar character 
 of the deafness. Many patients will most distinctly hear a single 
 voice, although low, but arc puzzled to hear anything distinctly 
 Avhen two or more persons arc speaking ; others hear the voice, but 
 cannot discriminate the words ; others again can hear slow conver- 
 sation, but cannot follow it when rapid. These symptoms indicate 
 that the adapting power of the ear, dependent, as already shown, 
 upon the ossicles and their muscles, is at fault. But the history of 
 the case, showing it to be one of slow hardening of the tympanic 
 mucous membrane, together with the absence of all those symptoms 
 which render it liable to be confounded with other diseases, as 
 nervous deafness, obstruction of the Eustachian tube, &c., are usually 
 sufficient to enable an attentive observer to form a correct diagnosis. 
 Treatment. — It is highly important to inquire whether any reme- 
 dial measures can be suggested which will tend to diminish a rigid 
 state of the mucous membrane, and consequently improve the power 
 of hearing. Practical experience induces me to believe that not 
 only may the thick membrana tympani be relieved, but the thick- 
 ened mucous membrane be so reduced as to off'er but little impedi- 
 ment to the function of hearing. 
 
 The most suitable application for this purpose which has been 
 tried by me, is that of a solution of nitrate of silver, of a strength 
 varying from half a drachm to a drachm of the salt to an ounce of 
 distilled water. Proceeding from the exterior orifice of the meatus 
 externus, the passage may be touched to an extent varying from 
 one-half to two-thirds of its length every third or fourth day. In 
 some cases the membrana tympani also may be Avashed with a solu- 
 tion of this salt of six i^rains to the ounce. "When the noises are 
 loud, and the symptoms indicate much congestion in the ear, leeches 
 should be applied immediately heJow., not behind the ears; and where 
 there is irritation of the external tube, an ointment, composed of 
 half a drachm of pulvis cantharidis added to an ounce of simple 
 
 19 
 
290 THE DISEASES OF THE EAR. 
 
 ointment, and applied behind the ear, either daily or every other 
 day, will be found beneficial. 
 
 The administration of alterative doses of pilula hydrargyri, hy- 
 drargyrum cum creta, or the hydrargyri bichloridum, is very useful; 
 but it should ahvays be recollected that these doses ought to be so 
 proportioned as not to produce debility or any other unpleasant 
 symptom ; in other Avords, so gentle should be the alterative that no 
 sensation should suggest to the patients that they are under a course 
 of medicine. 
 
 In addition to the medicines described, patients should be cautioned 
 to avoid warm rooms and sitting very near the fire ; daily exercise, 
 and, where possible, on foot, should be taken in the open air, to- 
 gether with a warm bath every week or ten days. This course of 
 treatment has been productive of the greatest advantage in several 
 cases of deafness of a most unpromising character. Some of the 
 cases about to be cited are those of patients who attributed their 
 failure of hearing to old age. 
 
 The treatment pursued b}" continental surgeons in cases of rigidity 
 of the tympanic mucous membrane, has been the injection of air by 
 means of the Eustachian catheter. There can be no doubt that tem- 
 porary benefit in these cases sometimes follows the use of the air- 
 douche, as well as the act of forcing the air into the tympanic 
 cavity, by the patient holding the nose while he attempts a forcible 
 expiration. But the very temporary character of this benefit, and 
 its occurrence in only a few cases does not induce me to recommend 
 the performance of an operation ; in fact, a forcible expiration by 
 the patient usually answers equally well. On this subject I may 
 quote the following judicious remarks from the article on the Dis- 
 eases of the Ear, in the Cyclopaedia of Surgery, by Mr. "Wharton 
 Jones, — an article characterized, as are all his Avorks, by the most 
 careful observation and patient research. He Avrites : " According 
 to Kramer's ' Tabular View of the Frequency and Curability of 
 Diseases of the Ear,' out of three hundred cases of diseases of the 
 ear of all kinds, tAvo hundred, in round numbers, required the air- 
 douche to assist the diagnosis, but about thirty only Avere impro- 
 vable or curable by it. Of the remaining one hundred and seventy 
 about thirty arc put doAvn as cured, and about fifty as relieved, by 
 the injection of vapors of acetic ether ; this treatment having been 
 continued for months. Of the remainder, eighty Avere considered 
 incurable from the first, and not treated further than Avas necessary 
 
THE CAVITY OF THE TYMPANUM. 291 
 
 for exploration, I suppose ; the rest remained rebellious to treatment. 
 Dr. Kramer does not tell us how permanent his cases were. It will 
 be seen from the above statement of the results of Itard's expe- 
 rience, and also from what I have related of my own, that the ad- 
 vantage gained is seldom permanent." 
 
 Case 1. lUgidity of tlie tympanic mucous membrane. — The Rev. 
 jNI. ^L, ?et. 70, consulted me in 1855, on account of an increasing 
 dulness of hearinjr, Avhicli caused him much inconvenience, as he 
 could not hear general conversation. It had come on very gra- 
 dually, without pain, noises, or any unpleasant sensation, beyond 
 that of a feelincr of heaviness in the ears. The deafness is increased 
 by a cold, but not by fatigue. On examination., each membrana 
 tympani was seen to be less translucent than natural ; and though 
 the Eustachian tube was natural, the air entered the tympanic cavity 
 in a puff instead of producing a faint crepitation. The treatment 
 consisted in keeping up a slight irritation by means of a vesicating 
 plaster behind each ear, and in giving the bichloride of mercury in 
 doses of one-thirtieth of a grain, using also a stimulating gargle. 
 This treatment was continued, with intermission of the mercury, for 
 a week at the end of each fortnight, for four months. At the expi- 
 ration of that time, the hearing power was greatly improved, and 
 the patient wrote to me as follows : — " I have not recovered the 
 quick hearing of early life, which a man in his TOtli year has no 
 right to have ; but I hear comfortably, and I am freed from that 
 dunny sensation as if sounds came through a damp cloth." 
 
 Case II. — R. B., Esq., aged 80, in tolerable health, consulted me 
 on 29th of March, 1844, on account of deafness in both ears. He 
 stated, that three years before, the power of hearing began gra- 
 dually to decline in the right ear, and had continued to do so up to 
 the time of consulting me; that about six months previously the left 
 ear had been similarly affected ; and that his deafness had so much 
 increased as to disable him from hearing the voice without tlie aid 
 of a speaking-trumpet. He was unable to assign any cause for the 
 deafness. On examination., the membrana tympani in each ear was 
 observed to be dull and opalescent ; and although by aid of the 
 otoscope the air was heard to pass into the tympanic cavities, yet it 
 did so with the bubbling, crackling sound, indicating obstruction. 
 Two grains of pilula hydrargyri were ordered to be taken every 
 night, and a stimulating liniment to be applied around and below 
 the ears. This plan having been persevered in for about three 
 
292 THE DISEASES OF THE EAR. 
 
 weeks, and some slight improvement experienced, the patient was 
 directed to take one grain of liydrargyrum cum creta daily. At the 
 end of two months this gentleman recovered his hearing, and gave 
 up the use of the speaking-trumpet. 
 
 Case III. — J. P., Esq., aged 64, consulted me in July, 1845. 
 During the last four or five years the right ear has been growing 
 deaf, and the deafness has now so far advanced as to render the ear 
 useless to him. Has been suffering from a cold for a few days, 
 during Avhich there has been a sensation of singing and of vibration 
 in the head and ears, accompanied with deafness. In each ear there 
 was a large collection of wax, on the removal of which the symp- 
 toms somewhat abated. The membrana tympani of both ears was 
 white. Air passed freely into the tympanic cavities. The fifteenth 
 of a grain of hydrargyri bichloridum thrice a day was prescribed, 
 and counter-irritation around the ears. In the course of six weeks 
 the patient had perfectly recovered. 
 
 Case IV. — Lady R., aged G2, consulted me in December, 1848, 
 for a deafness which had come on during the preceding month, and 
 gradually increased, till, by the time I saw her, it was requisite to 
 speak loud and close to the ears. The deafness had first been per- 
 ceived after a cold, and was accelerated by an attack of influenza. 
 The feeling in the right ear Avas that of a veil hanging over it. In 
 each ear the membrana tympani Avas white, and air passed freely 
 into the tympanic cavities. The treatment pursued consisted in the 
 application of a solution of argenti nitras to the outer half of the 
 external meatus ; beginning Avith the strength of half a drachm of 
 the salt to an ounce of distilled Avater, afterAvards increasing it to 
 double that strength. This course of proceeding, coupled Avitli the 
 administration of alterative doses of pilula hydrargyri, effected so 
 great an improvement, that in tAvo months this lady had no difficulty 
 in hearing in ordinary society. 
 
 Case V. — Mrs. A. T., aged 67, consulted me in April, 1845. 
 She stated, that Avhen eight years of age, she fell down on the left 
 ear, and had been deaf of that ear ever since. About four years 
 ago loud internal noises disturbed the right ear, and increased to so 
 distressing a degree, that this lady felt as if she Avere continually 
 travelling in a carriage OA^er gravel ; and at times a loud explosion 
 would be heard, succeeded by acute pain. She can scarcely hear 
 her own voice, and is obliged to use a trumpet in society. The ears 
 seem to her stopped up Avith pegs. She attributes this deafness to 
 
THE CAVITY OF THE TYMPANUM. 293 
 
 a close attendance in the sick-room of her husband durino; a long 
 illness. 
 
 Right car. — Membrana tympani concave, and evidently nearer 
 to the promontory than natural ; and the membrane is so white that 
 the malleus is not distinguishable. Left ear. — Membrana tympani 
 has been entirely removed by ulceration. 
 
 Treatment. — In the first instance leeches were placed imme- 
 diately below the ear ; tincture of iodine was applied to the external 
 meatus of the right car ; and three grains of pilula hydrargyri were 
 given every night. 
 
 June 3d. — Feels much better ; has less confusion in the head, 
 and more confidence in herself. 
 
 June 15th. — The noises are so much diminished that she is no 
 longer troubled by them ; is feeling stronger and better, and the 
 hearing improves. 
 
 Case VI. — J. C, Esq., aged 64, consulted me in November, 1844. 
 His father became deaf at the age of fifty, and he has a sister deaf. 
 About a year ago, he found that he was deaf in the left ear ; might 
 have been deaf a longer time ; but at the period mentioned, sing- 
 ing commenced in the left ear, which has continued without inter- 
 mission ever since. Occasionally it is much diminished. The noise 
 and deafness and are much worse during a cold. The right ear is 
 not so bad as the left. When he closes the right ear, he cannot 
 hear any sound naturally. 
 
 Ixight ear. — ]Mcmbrana tympani opaque, and the handle of the 
 malleus only just discernible. When air is forced into the tym- 
 panum it can be heard by the otoscope entering it in a series of 
 small pufis. After the air has been forced into the tympanum, a 
 crackling sensation is experienced. Hearing distance two inches. 
 
 Left ear. — Membrana tympani white ; handle of malleus indis- 
 cernible; air enters the tympanum in a short pufi". Hearing dis- 
 tance absolute contact. 
 
 For this gentleman two grains of the pilula hydrargyri were 
 prescribed, to be taken every night ; and tincture of iodine Avas 
 applied behind the ears. In the course of three months I saw him 
 again, and found the hearing decidedly improved ; the noises also 
 had diminished. 
 
 Case YII.— Mrs. R. N., aged 64, consulted me August 2d, 1844. 
 For the preceding four or five months deafness had been coming on, 
 and had lately so much increased that she finds it difficult to hear any 
 
294 THE DISEASES OF THE EAR. 
 
 conversation. Has for several years been subject to occasional dul- 
 ness of hearing. The present deafness was apparently produced by 
 an attack of cold, which left a sensation of fulness in both ears. 
 The membrana tympani of each ear is quite white. 
 
 Treatment. — One-twentieth of a grain of hydrargyri bichloridum, 
 in conjunction with vinum ferri, was administered thrice a day. The 
 dose of bichloride Avas subsequently increased to one-sixteenth of a 
 grain, and a solution of argenti nitras, half a drachm of the salt to 
 an ounce of distilled water, was applied to the outer half of the ex- 
 ternal meatus. In the course of three months this patient recovered 
 her hearing, and has remained quite well ever since. 
 
 ih.) MEMBRANOUS BANDS IN THE TYMPANIC CAVITY. 
 
 Membranous bands are formed in every part of the tympanic 
 cavity, connecting together the ossicles, and attaching them to the 
 walls of the tympanum and to the membrana tympani. In cases 
 where these bands are lax, it is probable that the movements of the 
 ossicles are not impaired, and that there is no diminution of the 
 power of hearing. In the majority of instances, however, these 
 membranous bands are so firm and unyielding as to cripple the 
 movements of the bones to which they are affixed. On reference 
 to the table it will be seen that these membranous bands most 
 usually connect the stapes with the promontory, and thus produce 
 one species of anchj^losis of that bone. These adhesions originate 
 either from the effusion of fibrin from the surface of the membrane, 
 and its conversion into a firm and vascular membrane, or from the 
 circumstance that when the mucous membrane is much hypertrophied, 
 there is an adhesion of the portions of it which are in contact, and 
 the neighboring parts are drawn into bands, when the membrane 
 subsides to its normal condition. 
 
 Care should be taken to distinguish between bands formed of 
 organized membrane, and those Avhicli are produced by dried mucus, 
 as pointed out by Mr. Ilinton in the paper before alluded to. 
 
 Let me now relate the results of some dissections of cases in 
 which these bands were found. 
 
 Case I. Considerable hardness of hearing for six years ; hands of 
 adhesion in the cavitij of the tympanum. — Mrs. L. died in December, 
 1848, at the age of 87, from a gradual decline of the vital powers. 
 
THE CAVITY OF THE TYMPANUM. 295 
 
 Until the age of oO, she had no symptoms of derangement of the 
 function of hearing ; but about that period slie was in tlie habit of 
 taking " cephalic snuff," Avhich she thought produced a buzzing 
 sensation in her ears, a symptom which disappeared as soon as the 
 use of the snuff was discontinued. At tliat })eriod there was no 
 sign of deafness ; but about the age of 81, she perceived that the 
 sense of hearinn; was becomin<2; blunted. From that time deafness 
 gradually and very slowly increased, attended now and then with 
 noises in the ears. The deafness would be temporarily increased 
 by a cold, but, as that vanished, the usual amount of hearing 
 returned. During the last year of her life the disease made but 
 little progress, though the deceased was obliged to use a speaking- 
 trumpet for the purpose of conversation. It was observed that the 
 sense of hearing became much more acute during the last few days 
 of her life. This lady took very little exercise during the ten years 
 preceding her death, but kept within doors, and sat in a warm 
 room the greater part of every day. She was troubled with a 
 chronic inflammation of the mucous membrane of the eyelids, 
 lachrymal sacs, and nasal ducts. It is worthy of notice that this 
 lady had two sisters, one of whom died at the age of 90. She was 
 a very active person nearly up to the period of her death, and was 
 but slightly deaf. The other sister, at the age of 89, is extremely 
 deaf, and has been confined to her room for years. 
 
 Dissection. Right ear. — The external meatus was dry and de- 
 prived of cerumen. The membrana tympani has its fibrous layer 
 slightly thickened and white, and is more concave than natural. 
 Tympanic cavity. — The mucous membrane appears to be healthy, 
 
 Fig. 88. 
 
 Membranous Bands connecting the Ossicles. 
 
 and not thicker than natural, but there are bands of adhesion by 
 which the ossicula are connected together and with the walls of the 
 tympanum. These bands of adhesion may be divided into two dis- 
 
296 THE DISEASES OF THE EAR. 
 
 tinct sets ; one placed between the incus and the innei* "wall of the 
 tympanum and stapes, and the other connecting the head of the 
 malleus and the body of the incus with the external wall of the 
 tympanum. The first-named set consists of two portions, of which 
 the one, measuring half a line from above downwards, and three- 
 quarters of a line from without inwards, connects the anterior part 
 of the long process of the incus with that part of the wall of the 
 tympanum which is posterior to the fenestra oralis. This band is 
 connected by several smaller ones to the superior surface of the 
 stapes, and also to a fine membrane which connects the two crura 
 of the latter bone. These small bands are so firm and so tightly 
 stretched between the stapes and the larger band, and between the 
 incus and the inner wall of the tympanum, as to keep the stapes 
 more fixed than natural. There are also adhesions between the 
 upper surface of the crura of the stapes and the margin of the fossa 
 fenestras ovalis. The outer portion of this band extends from the 
 posterior part of the long process of the incus to the inner wall of 
 the tympanum, posterior to that just described : this band is also 
 firm and tense. The second set of adhesions passes from the head 
 of the malleus and the body of the incus directly outwards, con- 
 necting them with the osseous walls of the tympanum, superior and 
 posterior to the attachment of the membrana tympani. It is in- 
 teresting to consider what efiect these bands must have had upon 
 the ossicula and membrana tympani during life. Those Avhich sur- 
 round the stapes and connect it with the fossa fenestra© ovalis, must 
 have impeded the movements of the stapes ; and those which con- 
 nect the long process of the incus with the inner wall of the 
 
 Fig. 89. 
 
 / 
 Membranous Bands connecting the Ossicles to the Promontory. (Magnified.) 
 
 tympanum, by pulling that process inwards, would probably have 
 been the means of pressing the stapes towards the vestibular cavity. 
 The effect of the adhesions between the bodies of the malleus and 
 
THE CAVITY OF THE TYMPANUM. 297 
 
 incus, and the outer -wall of the tympanum, would seem to have 
 been to draw those parts outwards, and, in consequence, their 
 inferior extremes iuAvards. This action upon the malleus is ap- 
 parent, and may account for the greater concavity of the mend^rana 
 tympani externally ; it having been carried inwards with the long 
 process of the malleus and being very tense. The bone of the 
 stapes is also fixed more firmly than is natural to the margin of the 
 fenestra ovalis. The membrane of the fenestra rotunda appears to 
 be in a normal state. The membranous labyrinth is healthy ; and 
 except that there is rather more black pigment than usual in the 
 cochlea of the left ear, it is in a similar condition to the right ear, 
 and presents adhesions connecting the ossicula. 
 
 Case II. 3Iemhrana tT/mjmni very concave externally: hands of 
 adhesion connecting the ossicula together and to the tympanic walls. — 
 Mrs. F. 0., died of gangrena senilis, at the age of 62. She had 
 been deaf for a considerable period previous to her death, especially 
 in the left ear. 
 
 Dissection. Right ear. — The membrana tympani is unusually 
 concave externally, and the central part of its internal surface is 
 not more than a quarter of a line from the promontory ; it is also 
 rather opaque in parts, especially at its circumference ; and its in- 
 ternal layer is white, and slightly hypertrophied. The mucous 
 membrane of the tympanic cavity is rather thicker and more vascular 
 than natural, and is very tough. A firm band of adhesion connects 
 the cervix of the malleus with the long process of the incus, and 
 another membranous band of adhesion connects the anterior surface 
 of the long process of the incus with the promontory and with the 
 stapes, which latter bone it completely envelopes. The tensor tym- 
 pani muscle is smaller than natural. 
 
 Left ear. — Although the surface of the membrana tympani is 
 smooth, it is white around the line of attachment of the malleus ; 
 the bloodvessels are enlarged and much distended with blood. The 
 membrana tympani is more concave externally than natural. /The 
 cavitas tympani is three parts filled with a thick, tenacious, white 
 mucus, which is partly the cause of the white appearance of the 
 membrana tympani, though the inner layer of the membrana tym- 
 pani being opaque and white, aids in producing this effect. The 
 mucous membrane lining the tympanum is thick and very vascular. 
 
 It is not possible to distinguish, during life, between the cases of 
 rigidity of the tympanic mucous membrane, and those of adhesions 
 
298 THE DISEASES OF THE EAR. 
 
 in tlic tympanic cavity ; but as the treatment in both cases is the 
 same, the distinction is not of much importance. 
 
 (c.) ANCHYLOSIS OF THE STAPES TO THE FENESTRA OVALIS. 
 
 In tlie published catalogue of the preparations contained in my 
 museum, I have described one hundred and thirty-six specimens of 
 anchylosis of the base of the stapes to the fenestra ovalis : and these 
 specimens form the basis from which the pathology of this articula- 
 tion has been studied. 
 
 In a tabular view of the morbid appearances found in 1149 dis- 
 eased ears, published originally in the Tratisactions of the Royal 
 Medical and Chirurgicai Society^ and afterAvards as an appendix to 
 the catalogue of my museum, fifty-three specimens of membranous 
 anchylosis are described, specimens in which the stapes was attached 
 more firmly than natural to the circumference of the fenestra ovalis ; 
 that is to say, upon the stapes being pressed by a fine probe, more 
 than usual resistance Avas offered before the stapes moved. Now, 
 in these cases, no expansion of the base of the stapes, or of the 
 articular surface of the fenestra ovalis, was observed : and the only 
 inference that could be drawn was, that these Avere cases of partial 
 anchylosis of the stapedio-A'estibular articulation, resulting from 
 rigidity of its capsular ligaments ; and I am disposed to think, that 
 this rigidity of the fibrous tissue is one of the earlier and more re- 
 mediable stages of anchylosis of this and other articulations, which, 
 if allowed to proceed, ends in the formidable pathological conditions 
 knoAvn under the name of rheumatic arthritis, and Avhich are about 
 to be more particularly described. 
 
 The second morbid change found in this articulation is a simple 
 expansion of the articular surfaces, Avhile the structure of the bone 
 itself remains, as far as can be ascertained, in a natural state. This 
 morbid condition of the articular surfaces was found in forty-nine 
 out of the one hundred and thirty-six cases of anchylosis ; and AAas 
 distinguishable from membranous anchylosis by the greater degree 
 of firmness Avith AA'hich the stapes adhered to the fenestra ovalis, and 
 by the presence of a distinct tumefaction of one or other articular 
 surface, but generally of the stapedial. 
 
 The third pathological condition is that in Adiich the Avhole of the 
 base of the stapes has become hypertrophied, and assumed a calca- 
 
THE CAVITY OF THE TYiMPANUM. 
 
 299 
 
 reous Avliitcness ; the border bcino; so miicli enlarffed as to be im- 
 pacted within the fenestra ovalis with that (U^grcc of firmness, that 
 the crura arc often broken from the base in the attempt to withdraw 
 
 Fig. 90. 
 
 The whole of the Circumference of the base of the Stapes anehylosed to the Fenestra 
 Ovalis, the Crura being detached, and seen below, a, the base of the Stapes ; i, the 
 Crura (magnified two diameters). 
 
 the hitter from the fenestra ovalis. In some instances, this expan- 
 sion of the base of the stapes is accompanied bj its protrusion into 
 
 Fig. 91. 
 
 Base of the Stapes expanded, and osseous matter thrown out around it and the Crura. 
 a, the Stapes ; i, the cavity of the Vestibule (magnified two diameters). 
 
 the cavity of the vestibule ; still there appears, even in these cases, 
 to be nothing more than hypertrophy and condensation of the normal 
 
300 
 
 THE DISEASES OF THE EAR. 
 
 osseous structure. This morbid condition shows itself in twenty-nine 
 specimens. 
 
 Fig. 92. 
 
 Expansion of the base of the Stapes, and its protrusion into the cavity of the Vestibule. 
 1 (Magnified.) 
 
 The fourth pathological condition is that in which the base of the 
 stapes is greatly expanded, and ncAv osseous matter is thrown out 
 
 Fig. 93. 
 
 Expansion of the Vestibular Surface of the Articulation. (Magnified two diameters.) 
 a, The Upper Margin of the Stapes free ; b, the Lower Margin of the Stapes anchy- 
 losed. 
 
 beyond the natural limit of the bone, so as to connect the stapes 
 ■with the adjacent parts of the fenestra ovalis ; a morbid condition 
 which is seen in twenty-five specimens. 
 
THE CAVITY OF THE TYMPANUM. 301 
 
 The fifth pathological condition is that in which the structure of 
 the base of the sta])es undergoes little or no alteration : but Avliere 
 ossific matter is thrown out at its circumference, and the base is 
 thus partially or wholly anchylosed to the fenestra ovalis. This 
 morbid condition is shown in twenty-one specimens, in eight of 
 which the lower border only was anchylosed ; there being a distinct 
 space between the upper margin of the base and the fenestra 
 ovalis : while in thirteen others, the whole circumference of the 
 base is firmly anchylosed to the fenestra ovalis. 
 
 The sixth pathological condition consists in the expansion of the 
 vestibular surface of the articulation, and the effusion of bone around 
 the fenestra ovalis, the stapes remaining perfectly healthy ; an ab- 
 normal condition which occurred in twelve instances. 
 
 The five morbid conditions last described, comprised in 13G speci- 
 mens, may be summarily stated in this form : — 
 
 1. Simple expansion of the articulating border of the base of the stapes, . 49 
 
 2. Expansion of the articulating border of the base of the stapes with calca- 
 
 reous \Yhiteness of the whole base, ........ 29 
 
 3. Expansion of the whole of the base and effused bone connecting the two 
 
 articulating surfaces, .......... 25 
 
 4. Osseous matter effused between the stapes and fenestra ovalis connecting 
 
 the two articulating surfaces, ......... 21 
 
 5. Osseous matter effused around the fenestra ovalis, . . . . .12 
 
 136 
 
 DIAGNOSIS AND PROGNOSIS. 
 
 The diagno.sis of this aftectiou is, in the majority of cases, at- 
 tended with little difficulty, if the origin and progress of the affec- 
 tion be carefully investigated, and the organ be examined with 
 sufficient accuracy. The symptoms, in fact, of this class of disease 
 are very similar to those occurring in cases of rigidity of the mucous 
 membrane, already described. After a certain duration of these symp- 
 toms, sometimes for many months, the patient is found to be growing 
 gradually deafer and deafer, frequently without any other marked 
 symptom, though often there is a feeling of fulness or pressure in 
 the ears, or a buzzing sound wlien laying the head upon the pillow. 
 The progress of the affection is at first usually slow ; at intervals of 
 two, three, four, or more months, the patient observes the deafness 
 to be decidedly on the increase, though mitigated temporarily per- 
 
302 THE DISEASES OF THE EAR. 
 
 haps by his resorting to very violent exercise, or by taking spare 
 diet or aperient medicines. If the progress of this aflFection be left 
 unchecked, total deafness results, and may take place at an early 
 period of life, as between the ages of twenty and thirty, though 
 commonly it does not happen till a much later period. Sometimes 
 the affection advances so far as to produce a certain degree of deaf- 
 ness only, as where the patient has to be addressed in a loud voice 
 within a yard or two of his ear, and then, from some constitutional 
 change, no further progress takes place. An interesting symptom 
 frequently met with in cases of this disease is the momentary im- 
 provement of the hearing produced by the acts of yawning widely, 
 or pulling the outer ear, or pressing the tragus hard and quickly 
 against the orifice of the meatus ; each of which actions is followed 
 by a temporary relaxation of the membrana tympani and chain of 
 ossicles. In the case of yawning, I am disposed to believe that this 
 relaxation is produced by the mechanical action of the chorda tym- 
 pani nerve, which, being drawn tight, slightly pulls out the chain 
 of ossicles. Another and peculiar symptom, is the effect produced 
 by very loud and sudden sounds, as in two of the appended cases. 
 In one of these, where, doubtless, the stapes Avas fixed by the expan- 
 sion of its border, a loud scream in the ear at once restored the 
 hearing by, as it would seem, suddenly releasing the bone ; a resto- 
 ration which lasted for several days, until, in fact, the two again 
 became fixed : in the other, a very loud sound of bagpipes in the 
 patient's hall, where he was sitting, so increased his deafness, that 
 his friends were obliged temporarily to use a slate and pencil to 
 communicate Avith him. This increase of deafness also disappeared, 
 and the patient recovered his previous amount of hearing. 
 
 A third interesting and very common symptom of the early stages 
 of anchylosis of the stapes, is the loss of what I am in the lial)it of 
 calling the adapting power of the organ. Thus the patient will hear 
 perfectly a single distinct voice, but a second voice intermingling, 
 completely disables him from hearing either ; he having lost the 
 power of rapidly adjusting his ear to suit the sound of the voice of 
 the person immediately addressing him to the exclusion of that of 
 the other. Yet another striking symptom of the early stages of the 
 affection, is the necessity of exercising an act of sustained volition, 
 in order to catch the sound of a voice, Avhich ceases to be perceptible 
 as soon as the effect is relaxed. It has, indeed, happened to me to 
 receive patients Avhose complaint consisted not in being dull of hear- 
 
THE CAVITY OF THE TYMPANUM. 303 
 
 ing, since they could liear everything said in a room, but in not 
 being able to do this 'without a prolonged cftbrt of attention, the 
 fatigue of ^hich soon became intolerable. Tiiis latter condition is, 
 of course, perfectly explicable, from the more or less rigidity of the 
 chain of bones in this disease, and the muscular eftbrt consequently 
 required to move it and keep it in constant motion. 
 
 Another symptom, and one certainly characteristic of the later 
 stages of this afl'ection, but which it is not in my poAver to deny may 
 not also be present in another disease of the ear, is the immense 
 improvement to the hearing which attends the patient's travelling in 
 a carriage over a hard road, by which considerable vibration is com- 
 municated to his body, — a vibration that doubtless in a degree 
 shakes the chain of bones, and imparts to them a kind of vibratory 
 movement, which permits the muscles, Avhile it lasts, so to act on 
 these bones as to restore more or less of their proper functions in 
 adjusting the pressure on the labyrinth. 
 
 On examining the patient, there is usuall}^ abundant evidence of 
 the rheumatic or gouty diathesis having been or being present, such 
 as congestion or tumefaction of the nasal and faucial mucous mem- 
 branes, and, in addition, hypertrophy of the tonsils in young per- 
 sons. On inspecting advanced cases, there is usually an absence of 
 cerumen from the external meatus, the result of the congestion of 
 this part of the organ, of which the membranous meatus presents 
 most characteristic symptoms, in being red and so swollen as gene- 
 rally to have lost its oval form and to have become, in parts, con- 
 stricted. Thus the upper half of the tube may retain its normal 
 size and shape, while the lower may be reduced to a narrow fissure 
 only one-half or one-third of its proper dimensions. Sometimes this 
 diminution of the calibre of the meatus arises from a bulging of the 
 bone forming the walls, so as to become a convex protuberance ; in 
 other instances, these osseous protuberances are so prominent as to 
 gain the name of tumors, and as such they have been described in 
 treating of the meatus. 
 
 The dermis covering this bone is usually of a deep red color ; in- 
 deed, as a rule, the dermoid meatus is highly congested in cases of 
 gouty and rheumatic affections of the ear. The condition of the 
 mcmhrana tympani does not afford much aid in forming a diagnosis, 
 though as a general rule, to which there are many exceptions, it is 
 somewhat more opaque, and its surface duller than natural. Often 
 it is very opaque, and white as parchment, and not unfrequently it 
 
304 THE DISEASES OF THE EAR. 
 
 exhibits patches of opacity in diifercut parts. Occasionally the 
 membrane is more concave externally than is natural. In advanced 
 cases, like those where the base of the stapes has become fixed, the 
 membrana tympani is rigid. The presence of this' rigidity is, how- 
 ever, difficult to ascertain by simple pressure on the surface ; but 
 its existence may be proved b}'' the use of the otoscope, while the 
 patient either swalloAvs Avitli closed nostrils, or forces the air into 
 the tympanic cavity by blowing the nose forcibly, the nose and 
 mouth being at the same time closed. In each of these acts the air 
 is heard to enter the tympanic cavity, for the Eustachian tube in 
 these instances is usually open ; but in place of the fine crackling 
 sound elicited by these operations, when performed on a healthy ear, 
 a flapping, or coarse crackling, is heard, produced by the air striking 
 against the inner surface of the unyielding or tense drum. A yet 
 further symptom of this disease is, that the patient commonly hears 
 better in proportion to the loudness of the speaker's voice ; whereas, 
 in cases of debility of the nervous apparatus of the ear, it is not the 
 loud voice, but that which is peculiarly modulated which is heard 
 the best, occasionally even when as low as a whisper. In addition 
 to the foregoing symptoms, the existence of anchylosis of the stapes 
 may be diagnosed by a careful attention to the causes producing it, 
 and to the stages of its progress, which offer so marked a contrast 
 to cases of debility of the nervous apparatus, Avith which cases of 
 anchylosis of the stapes may, doubtless, otherwise be confounded. 
 
 AVith regard to the prognosis, it may be laid down as a general 
 rule, that so long as the affection depends upon rigidity of the liga- 
 ments, or upon a slight expansion of the basis of the stapes (and the 
 surgeon can judge of the existence of these conditions during life 
 by the symptoms being but little advanced), then there is every pros- 
 pect that considerable amelioration may be effecte<l, and the patient, 
 in fact, be enabled to hear without any inconvenience, for experience 
 has taught me that a rigid ligament may be relaxed, and an expanded 
 bone be reduced in size. I may even venture on the further state- 
 ment, that, judging from the visible diminution of the bony tumors 
 in the external meatus under the influence of remedial measures, and 
 taking into account also the decided improvement which at times 
 takes place in cases where, from the symptoms, there Avas every 
 reason to believe that the stapes or vestibule had become similarly 
 expanded, there can be but little doubt that, even in tlie more ad- 
 vanced stages of anchylosis by expansion, some benefit can be ob- 
 
THE CAVITY OF THE TYMPANUM. 305 
 
 tained by the use of remedies which shall cause the effused matter 
 to be absorbed. The more liopeless cases are those in Avhich the op- 
 posing articular surfaces of the stapes and vestibule are united by 
 ossific matter ; and at present I am unaware of any means by which 
 they can be diagnosed and discriminated from cases of anchylosis by 
 expansion of the articular surfaces. 
 
 Treatment. — The treatment in these cases differs in no essential 
 respect from that recommended for cases of rigidity of the fibro- 
 mucous membrane. 
 
 Case I. — Mr. W., aged 47, consulted me, in the year 1848, on 
 account of the state of his health, which was greatly impaired by at- 
 tacks of rheumatic gout and congestion of the liver. When I saw 
 him, he Avas so deaf that lie required to be loudly spoken to, within 
 tlio distance of a yard from his head. His habits were fur from 
 being temperate, as he indulged freely in alcoholic drinks. The his- 
 tory of his deafness was, that many years previously he liad gradu- 
 ally become dull of hearing, and that this dulness had increased 
 slowly up to the period of my seeing him. The only occasion upon 
 which he had been temporarily benefited, was on the removal of a large 
 mass of cerumen from the meatus. I did not examine the ears, as 
 I was not consulted on account of the deafness ; but this omission is 
 supplied by the particulars of the post-mortem inspection. After 
 having known him for a few years, he died from an attack of inflam- 
 mation of the lungs. 
 
 Dissection. Might ear. — The meatus externus was somewhat con- 
 tracted, the lower part being rough, and the surface irregular. The 
 membrana tympani was thicker, and more opaque and rigid than 
 natural ; the chain of ossicles formed so solid a l)ridge between the 
 membrana tympani and the vestibule, that considerable pressure on 
 the handle of the malleus at the outer extremity of this bridge was 
 requisite to produce the slightest movement of the chain. In the 
 lower part of the tympanic cavity, a white deposit adhered to the 
 surface of the bone, and was so closely incorporated with tlie fibro- 
 mucous membrane, as to render it difficult to pronounce whether it 
 was in the substance of, or below the membrjine. The base of the 
 stapes was somewhat expanded, and its circumference was perfectly 
 anchj'losed to the fenestra ovalis. This anchylosis was partly effected 
 by the expajision of the bone of the stapes, and partly by the effusion 
 or prolongation from it, especially at the posterior part, of hard white 
 matter. 
 
 20 
 
306 THE DISEASES OF THE EAR. 
 
 Left ear. — The meatus externus was contracted, presenting at its 
 posterior part a bulging of bone, and at its inferior part being very 
 narrow. The membrana tympani was opaque, and the chain of 
 bones as rigid as in the right ear. The head of the malleus pre- 
 sented small nodosities, similar to those on the heads of other bones 
 affected with rheumatic gout. The stapes was perfectly anchylosed 
 to the fenestra ovalis by the expansion of its base, and by the pre- 
 sence of a large quantity of hard white matter which surrounded it. 
 The cavity of the vestibule contained also a great deal of white 
 matter, similar to that in the righf tympanic cavity. 
 
 In another case, somewhat analogous in its morbid condition to 
 the foregoing, and in which the deafness and anchylosis were equally 
 complete, the patient died with consumption under the care of Dr. 
 Sibson, in St. Mary's Hospital, at the early age of 20, clearly show- 
 ing that this affection is not necessarily an accompaniment of ad- 
 vancing years. 
 
 Case II. — Mr. L. J., aged 90, in good health, except that he suf- 
 fered from attacks of gout, often complicated with rheumatism. 
 About the age of 40, he found a dulness of hearing gradually com- 
 ing on, which as gradually increased, until, at the time I saw him, 
 he could only hear the voice Avhen loudly spoken to close to the head. 
 This gentleman had no desire for any treatment to be pursued, and 
 I merely diagnosed the affection from the history of the case, — its 
 slow, insidious progress, the absence of all symptoms of nervous 
 debility, and the attacks of gout with which the patient Avas troubled. 
 My opinion, thus formed, was that the cause of the deafness was 
 anchylosis of the stapes ; an opinion that I expressed to his medical 
 and other friends. He died, some years after my first seeing him, 
 of gouty inflammation of the bladder, and the opportunity was 
 afforded me of carefully dissecting both petrous bones. 
 
 liiglit ear. — Meatus externus. At the posterior and upper part 
 there was a distinct, smooth, and rounded projection of the bone, 
 which extends obliquely from Avithout and below, inwards and up- 
 wards, and is continuous Avith the rough scabrous portion of bone 
 which forms the loAver part of the meatus externus at its orifice, and 
 is quite distinct from the mastoid portion of the bone. This pro- 
 jection measures about three lines from above dowuAvards. At the 
 upper part of the meatus the bone is rough and hypertrophied. 
 
 The membrana tympani was more concave externally, and much 
 thicker and more opaque than natural. It Avas so rigid that pressure 
 
THE CAVITY OF THE TYMPANUM. 307 
 
 upon the outer surface of the malleus by means of a fine probe was 
 not followed by any movement of the chain of bones. Upon laying 
 open the tympanic cavity and pressing upon the stapes, this bone 
 was found to be so compactly attached to the inner wall of the tym- 
 panum, that upon pressure there was not the slightest degree of 
 movement. A broad membranous quadrilateral band entirely filled 
 the space between the long process of the incus, the internal Avail, 
 the stapes, and the posterior wall of the tympanum. On laying 
 open the vestibule, the base of the stapes was observed to be of a 
 Avhite calcareous aspect, and perfectly united to the circumference 
 of the fenestra ovalis by calcareous matter. The membrane of the 
 fenestra rotunda appeared to be healthy, except that it Avas, if any- 
 thing, slightly thicker than natural. 
 
 Left car. — The meatus externus presented a bulging similar in 
 shape and direction to that in the right ear, though somewhat larger. 
 The membrana tympani Avas thicker and more rigid than natural, 
 but not more concave externally than usual. The difference in the 
 degree of concavity of this membrane in the tAvo ears Avas so decided, 
 that the inner surface of its central part, in the right ear, Avas one- 
 third nearer to the inner Avail of the tympanum than it Avas in the 
 left ear. The stapes was firmly fixed, and its base, Avhen the A^es- 
 tibule was opened, Avas found to be expanded and completely anchy- 
 losed to the fenestra ovalis. 
 
 Case III. — Mr. T. L. J., aged 50, of a gouty diathesis, the son 
 of the above patient, consulted me, in 1852, on account of gradually 
 increasing deafness. When I saAv him, he had to be loudly spoken 
 to Avithin the distance of a yard of the head. He stated that the 
 deafness had come on very gradually Avithout any pain or uneasy 
 feeling in the ears, and that no relief Avas ever experienced except 
 from taking long walks, and perspiring A^ery copiously. On exam- 
 ination, the membrana tympani in each ear Avas somcAvhat opaque, 
 and the Eustachian tube pervious ; the air entering in a loud puff. 
 The history of the case, and its similarity to that of the father, 
 made me sure that the cause of deafness was anchylosis of the stapes. 
 I laid down certain rules to be carried out, but on account of the 
 sedentary nature of the patient's occupation, they could not be ob- 
 served; attacks of gout became more frefpu'iit, and total deafness 
 ensued. 
 
 Case IV. — Mr. N. C, aged GO, a man of intemperate habits, 
 gradually became deaf at the age of 24. The deafness sloAvly in- 
 
308 THE DISEASES OF THE EAK. 
 
 creased to the day of his death, which took place at the age of 60, 
 from an attack of bronchitis. There was hereditary deafness in this 
 gentleman's family, several sisters and brothers becoming slowly 
 deaf about the same age as did this patient. For some time previous 
 to his death, the patient's right ear was useless, but, by means of a 
 trumpet, he could manage to hear loud conversation addressed to 
 him in the left. 
 
 Dissection of right car. — (This dissection was made by Mr. A. 
 Nopper, who kindly forwarded to me the specimen and his notes.) 
 Membrana tympani more opaque than natural. Numerous transpa- 
 rent, membranous bauds traverse the tympanic "cavity. The ossicles 
 were in a healthy state, with exception of the stapes, the crura of 
 which had disappeared.^ The fenestra ovalis was closed by the base 
 of the stapes, which projected slightly into the cavity of the vesti- 
 bule. In the vestibular cavity surrounding the fenestra ovalis, was 
 a white mass of bone, which formed an annular protuberance around 
 the interior two-thirds of the fenestra ovalis. 
 
 Case y. Partial anchylosis of the staj^cs temporarily cured by the 
 effect of a loud shout in the ear. — The Rev. L. D., aged between 50 
 and 60, saw me in the year 1856, but not on account of his deaf- 
 ness, for which he did not seek advice ; I, however, was able to glean 
 the following interesting details of his case. The general health of 
 this gentleman was good, with the exception of attacks of indiges- 
 tion and rheumatism, which caused him great inconvenience. In a 
 letter to me, he says, "I have had rheumatism in the shoulder-joint, 
 which I always walked off, the pain becoming much aggravated as I 
 got warmer, but being always at last driven out. I suffered for some 
 weeks, three winters ago, from extreme weakness in both ankle- 
 joints, so that I could scarcely go about my parish work. My 
 friends assured me that it was the beginning of creeping paralysis, 
 but I was sure that the stomach was the enemy. My work must be 
 done, and I gradually walked my legs back into use." Deafness in 
 the right ear appeared to have come on suddenly a few years before 
 my seeing the patient, when the left ear was puzzled to know the 
 direction of sounds. "I had no conception," he writes, "whence 
 sounds came, until by degrees the left ear learnt to put sounds into 
 their right places, or rather to settle the place of the cause of 
 
 ' It is probable that the crura of the stapes had been accidentally disconnected from the 
 base in the act of dissecting the ear. 
 
THE CAVITY OF THE TYMPANUM. 309 
 
 sound." No treatment Avas adopted, and tlic patient for some years 
 remained in the same condition, the left ear being useless, or nearly 
 so, and the right remaining tolerably perfect. In the year 1856, 
 ■while this gentleman Avas superintending his Sunday-school, he was 
 called upon to seize a boy who was endeavoring to bite his teacher, 
 when, to use the clergyman's OAvn words, " he (the boy) sent such a 
 yell into my right ear, that I heard not only the yell, but for some 
 daA'S I heard all other sounds most distinctly, Avhen it, the hearing, 
 again relapsed, and my left ear had again to learn its duties." From 
 the history and examination of this case, I have no doubt that the 
 affection consisted of rheumatic disease of the stapedio-vestibular 
 articulation, and that the morbid condition Avas no other than that 
 peculiar expansion of the base of the stapes so frequently adverted 
 to. The effect of the loud scream Avas doubtless to release the stapes 
 for a time, so as to alloAV of its movement by its muscles. It may 
 here be added, that in another patient who was under my care for 
 some time for deafness produced by rheumatism of the ears, an ex- 
 actly opposite effect, A'iz., complete deafness, was temporarily pro- 
 duced by a sudden loud sound. This gentleman was quite deaf in 
 one ear, but Avitli the other heard a loud voice, Avhen distinctly 
 spoken, at a short distance from him. In this condition he Avas 
 subjected to the sudden shrill sound of bagpipes played in the hall 
 Avhere he sat, by which he Avas at once rendered too deaf to hear the 
 human voice, and all communications to him Avere obliged to be in 
 writing. This increased deafness lasted for several days, and then 
 the ear recovered the hearing power it possessed previous to the ac- 
 cident. There appears to be great probability that in the latter 
 case the cause of the increased deafness was, that the stapes were 
 driven inwards and held tight by the fenestra ovalis, and that the 
 return of the hearing poAvcr Avas due to the release of the stapes. 
 
 (d.) DISCONNECTION OF THE INCUS AND STAPES. 
 
 An affection of the ear directly opposite to rigidity of the chain 
 of bones sometimes takes place, and this consists in the disconnec- 
 tion of the incus and stapes. I will preface my account of this 
 affection by making some physiological observations bearing on the 
 subject. 
 
 Physiological Observations. — The opinion usually entertained is, 
 
310 THE DISEASES OF THE EAR. 
 
 that two channels are requisite for the transmission of sonorous un- 
 duhitions to the hib^'rinth from the membrana tympani; one channel 
 being the air in the tympanic cavity, which conducts the undulations 
 to the membrane of the fenestra rotunda and the cochlea ; the other 
 channel being the chain of ossicles, which conducts the undulations 
 to the vestibule. 
 
 Tliat this opinion is not universally received is apparent from the 
 following quotation from an authority highly deserving of attention, 
 Mr. Wharton Jones. He says : — " Some physiologists assert that 
 the sonorous undulations are communicated from tlie membrana 
 tympani to the ossicles, and through them conducted to the vestibular 
 fenestra ; others suppose the undulations to be propagated merely 
 through the air in the cavity of the tympanum, to the membrane of 
 the fenestra rotunda ; the ossicles and their muscles serving the 
 purpose of regulating the tension of the membrana tympani, the 
 membrane of the vestibular fenestra, together with the membranous 
 labyrinth. A combination of the two views is most generally re- 
 ceived. However well founded the view may be that sound is pro- 
 pagated through the chain of small bones, the circumstance that 
 some degree of hearing may persist along with loss partial or com- 
 plete of the membrana tympani, and of the malleus and incus, is a 
 conclusive proof that sound may be conveyed through the fenestra 
 to the labyrinth, by the vibrations of the air in the tympanum alone. 
 It would appear also, that the integrity of one fenestra may suflSce 
 for the exercise of hearing."^ 
 
 Mr. Brooke, Avhosc views on questions of experimental science are 
 worth}' of the 'fullest consideration, has published his reasons for 
 believing that it is not possible for the sonorous undulations to be 
 conducted to the labyrinth by the chain of bones. 
 
 He says : " The transmission of sound cannot take place through 
 the ossicula, as it was formerly supposed, inasmuch as the plane in 
 which the crura of the stapes lie, is exactly perpendicular to the 
 plane passing through the manubrium of the malleus and long leg 
 of the incus ; and consequently, the vibrations passing througli them 
 Avould be almost entirely intercepted by the stapes. And, moreover, 
 it appears essential that the transmission of vibrations through the 
 chain of ossicula should be prevented ; for as the velocity with Avhich 
 sound is transmitted through solids, such as bone, so very far cx- 
 
 ' Cyclopaedia of Surgery. Article, "Diseases of Ear and Hearing," p. 23. 
 
THE CAVITY OF THE TYMPANUM. 311 
 
 ceeds the velocity in air, if the same undulations reach the labyrinth 
 through this channel, and through the channel previously described 
 (the air in the tympanum), they would reach in different times, and 
 constant interference ^vould be produced."^ 
 
 Although Mr. Brooke has thus confidently expressed his opinion 
 that " the transmission of sound cannot take place through the 
 ossicula," his statement, unsupported by experiments, and obser- 
 vations, does not seem to have induced 'writers on the physiology of 
 the ear to adopt his conclusions. Thus Dr. Carpenter, in the latest 
 edition of bis Ilvmian Physiology, having referred to Mr. Brooke's 
 paper, says : — " From what has been stated, it is evident that 
 sonorous undulations in the air will be propagated to the fluid con- 
 tained in the labyrinth through the tympanum, the chain of bones^ 
 and the membrane of the fenestra oralis to which the stapes is 
 attached without any loss, but rather an increase of intensity."^ 
 
 Indeed, with a consciousness of the wonderful accuracy of M. 
 Savart's experiments in acoustics, it appears impossible, without fur- 
 ther experiment, to disbelieve the assertion he made in the following 
 quotation from his Avritings : — " Les vibrations do la membrane 
 se communiquent sans alteration au labyrinthe par le moyen des 
 osselets, comme les vibrations de la table superieure d'un instru- 
 ment communiquent a la table inferieure par le moyen de I'ame."* 
 
 But supposing with Savart, that under ordinary circumstances 
 sonorous undulations are conducted to the labyrinth by the chain of 
 ossicles, is it also possible, under certain conditions, for the function 
 of hearing to be carried on without the aid of these bones ? Mr. 
 Wharton Jones has answered this question in the affirmative, as he 
 says, that "the integrity of one fenestra may suffice for the exer- 
 cise of hearing;" and Sir J. Ilerschel inclines to the same opinion. 
 lie says : " These bones form a kind of chain, and no doubt vibra- 
 tions excited in the tympanum by vibrating air, as in the experi- 
 ments above detailed, are somehow or other propagated forward 
 through these ; but they are so far from being essential to hearing, 
 that when the tympanum is destroyed, and the chain in consequence 
 hangs loose, deafness does not follow."^ 
 
 ' Report of a Lecture delivered at the Roj-al Institution; Lancet, 1843, p. 380. 
 - Page 733. 
 
 ' Recherches sur les Usages de la Membrane du Tympan, et de 1" Oreille externe. 
 Journal de Phj-siologie. Par F. Majendie. Tome iv, p. 219. 
 * Encyelopnedia Metropolitana. Article, "Pound," p. 810. 
 
312 THE DISEASES OF THE EAR. 
 
 My object at present is to attempt to ascertain, — 
 
 FirstJij, whether sonorous undulations from the external meatus 
 can reach the labyrinth -without the agency of the ossicles ; and, 
 
 Secondly, Avhether the chain of ossicles can conduct sonorous un- 
 dulations to the labyrinth. 
 
 Firstly. Can sonorous undulations reach the labyrinth from the 
 external meatus without the agency of the ossicles. - 
 
 There can, I think, be no doubt but that the malleus and incus, 
 and even the crura of the stapes, can be removed without the pro- 
 duction of any very serious detriment to the hearing, but there is 
 no ■vvell-authenticated case in which the base of the stapes has been 
 removed in ■svhich total deafness did not ensue, but this deafness 
 must doubtless be attributed to the removal of the fluid of the laby- 
 rinth at the time the stapes was withdrawn. 
 
 But what is the effect of a fixed condition of the base of the 
 stapes ? Now it happens that bony anchylosis of the base of the 
 stapes to the margin of the fenestra ovalis is by no means a rare 
 morbid condition, and I have had several opportunities of seeing 
 patients with this affection during life, watching their symptoms, 
 and subsequently dissecting the organ. The result of my observa- 
 tions is to demonstrate that simple bony coalescence of the base of 
 the stapes to the wall of the vestibule -is productive of so higli a 
 degree of deafness, that the sonorous undulations could reach the 
 nerve only by passing through the walls of the cranium ; and this 
 statement accords with that of Dr. Pappenheim, who found merely 
 " some degree of hearing" in a similar case. It may possibly be 
 argued that the deafness occurring in cases of anchylosis of the 
 stapes to the fenestra ovalis, may be accounted for by the fixed con- 
 dition of the memhrana fenestrce rotundoi which necessarily results, 
 but I think it is palpable that the mere incapacity of this membrane 
 to alter its state of tension would not be suflficient to account for 
 the high degree of deafness to sounds (acute equally with the bass) 
 which characterized the whole of the cases that have fallen under 
 my observation. It may however be asked, is it not possible for 
 sonorous undulations to reach the labyrinth without the aid of the 
 stapes, since the function of hearing is but slightly impeded by the 
 removal of the incus, and when c()nsc([uently no vibrations can reach 
 the stapes, except througli the air in the tympanum ? It seems in- 
 deed to have been assumed, that when the stapes is thus detached 
 from the incus, it cannot receive vibrations from the air externally 
 
THE CAVITY OF THE TYMPANUM. 313 
 
 and conduct them to the vestibule ; -what grounds there exist for this 
 conclusion ■will be seen from the following experiments. 
 
 That solid bodies are capable of being thrown into a state of vibra- 
 tion by the agency of sonorous vibrations existing in, and commu- 
 nicated by, the air, is a fact too Avell known to require demonstra- 
 tion ; but the following experiments show how far the solid stapes, 
 when isolated from the incus, may possibly receive vibrations from 
 the air and conduct them to the labyrinth. 
 
 Experiment. — The ears having been closed, a piece of Avood, five 
 inches long and half an inch in diameter, was held between the teeth, 
 and a vibrating tuning-fork, C, having been brought within the 
 eighth of an inch of its free extremity, Avas distinctly heard, and it 
 continued to be heard for betAveen five and six seconds. 
 
 ExpeMment. — One end of the piece of Avood used in the previous 
 experiment being pressed gently against the outer surface of the 
 tragus, so as just to close the meatus, a A'ibrating tuning-fork, C, 
 placed within a quarter of an inch from the free extremity, was 
 heard very distinctly at first, and it did not cease to be heard for 
 fifteen seconds. 
 
 Experiment. — Three portions of wood, having the same length 
 and thickness as those used in the above experiments, were glued 
 together so as to form a triangle liaA'ing somewhat the shape of the 
 stapes. The base of this triangle being placed against the outer 
 surface of the tragus so as to close the meatus, the tuning-fork, C, 
 vibrating Avithin a (quarter of an inch from the free apex, Avas heard 
 for twelve seconds. 
 
 From the aboA'e c^bservations and experiments, I think it may be 
 reasonably inferred that the stapes, even when detached from the 
 ossicles, if free to move in the fenestra ovalis, will receive sonorous 
 undulations from the air in the tympanic cavity, and will conduct 
 them to the labyrinth,"^ and that there is no evidence that sonorous 
 undulations can reach the labyrinth from the external meatus ivithout 
 the agency of at least one of the ossicles, viz., the stapes. 
 
 I shall proceed to inquire, in the second place, Avhether the chain 
 of ossicles can conduct sonorous undulations to the labyrinth. 
 
 In this second part of the inc^uiry, I shall endeavor to determine, 
 
 ' The result of these experiments accords with the fact I have observed, viz., that an 
 amount of hearing so eflScient that the patient was not supposed to be deaf, or to have 
 deficiency of hearing power, has been found to coexist with isolation, apparently conge- 
 nital, of the stapes from the incus. 
 
314 TUE DISEASES OF THE EAR. 
 
 a. How far the sonorous undulations excited in the membrana 
 tympani are intercepted in the chain of ossicles by " the plane in 
 which the crura of the stapes lie, being exactly perpendicular to the 
 plane ])assing through the maiiubriuni of the malleus and the long 
 leg of the incus;" and 
 
 b. To what extent the articulations of the chain of bones impede 
 the passage of these inidulations. 
 
 (a.) To what extent are these vibrations, excited in the membrana 
 tympani, arrested by the variation in the plane of the chain of ossicles. 
 
 After M. Savart's conclusive experiments, repeated and verified 
 by so many subsequent observers, it is needless for me to point out 
 how freely sonorous undulations excited in the air, are connnuni- 
 cated to a membrane like that forming the membrana tympani ; nor 
 how fully they are conducted from a stretched membrane,- like the 
 membrana tympani, to a solid attached to this membrane like the 
 malleus, and free to oscillate. Assuming, therefore, that the vibra- 
 tions reach the malleus, I will proceed to examine how far they are 
 conducted through it and the other ossicles. 
 
 Experiment. — Three pieces of wood, each five inches in length 
 and half an inch thick, Avere glued together so as to represent the 
 planes of the three bones of the ear ; while three other portions were 
 glued together end to end, forming a straight rod. A watch was 
 placed at one end of the straight rod, while the other end was ap- 
 plied against the tragus of the ear, which it pressed firmly inwards 
 so as to close the meatus completely and to exclude *;ounds from 
 entering the ear by it. The result was, that the watch Avas heard 
 nearly as distinctly as when it was placed in contact Avith the ear. 
 When a similar experiment Avas performed Avith the angular piece of 
 Avood representing the chain of bones, the Avatch Avas still heard, but 
 less distinctly. 
 
 Experiment. — A tuning-fork, C, being made to vibrate, Avas placed 
 in contact Avitli one extremity of the angular piece of wood, the other 
 being placed against the tragus of the ear ; and Avhen the straight 
 portion Avas similarly used, it Avas found, as in the former experi- 
 ment, that the sound Avas decidedly less loud Avhen heard through 
 the angular than through the straight portion ; and after the sound 
 had altogether ceased to be heard through the angular portion, the 
 same tuning-fork Avas heard for about three seconds, Avhen the straight 
 piece Avas substituted. 
 
 FindiuiT that there existed some little difficultv in excrcisino- the 
 
THE CAVITY OF THE TYMPANUM. 315 
 
 same amount of pressure on the tragus of tlie ear in each experiment, 
 and considering that a variation in the amount of pressure might 
 cause the air in the meatus to assume different degrees of density, I 
 had recourse to the teeth as a medium for the transmission of the 
 sound. I found that a solid phiced in contact with the teeth of the 
 lower jaw conducted vibrations with rather greater facility than when 
 in contact with those of the upper jaw, and I therefore adopted the 
 plan of holding the conducting body between the teeth. 
 
 Experiment. — A tuning-fork, C, Avas placed at one extremity of 
 the angular piece of wood, the other extremity being held between 
 the teeth ; the fork was at first heard very distinctly, and when this 
 sound could no longer be distinguished, the straight piece was sub- 
 stituted, and it was again heard for the space of two seconds. 
 
 Erperimcnt. — Instead of the horizontal portion of wood repre- 
 senting the stapes, three portions of the same size were made into a 
 triangle, and this was glued to the anterior surface of the inferior 
 extremity of the piece representing the incus ; the last experiment 
 was repeated, with the substitution of this apparatus for the angular 
 portion, and Avith very nearly the same result, viz., the fork was 
 hoard through the straight piece about three seconds after it had 
 ceased to be heard b}" the apparatus representing the chain of bones. 
 
 Experiment. — A piece of iron wire eighteen inches long and about 
 two lines in diameter, was bent so as to represent the different planes 
 of the chain of ossicles of the human ear ; the tuning-fork, C, Avas 
 placed at one extremity, while the other was held betAveen the teeth. 
 The sound Avas heard very distinctly at first, and when it ceased to 
 be heard, a straight portion of the same length Avas substituted, 
 through which the tuning-fork Avas heard for three seconds. 
 
 Experiments. — A piece of very thin paper was gummed over one 
 end of a glass tube three inches in diameter. To the outer surface 
 of this paper a model of the ossicula, similar to the one Uh^ed in a 
 previous experiment, Avas glued. A vibrating tuning-fork, C, being 
 placed in the interior of the tube and Avithin a quarter of an inch of 
 the paper, the end of the chain representing the base of the stapes 
 was placed betAveen the teeth ; the sound Avas heard distinctly, and 
 it continued to be heard for ten seconds. The sound of the tuning- 
 fork, C", Avas heard for tAventy seconds. 
 
 Tlie results of these experiments appear to indicate that the passage 
 of sonorous undulations is sometvhat, but only slightly, impeded by 
 the variation of the plane in ivhich the ossicles are placed. 
 
316 TUE DISEASES OF THE EAR. 
 
 I proceed, secondly, to consider tlie effect of the articulations 
 between the ossicles, upon the passage of sonorous undulations 
 through them. 
 
 The articulating surfaces of the small bones of the ear are usually 
 described as being incrusted by cartilage, which is covered with sy- 
 novial membrane. Professor Kolliker, speaking of these bones, 
 says, "Their articulations and ligaments resemble in miniature 
 those of other similar organs in all respects, even down to the carti- 
 laginous layer, consisting of scarcely more than a single stratum."' 
 
 Before proceeding with the inquiry concerning the passage of 
 sonorous undulations through the chain of bones, it is desirable to 
 consider carefully the structure of their articulations. 
 
 They may be considered as four in number, viz. : — 
 
 1. The malleo-incudal. 
 
 2. The inco-orbicular. 
 
 3. The orbiculo-stapedial. 
 
 4. The stapedio-vestibular. 
 
 (1.) The malleo-incudal articulation. 
 
 The convex surftice on the lower and posterior part of the head of 
 the malleus is received into the concavity on the anterior part of 
 the body of the incus ; when applied together, as they are retained 
 by their ligaments in a natural state, the surfaces of these two bones 
 appear to be in close contact. Upon examining the articulating 
 surfaces of the malleus and incus in a recent specimen, by means of 
 a lens magnifying five or six diameters, no appearance of cartilage 
 can be detected ; and when touched with a fine probe, the surface 
 is felt to be hard, as if no membrane were present. If, however, 
 these articulating surfaces be scraped Avith a small scalpel, fine 
 pieces of transparent membrane are removed. Examined by the 
 microscope, this membrane, in some parts, is seen to be homoge- 
 neous, having no appearance either of fibres or cells ; in other por- 
 tions, delicate fibres can be detected, while here and there a single 
 layer of cartilage cells can be distinctly recognized. As a general 
 rule, more cartilage cells are to be found in the membrane removed 
 from the incus than in that from the malleus. 
 
 ' Manual of Human Histiology. By Bu^k and Huxley. Vol. ii, p. 404. 
 
THE CAVITY OF THE TYMPANUM. 317 
 
 (2.) The inco-orhicidar articulatio7i. 
 
 The orbicular bone is sometimes described as a process of the 
 incus. Careful examination of recent specimens shows, however, 
 that the orbicular bone is connected to the incus l)y firm fibrous 
 tissue. 
 
 (3.) TJic orhicido-stapedial articulation. 
 
 The orbicular bone, on its surface towards the stapes, presents a 
 slightly convex head, which is received into the superficial con- 
 cavity on the head of the stapes. This convex surface of the orbi- 
 cular bone is covered by a membrane, in which I have not been 
 able to detect any cartilage cells. The outer extremity of the 
 stapes is covered by a saucer-shaped cushion, soft to the touch ; 
 and upon examination by the microscope, it is seen to be a disk of 
 fibro-cartilage, being a representation in miniature of those existing 
 between the bodies of the vertebriio, the circumference being com- 
 posed of fibres arranged concentrically around cartilage cells which 
 occupy the. central position. 
 
 (4.) The stapedio-vestibidar articidation 
 
 is formed by the circumference of the base of the stapes, which is 
 applied against the inner surface of the fenestra ovalis ; the stapes, 
 as I have shown, being moved by muscles to and fro in the fenestra 
 ovalis, as a piston moves in a cylinder. I have not been able to 
 detect any cartilage on the surface of either the base of the stapes 
 or of the fenestra ovalis, a very fine membrane alone being dis- 
 cernible. 
 
 The articulatin<2; surfaces formin^r the several articulations, are 
 connected together by very delicate capsular ligaments. 
 
 The next step of my inquiry was to ascertain by experiment how 
 far these articulations tend to impede the passage of sonorous undu- 
 lations through the chain of ossicles. As in the former experiments, 
 these tympanic ossicles were represented by portions of wood ; while 
 the cartilage and synovial membrane Avere represented by layers of 
 vulcanized india-rubber. 
 
318 THE DISEASES OF THE EAR. 
 
 Experiment. — Three pieces of wood, each about five inches long 
 and half an inch in thickness, were separated from each other by a 
 piece of vulcanized india-rubber about as thick as ordinary writing- 
 paper; they were held together by means of elastic bands, and so as 
 to assume the angular form possessed by the chain. The tuning- 
 fork ])l:iced at the distal extremity of the chain, the other end being 
 placed in the mouth, it was found that the sound Avas heard as dis- 
 tinctly, and for the same length of time, as when it passed through 
 the chain formed of the three portions glued together. 
 
 Experiment. — A similar result took place when two layers of 
 india-rubber were placed between each piece of wood. 
 
 Experiment. — When eight layers of the india-rubber Avere placed 
 between each piece of wood, there Avas still very little diflference in 
 the intensity of the sound when it passed through these, and Avhen 
 it passed through the portions glued together. 
 
 Experiment. — One, two, or three fingers being placed between the 
 first and second pieces of wood, and eight la^'crs of india-rubber 
 between the second and third, a very slight diminution in the in- 
 tensity and duration of the sound was observed as compared with its 
 passage through the pieces glued together, it being requisite that 
 the fingers be pressed tolerably firm against the Avood. 
 
 Experirnent. — If the back of the hand be placed against the teeth, 
 and the end of the vibrating tuning-fork be pressed against the palm, 
 the sound is heard very distinctly for several seconds ; and when it 
 has ceased to be heard, if a piece of solid Avood three inches long be 
 substituted for the hand, fjiint vibrations are again heard, but for 
 about four seconds only. 
 
 Considering the extreme tenuity of the layers of cartilage and 
 synovial membrane Avhich are interposed betAveen the ossicula auditiis, 
 and the very slight influence in arresting the passage of the sonorous 
 undulations produced by layers of india-rubber, the inference is that 
 the ai-ticulations bettveen the bones forming the chain in the human 
 ear, im2)ede vert/ slightly, if at all, the passage of vibrations from the 
 memhrana tjpnpani to the lahgrinth. 
 
 The experiments and observations detailed above, lead to the fol- 
 loAving conclusions: — 
 
 First. — Tliat the commonly-received o})inion in favor of the sono- 
 rous undulations passing to the labyrinth through the chain of 
 ossicles in the human ear, is correct. 
 
 Second. — That the stapes, Avhen disconnected from the incus, can 
 
THE CAVITY OF THE TYMPANUM. 319 
 
 conduct sonorous undulations from the tympanic cavity to the ves- 
 tibule. 
 
 Tliinl. — So far as our present experience extends, it appears that 
 in the human ear sound always travels to the labyrinth through two 
 media, viz., the air in the tympanic cavity to the cochlea, and one 
 or more of the ossicles to the vestibule. 
 
 After a detail of the above results, it will readily be assumed that 
 a simple disconnection of the incus from the stapes is not productive 
 of any large amount of dulness of hearing. In the course of my 
 dissections I have met with eight cases in which the incus was dis- 
 connected from the stapes, and in no instance could I trace deafness 
 specially to this cause. Some of the patients from whom the dis- 
 sections were taken were undoubtedly deaf, but their deafness could 
 be assigned to other causes than the existence of the solution of con- 
 tinuity in the chain of bones. One of the patients in whom it 
 occurred was not detected by the surgeon to be deaf; but this might 
 arise from the fact that the lesion existed in one ear only. From 
 some researches I have made on the subject, it appears probable 
 that the cause of this peculiar lesion is hypertrophy of the mucous 
 membrane of the tympanum ; in cases of this disease, the supply of 
 blood to the substance of the incus being interfered with. It is im- 
 portant to recognize the existence of this disease, and to do all that 
 is possible to avert it by subduing any thickening of the tympanic 
 mucous membrane, but it remains for future investigations to decide 
 to what extent this lesion interferes with the hearing power. 
 
 Case I. — A man, get. 19 ; deaf in the left ear ; died of apoplexy. 
 In this ear the membrana tympani contained calcareous matter. 
 The mucous membrane of the tympanum Avas very thick. The ex- 
 tremity of both long and short process of the incus had disappeared, 
 and the surface of the adjacent bone was rough. 
 
 Case II. — A man, jct. 67. Right ear. — The inferior extremity 
 of the long process of the incus has been absorbed, and the os or- 
 biculare is attached to the stapes. On the inner surface of the 
 head and long process of the incus are numerous orifices which 
 lead into the interior of the bone, giving it a worm-eaten appear- 
 ance. 
 
 Cuiic III. A boy, ait. 5; died from scarlatina, and was not known 
 to be deaf. Right ear in a normal state. Left ear. — The os orbi- 
 culare is separated from the incus, and is attached to the stapes ; 
 the stapes is fixed to the fenestra ovalis more firmly than natural. 
 
320 THE DISEASES OF THE EAR. 
 
 The tympanic cavity contained mucus ; lymph Avas also effused, and 
 bands of adhesion between the membrana tympani and tlie inner 
 ■wall of tlie tympanum were in process of formation. The Avhole of 
 the inner surface of the long process of the incus presented a worm- 
 eaten appearance, and its lower extremity has disappeared, appa- 
 rently from absorption. The os orbiculare is attached to the neck 
 of the stapes, the part usuall}^ attached to the incus being free and 
 rough, and projecting somewhat from the neck of the stapes. 
 
 Case IV. A boy, set. 3J years ; died from dysentery ; he was not 
 ascertained to be deaf. Right ear. — The incus on the inner surface 
 of its long process presented numerous foramina, and the orbicular 
 process was partly absorbed, only a small rougli portion of it re- 
 maining attached to the incus — the inner surface of the extremity 
 of the process being hollowed out, and having sharp margins. Left 
 ear. — The incus is in the same state as that of the right ear, and 
 the larger part of the orbicular process is attached to the stapes. 
 
CHAPTER XIV. 
 
 THE MASTOID CELLS. 
 
 ANATOMICAL OBSERVATIONS : O, DISEASES OF THE MASTOID CELLS IN CHILDHOOD — 
 CASES OF THE DISEASE ADVANCING TO THE BONE AND THE CEREBRUM. b, DISEASES 
 OF THE MASTOID CELLS IN THE ADULT — ACUTE INFLAMMATION OF THE MUCOUS MEM- 
 BRANE — CHRONIC INFLAMMATION OP THE MUCOUS MEMBRANE — PURULENT INFECTION 
 — SYMPTOMS OF REMITTENT FEVER — CARIES OF THE LATERAL SULCUS — ABSCESS IN 
 THE CEREBELLUM. C, NECROSIS OF THE MASTOID PROCESS — PARALYSIS OP THE POR- 
 TIO DURA NERVE — TREATMENT — OPINION RESPECTING LIFE-INSURANCE IN CASES OP 
 DISCHARGE FROM THE EAR. 
 
 As regards their functions, the mastoid cells may be considered 
 merely in the light of an appendage to the tympanic cavity ; but 
 their peculiar conformation and intimate relations Avith the lateral 
 sinus render a special study of their diseases necessary, previous to 
 entering on which it is, however, important thoroughly to under- 
 stand their anatomical relations. 
 
 Anatomical Observations. — Like the mastoid process, the mastoid 
 cells vary much in size in different individuals. In some persons 
 they occupy the whole of the interior of the bone behind the meatus 
 externus for the distance of an inch and a half ; their vertical dia- 
 meter is two inches, and they extend inwards as far as the fossa 
 jugularis; in other cases the mastoid process is almost solid, and the 
 cells communicating with it are small and few in number. The mas- 
 toid cells may be considered as consisting of two portions : one con- 
 tained in the mastoid process, where the cells have more or less of a 
 vertical arrangement, the other situated between the mastoid process 
 and the tympanic cavity : this latter portion is generally horizontal 
 and frequently presents a concavity at its floor, in which mucus or 
 other secretions are apt to lodge. On the inner surface of the mas- 
 toid process is the sulcus lateralis, which is occupied by the lateral 
 sinus. Numerous orifices exist in this sulcus for the passage of 
 veins from the mastoid cells to the lateral sinus, which is generally 
 
 21 
 
322 THE DISEASES OF THE EAR. 
 
 the part first aifected in disease of the mastoid cells occurring in 
 the adult. These cells are bounded anteriorly by part of the poste- 
 rior wall of the meatus. At birth and during early life, the mastoid 
 process is in a rudimentary state, and the only representative of the 
 mastoid cells is the horizontal portion -which is adjacent to the tym- 
 panic cavity ; the extension of which backwards and downwards, in 
 later periods, forms the cavity of the mastoid process. It .is essen- 
 tial that the relations of this horizontal portion of the mastoid cells 
 in the earlier periods of life should be well understood, since disease 
 occurring in it then produces entirely difierent results from those of 
 a later period. If a vertical section be made so as to pass through 
 this horizontal portion in the temporal bone of a child about two 
 years of age, these mastoid cells will be observed to be bounded 
 externally by a part of the S({uamous bone, which is superior and 
 
 Fio. 94. 
 
 
 The External Surface of the Temporal Bone of a child. The outer wall of the horizontal 
 portion of the cells has been removed, and the cavity of this portion of the cells above 
 the Mastoid Process is exposed. 
 
 slightly posterior to the meatus externus ; and it is this particular 
 part which becomes affected in cases of disease of the mastoid cells 
 in early life. The upper Avail of the horizontal portion of tlie mas- 
 toid cells is formed by a layer of bone, continuous with that of the 
 upper wall of the tympanum. This lamina partakes of the disease 
 of the cavity, and thus the dura mater and cerebellum become liable 
 to be affected when, in early life, disease occurs in the mastoid cells. 
 Before the second year this cellular cavity is comparatively much 
 larger than at a later period. 
 
THE MASTOID CELLS. 
 
 323 
 
 The diseases of the mastoid cells in the child will be first described, 
 and afterwards those in the adult. 
 
 Fig. 95. 
 
 A Vertical Section of the Temporal Bone of a child through the horizontal portion of the 
 Mastoid Cells. It is seen to he hounded externally by the layer of bone, which has 
 been removed in the preceding cut, and which usually becomes carious in cases of dis- 
 ease in the horizontal portion of the cells in early life. 
 
 {a.) DISEASES OF THE MASTOID CELLS IN CHILDHOOD. 
 
 The most frequent causes of disease in the mastoid cells, as in 
 the tympanum, at this period, are scarlet fever, measles, small-pox, 
 and scrofulous affections. In the three former of these affections, 
 the mucous membrane is usually the subject of chronic catarrh, 
 becomes hypertrophied, and mucus collects in the cells. In the 
 undeveloped state of the mastoid process in childhood, the mucus 
 collects in the horizontal portion, bounded externally, as already de- 
 scribed, by the squamous bone, and above by the continuation of the 
 lamina forming the upper tympanic wall. Hence it is evident that 
 the portions of bone liable to be affected by disease in the mastoid 
 cells of the child, are the squamous bone immediately above and 
 behind the external meatus, and the posterior part of the upper 
 wall of the tympanum. Dissection shows also that these two parts 
 are in fact those which do become affected, and that in cases of dis- 
 ease attacking the mastoid cells in early life, the cerebrum is the 
 
324 THE DISEASES OF THE EAR. 
 
 part of the brain Avliich suffers, while, as we shall see in later 
 periods of life, the cerebellum becomes affected. 
 
 In disease of this part the discharge from the affected ear often 
 dates from birth, and is generally at first unaccompanied by any 
 pain ; so that too often (especially among working people) no notice 
 whatever is taken of it. In its earlier stages the discharge appears 
 to be purely sympathetic, and, as in many other cases of irritation 
 of the tympanic mucous membrane, it proceeds from the meatus and 
 the outer surface of the membrana tympani. As the disease pro- 
 gresses, the tympanum becomes filled by mucus or scrofulous matter, 
 and the membrana tympani yields to the pressure on its inner sur- 
 face; and no doubt in some cases, if a thorough outlet be thus made 
 for the discharge from the mastoid cells, while the health of the 
 patient at the same time improves, no further mischief accrues ; but 
 unfortunately the peculiar conformation of this part of the mastoid 
 cells usually prevents the free escape of the matter ; part of it, at 
 least, remains lodged in its concavity, or the whole is barred from 
 exit by the closure of the tympanic cavity through the hypertrophy 
 of the lining mucous membrane. In all fatal cases the discharge 
 has been deprived of a free egress. 
 
 One of the peculiar features of the disease is, that it sometimes 
 causes death, by producing general cerebral irritation rather than 
 inflammation. In the first two cases* which follow, there was no 
 appearance of disease in the brain, pia mater, or arachnoid ; in the 
 third case these parts were but slightly affected in comparison with 
 the large amount of disease in the ear. 
 
 Case I. Scrofulous disease of the liorizontal portionof the mastoid 
 cells before the first year of life ; caries of the squamous bone; disease 
 of the dura mater. — J. R., aged thirteen months, Avas admitted under 
 my care as an out-patient, at St. Mary's Hospital, on the 12tli 
 February, 1852. Although she had a good color and was not thin, 
 her mother stated, tliat since her birth she had never been strong, 
 and that she had been brought up by hand, on account of herself 
 (the mother) having an abscess in one breast. The history was, 
 that at six ^'cars old a discharge was observed to flow from the right 
 car, Avhich had continued to the present time with but short inter- 
 missions. Three weeks ago an abscess formed at the back of the 
 car and discharged into the meatus. On inspection, the surface of 
 
 ' A somewhat analogous case has been cited as having occurred to Dr. Chambers. 
 
THE MASTOID CELLS. 825 
 
 the meatus was seen to be red, and its substance so much tumefied 
 as to prevent its being ascertained Avhether the niembrana tympani 
 ■was or was not present. The discharge consisted of pus and mucus. 
 The abscess behind the ear communicated with the meatus by an 
 aperture at its posterior part. The ear was ordered to be syringed 
 with warm water. 
 
 February 19th. — Symptoms much the same, but the discharge 
 more oifensive. 
 
 Until the 1st of April "the symptoms gradually subsided, the dis- 
 charge diminished, and the child appeared stronger. On the 2d, 
 however, the discharge grew more offensive, and less in quantity. 
 On the 8th the child cried, as if in pain, and started in her sleep. 
 
 April 15tli. — Leeches afforded some relief, and were ordered to 
 be continued. 
 
 19th. — Has had shivering fits to-day. From this date the head- 
 symptoms gradually increased ; the respiration became difficult, and 
 the child died in convulsions on the 29th. 
 
 Autopsy. — The part of the sterno-mastoid muscle attached to the 
 mastoid process was discolored. The membranous meatus was much 
 thickened, and of a dark purple color. The posterior part of the 
 osseous meatus was carious ; and the bone continuous with and above 
 it, for a space the size of a sixpenny-piece, was also carious ; this 
 being the portion of bone which bounds externally the horizontal 
 mastoid space. The periosteum covering this carious bone is thick 
 and soft in some parts, and ulcerated in others. There is also in- 
 ternally a portion of necrosed bone about one-half the size of that 
 externally ; and upon a section the inner surface is found to be part 
 of the necrosed portion of bone which is seen externally, where it 
 covers the tympanic cavity and extends above it. The outer surface 
 of the dura mater which is in contact with the dead bone, is soft, 
 spongy, and of a dark color, and partly filled the superficial cavity 
 formed by the necrosed bone : in immediate contact with that bone, 
 however, was a soft pulpy tissue. The'membrana tympani was 
 absent, the mucous membrane of the tympanum ulcerated, and the 
 ossicles carious. The lungs were tuberculous, the mesenteric glands 
 large, containing also scrofulous matter. 
 
 The following case is very analogous to the one just reported. 
 
 Case II. Scrofulous disease in the horizontal portion of the mas- 
 toid cells in the frst year of life ; caries of squamous hone and dis- 
 ease of dura mater. — E. B., aged sixteen months, subject to scro- 
 
326 
 
 THE DISEASES OF THE EAR. 
 
 fulous glands, was admitted under my care at the St. George's and 
 St. James's Dispensary, in November, 1849. When seen, there 
 was a large abscess behind the left ear and discharge from the 
 
 The External Surface of the Temporal Bone, showing the irregular-shaped carious portion 
 of bone above the Meatus. 
 
 meatus. The merabrana tympani was absent, the mucous mem- 
 brane of the tympanum thick and red. At the bottom of an 
 abscess behind the ear, dead bone could be felt. Her mother stated 
 that there was discharge from the right ear at the age of three 
 months, which lasted six or seven weeks, and then disappeared. 
 "When five months old, discharge took place from the left ear, and 
 after continuing for a month, a swelling appeared at the back of the 
 ear, which was opened and continued discharging, as well as the 
 meatus, to the time I saw the patient. Soon after seeing her, the 
 symptoms of cerebral irritation, which had shown themselves at 
 times in the form of great pain in the left side of the head, rapidly 
 increased ; and in face of all the remedial measures employed, death 
 ensued in a few days. 
 
 Autopsy. — On slitting open the abscess at the back of the ear, 
 the bone above and posterior to the meatus externus, over the space 
 of a sixpence, was denuded, and was rough, black, and soft : the 
 external table had been removed. On making a vertical section of 
 the bone through the horizontal portion of the cells, thg walls of 
 the latter were observed in a state of disease, and the cavity con- 
 tained purulent matter. The outer wall of this portion of the cells 
 
THE MASTOID CELLS. 
 
 327 
 
 was carious throughout. The membranus meatus was softer than 
 natural. The membrana tympani liad been entirely removed by 
 ulceration, as also parts of the tympanic mucous membrane ; the 
 
 Fig. 97. 
 
 A Vertical Section of the Diseased Bone. The walls of the horizontal mastoid cavity are 
 diseased ; the upper wall forming part of the cerebral cavity, and continuous with the 
 external wall, is carious ; the entire substance of the external wall is dead. 
 
 small portions remaining being thick, soft, and of a livid color. The 
 long process of the malleus had disappeared, and the remnant was 
 partially disconnected from the incus, as was the incus from the 
 stapes. The inner surface of the carious bone is of a dark color, 
 and is itself carious, presenting numerous small depressions. The 
 thick, soft, and red dura mater was separated from the carious bone 
 by a transparent fluid. On examining the right ear, the same dis- 
 ease appeared, but in an incipient state ; the meatus was soft and 
 red ; the membrana tympani thick, white, and concave ; the mucous 
 membrane lining the tympanum and mastoid cells, was thick and 
 red ; and there Avas a collection of mucus. Another case, which 
 occurred under the care of Mr. II. J. Johnson, when assistant-sur- 
 geon to St. George's Hospital, is as nearly as possible a counterpart 
 of the one just cited ; and the specimen for which I am indebted to 
 that gentleman, is almost a fac-similc of the preceding one. 
 
 Disease sometimes extends uj^Avards and outwards, and destroys 
 nearly the whole of the squamous portion. A case of this kind Avas 
 brought under my notice by Mr. "Willing, of Ilampstead. The fol- 
 lowing are the particulars furnished by him. 
 
328 THE DISEASES OF THE EAR. 
 
 Case III. Scrofulous disease in the horizontal j^ortion of the mas- 
 toid cells before the first year; destruction of a large' part of the 
 squamous hone by caries; disease of the dura mater ; a small abscess 
 in the cerebrum, — M. A. W., aged 11 months, the youngest of three 
 children ; the other tAvo were healthy. The parents are in bad 
 circumstances ; the mother very emaciated, having during her preg- 
 nancy had very insufficient food, owing to her husband, a brick- 
 layer's laborer, being out of work for a long time. The child was 
 first seen by Mr. Willing in June, 1850, and was then three months 
 old, small and much atrophied. The mother said it was small Avhen 
 born ; and as she had no milk, she endeavored to bring it up by 
 hand. There had been, she added, a discharge from the right ear 
 since birth. On examination, a redness and tumefaction both of 
 the meatus and ear were observed, with evident tenderness on pres- 
 sure of the mastoid process, and the cervical glands were enlarged. 
 The child suffered under diarrhoea, and was extremely weak. Cod- 
 liver oil was administered, and emollients applied to the ear, which 
 was syringed daily with warm water. Under this treatment, the 
 child somewhat improved until October, when paralysis occurred on 
 the left side of the face. The discharge grew more abundant, the 
 soft parts round the ear became sloughy, and the mastoid process 
 offered no resistance to pressure. These symptoms lasted till the 
 death of the child in February. 
 
 Autopsy,, thirty-tivo hours after death. — The body was so much 
 emaciated as to be scarcely larger than at birth. The dura mater 
 was very thin, and the surface of the brain greatly congested, with 
 patches of dark-colored blood scattered over its hemispheres, espe- 
 cially on the right side, where, in one or two places, they extended 
 to the depth of three or four lines into the substance of the brain. 
 The cerebral veins were distended by coagula. At the surface of 
 the posterior part of the middle lobe, on the right side, was a small 
 abscess, the size of a pea. The ventricles contained about three 
 ounces of thick, turbid serum. The middle cerebral artepes Avere 
 distended by firm fibrin, and there were about four ounces of fluid 
 at the base of the brain. The dura mater covering the petrous 
 portion of the right temporal bone was separated from it by pus, 
 and very much thickened. 
 
 On examining the temporal bone, which Mr. Willing presented to 
 me, I found that the part of the squamous portion between the root 
 of the zygomatic process and the mastoid process had been entirely 
 
THE MASTOID CELLS. 
 
 329 
 
 destroyed ; and that the larger part of the mastoid process had 
 also disappeared, causing an aperture an inch in length, and three- 
 quarters of an inch in depth. The petrous bone was detached, and 
 both its superior and posterior sm-faces were carious. The small 
 remaining portion of the mastoid cells contained scrofulous matter. 
 
 In other cases the diseases may advance to a very considerable 
 extent, and then, supposing the health to improve, reparative efforts 
 may be made. A highly interesting case of this kind was brought . 
 under my notice through the kindness of Mr. French, to whom I 
 am indebted for the opportunity of making a careful dissection of 
 the ear. The case derives additional interest from the fact tliat it 
 was the subject of judicial proceedings, the exciting cause of the 
 fatal symptoms being a blow on the head. 
 
 Case IV. Catarrh of the mucous membrane of the horizontal por- 
 tion of the mastoid cells in childhood; caries of the hone; imrtial 
 reparation hy deposit of neio hone. Death folloiving a hloiv on the 
 head; abscess in cerebrum. — E. C, aged 12, previously in good 
 health, Avas seen on the 3d of July, 1850, on account of violent pain 
 in the head, chiefly in the left temporal region, accompanied by severe 
 febrile symptoms. The day before she had received a violent blow, 
 on the head, during a scuffle ; she was thrown down, her head struck 
 against the door, and subsequently against the wall : a similar, but 
 less severe assault, was repeated a few minutes afterwards. On 
 examination, there was a fulness of outline, and a puffiness of the 
 temporal muscle. The symptoms of cerebral irritation and fever 
 rapidly increased ; a large abscess formed beneath the temporal 
 muscle ; discharge issued from the ear ; coma ensued ; and death 
 occurred twenty-two days after the injury. It could not be ascer- 
 tained whether there was a history of discharge from the ear in 
 earlier childhood. 
 
 Autopsy. — The pericranium was found separated from the squa- 
 mous bone by purulent matter ; the dura mater lining the squamous 
 bone, and covering the upper wall of the tympanum, was thicker 
 than natural, and but slightly adherent to the bone ; the arachnoid 
 and a portion of cerebral matter Avere attached to this part of the 
 dura mater. In the cavity of the middle cerebral lobe was an 
 abscess containing four ounces of pus. The petrous bone was dis- 
 eased. The membranous meatus was thicker than natural, and its 
 free surface was smooth, presenting no signs of ulceration. The 
 superior and posterior walls of the osseous meatus were rough, and 
 
330 THE DISEASES OF THE EAR. 
 
 this roughness was produced by a deposit of new bone, which was 
 also found to extend on the outer surface of the squamous bone, 
 above the meatus, for a space measuring half an inch in its vertical, 
 and an inch in its antero-posterior diameter. The posterior tAVO- 
 thirds of the mombrana tympani were absent ; the mucous membrane 
 of the tympanum was liealthy ; but in the passage to the mastoid 
 cells there was a collection of pus and scrofulous matter, which had 
 ■ not been freely discharged on account of the small size of the aper- 
 ture leading into the tympanum, contracted as it was by the thick 
 mucous membrane. The upper wall of the tympanum was in a dis- 
 eased state; the surface next to the dura mater being composed of 
 a very fine scale of dead bone, about six inches long by four broad, 
 which was perforated by small orifices, and eaten away posteriorly 
 in parts. Beneath this dead bone Avas a layer of new bone, which 
 formed the upper wall of the tympanum, and was continued upwards 
 and outwards on the inner surfi\ce of the squamous bone to its upper 
 margin. The old bone underneath and adjacent to the new bone 
 was worm-eaten, and had been the seat of the disease ; it was about 
 half an inch in breadth. 
 
 • There can be no doubt, from tlie examination of the specimen, 
 that disease in the horizontal portion of the mastoid cells had com- 
 menced in early childhood ; that, as in the cases previously cited, 
 the squamous bone became diseased, the dura mater and the cere- 
 brum being also afiected, but not to such a degree as to endanger 
 life. It would further appear, that as the bone was developed, new 
 bone was deposited on each side of the diseased squamous bone, and 
 extended into the meatus, which, it will be remembered, forms in the 
 first few years of life part of the squamous bone ; and it is possible 
 that, in spite of the disease of the brain and dura mater, the patient 
 might have lived many years, if no very active exciting cause had 
 been brouglit into operation. At the same time, it is most probable 
 that the blow on the head would not have caused death had there 
 not been pre-existing disease ; and in this view the Grand Jury 
 concurred. 
 
 The peculiar anatomical relations of the mastoid cells in childhood 
 have now been pointed out : it has been shown, that in the first year 
 of life the mastoid process is not developed, and consists merely of 
 the horizontal portion, wliich is intimately connected with the cere- 
 bral cavity, to whicli, in cliihlhood, disease is usually propagated 
 ratlicr than to the cavity of the cerebellum. Those cases of disease 
 
THE MASTOID CELLS. 331 
 
 in early life which have been hitherto described, must be, therefore, 
 Considered as exceptions to the rule previously laid down by nie, — 
 that affections of the mastoid cells produce disease in the cerebellum. 
 
 {h.) DISEASES OF THE MASTOID CELLS IN THE ADULT. 
 
 Subsequent to the second or third year of life, when the mastoid 
 process is somewhat developed, it will be found that the layer of 
 bone bounding the horizontal portion externally, attains to a thick- 
 ness of three or four lines, and becomes extremely dense. Hence, 
 after the first or second year of life, disease is scarcely ever observed 
 to extend from the horizontal portion to the outer surface of the 
 squamous bone ; but as the cells are developed posteriorly, and con- 
 tract intimate relations with the lateral sinus and the cerebellum, it 
 is to these two parts that disease is communicated. 
 
 Cases of disease in the mastoid cells may be divided into acute 
 and chronic. 
 
 I. Acute inflammation of the mucous membrane lining the mastoid 
 cells. — This affection is somewhat rare, and when it does occur, is 
 usually subdued before it progresses to the bone or dura mater. 
 
 Cases, however, are occasionally met with in which acute inflam- 
 mation of the mucous membrane lining the mastoid cells ends in 
 suppuration, the lateral sinus becomes inflamed, and abscesses occur 
 in the brain. The following is a case of the kind which occurred to 
 Dr. Brinton, at the Royal Free Hospital, to whom I am indebted 
 for the notes of the case, and for the opportunity of making the 
 dissection. 
 
 Case I. Acute inflammation of the mucous membrane lining the 
 mastoid cells ; suppuration ; disease of the lateral sinus ; abscess in 
 the cerebellum. — A girl, aged 21, was admitted into the hospital, 
 three weeks subsequent to an attack of scarlet fever. The history 
 was, that since the fever, she has had a constant and abundant dis- 
 charge from the left ear. On admission, this discharge was observed 
 to be copious ; she was drowsy, and at times almost comatose, with 
 a rapid feeble pulse, a cold body and limbs, and a hot face and head. 
 In spite of all the remedies employed, the coma gradually grew more 
 intense, and she died ten days after her admission. 
 
 Autopsy. — An abscess Avas found in the left lobe of the cerebellum, 
 of the size of a walnut. It extended to the surface, and thus came 
 
332 THE DISEASES OF THE EAR. 
 
 in contact with a large qnantitv of pus, bounded by the diseased and 
 distended -walls of the lateral sinus, Avhich latter contained pus and 
 blood. There was an opening through the membrana tympani of a 
 regular shape, and of a size one-third the whole dianfeter of the mem- 
 brane. The upper wall of the tympanum was healthy, and not eyen 
 discolored. The portion of the mastoid cells posterior to the incus 
 contained some pus and blood mixed together ; this extended down 
 as far as the mastoid process. The portion of the lateral sulcus, 
 about an inch long by half an inch broad, Avhich forms the exterior 
 boundary of this part of the mastoid cells, was of a dark leaden 
 color. The canals in this portion of the bone were also distended 
 with black matter. 
 
 It seems to me, there can be no doubt that, in this case, the puru- 
 lent matter from the mastoid cells was the cause of the disease in the 
 lateral sinus, for the bloodvessels between the two parts were dis- 
 tended with dark pus and blood. 
 
 II. Chronic injlammation of the mucous membrane lining the mas- 
 toid cells. — Cases of chronic disease of the mastoid cells usually take 
 their origin before the adult period of life, although the more seri- 
 ous symptoms may not be developed until after that period. As 
 in disease of the tjnnpanum, the cases now under consideration 
 commonly originate in chronic inflammation of the mucous mem- 
 brane. Whatever may be the cause of this inflammation, — whether 
 scarlet fever, measles, or an ordinary cold, — the result is the secre- 
 tion of a larger quantity of mucus than is natural, which in the 
 milder forms of the affection is afterwards absorbed, or else dis- 
 charged through the tympanic cavity and Eustachian tube, into the 
 cavity of the fauces ; but in the more severe, to which attention has 
 now to be directed, the mucous secretion is too abundant to escape 
 from the cells, and the bone becomes affected. 
 
 The effects of chronic disease in the mastoid cells upon the lateral 
 sinus and cerebellum are : — 
 
 1st. Suppuration in the lateral sinus with or without secondary 
 purulent deposits. 
 
 2d. Inflammation of the dura mater and arachnoid, and the forma- 
 tion of pus on the surface of the cerebellum. 
 
 3d. Abscess in the cerebellum. 
 
 The history of cases of chronic disease in the mastoid cells bears 
 some analogy, to that of those occurring in the tympanic cavity, al- 
 though, as a general rule, there is more irritation from the outset of 
 
THE MASTOID CELLS. 333 
 
 the aifcction, and consequently attention is attracted to the case in 
 its early stages ; and this is the reason, as will be seen when the 
 treatment is spoken of, Avhy the disease is more amenable to reme- 
 dial measures than when it attacks the tympanum. The following 
 may be taken as the ordinary history of a case of disease advancing 
 from the mastoid process to the lateral sinus or cerebellum. The 
 patient, who has often a tendency to glandular enlargements, has 
 suffered when a child from pain in the ear, followed by discharge. 
 During childhood, and perhaps up to adult age, there have occurred 
 attacks of pain and discharge at intervals of some months. Between 
 the attacks there is often a sensation of pain in the region of the 
 mastoid process and back of the head, and giddiness sometimes 
 comes on. These symptoms are aggravated by fatigue or any other 
 depressing influence. Upon examination, the surface of the meatus 
 is seen to be red, and to be the source of the discharge. No perfo- 
 ration exists in the membrana tympani, which, however, is white and 
 thickened, so that the discharge is purely sympathetic. The surgeon 
 is more commonly called, however, to cases where the symptoms 
 have become much more urgent, and where, indeed, the disease has 
 advanced so far that the brain or its membranes have become so 
 greatly disorganized as to defy all remedial measures. 
 
 Cases of disease in the mastoid cells terminate fatally from two 
 different causes. 
 
 1st. From purulent infection, arising from the introduction of pus 
 into the circulation through the lateral sinus. 
 
 2d. From disease of the cerebellum or its membranes. 
 
 Cases of pwulent infection have not been met with- when the 
 disease occurs in the tympanic cavity. On account of the proximity 
 of the jugular vein to the lower wall of the tympanum, it is, however, 
 quite possible for disease to extend to the venous system. 
 
 Dr. Abercrombie published an interesting case of purulent infec- 
 tion from disease of the ear ; but the subject has been more 
 thoroughly investigated by Dr. Watson, who, although deprived of 
 the opportunity of making post-mortem inspections of the highly 
 important cases he has so fully described, had no doubt in his mind, 
 and leaves no doubt in the minds of his readers, that the cause of 
 death was the introduction of pus into the system from the mastoid 
 cells. Dr. Bruce has since published some valuable cases bearing 
 upon the subject ; Mr. Wilde gives the details of a case in his work 
 on the ear ; and more recently still. Dr. Gull, in the Guy's Hospital 
 
331: THE DISEASES OF THE EAR. 
 
 Reports, has thrown much light on the subject. The facts brought 
 forward by these gentlemen, coupled with those which are now to be 
 related as the result of my own experience, will, I trust, lead to a 
 thorough comprehension of the nature and progress of the disease. 
 Dr. Abercrombie's case is the following : — 
 
 Disease of the mastoid cells ; deposit in the lateral sinus ; secon- 
 dary deposit in the pleura. — A young lady, aged 15, had been liable 
 for six or seven years to attacks of pain in the right ear, followed 
 by discharge of matter ; but she had been free from any of these 
 attacks for some time previous to the abscess which forms the sub- 
 ject of the following history. On the 25th April, 1822, she com- 
 plained of cold shivering through the day, and in the evening had 
 headache with pain in the right ear, symptoms which continued on 
 the following day. On the 28th she was seen by Mr. Brown, who 
 found her with quick pulse and foul tongue, severe pain in the ear, 
 and slight headache. On the 29tli some discharge took place from 
 the ear, but without relieving the pain which continued with violence 
 until the next day. On the 1st of May the pain had somewhat 
 abated in the ear, but had extended over the right side of the head; 
 pulse frequent. General and local bloodletting were employed 
 with partial relief. I saw her on the 3d ; the headache Avas then 
 rather abated ; the pulse was frequent and weak ; she had a pale, 
 unhealthy aspect, and a look of oppression bordering upon coma. 
 The pain Avas chiefly referred to the parts above and behind the 
 right ear, Avhere the integuments were painful on pressure, and, at 
 one spot near the mastoid process, felt soft and elevated. A punc- 
 ture was made at this place with a lancet, but nothing was discharged. 
 Topical bleeding, blistering, (fcc, were recommended. 
 
 4th. — Pulse in the morning 148 ; in the course of the day it fell 
 to 84 ; looking very languid and exhausted. 
 
 5th. — Dark-colored matter of intolerable fetor began to be dis- 
 charged from the puncture Avhicli had been made behind the ear. 
 The opening here was enlarged, and a probe being introduced, the 
 bone was felt bare and rough over a considerable space ; headache 
 much relieved ; pulse natural. 
 
 Gth. — Great discharge from the opening, headache much relieved; 
 pulse 112 ; complained of some pain in the left side of thorax, and 
 there was considerable diarrhoea. 
 
 7th. — No headache; there was much discharge of fetid matter 
 from the opening near the mastoid process, and a probe introduced 
 
THE MASTOID CELLS. 335 
 
 by it passed downwards and backwards, under the integuments, as 
 far as the spine. 
 
 8th. — Pain in the thorax continued, and was noAV so urgent that a 
 small bleeding was employed with partial relief; it could not be 
 carried further on account of increasing weakness; pulse 140. 
 
 9th. — Said she felt better, and made no complaint of pain ; pulse 
 very rapid, and strength sinking. 
 Died on the 10th. 
 
 Autopsy. — Every part of the brain was in the most healthy state, 
 except a small portion on the right side, near the ear, which was of 
 a dark leaden color ; the tinge, however, was entirely superficial. 
 The right temporal bone externally was bare, through a great part 
 of its extent ; internally, it was in many places rough and dark- 
 colored ; and there was some dark-colored matter betwixt it and the 
 dura mater. The dura mater at this place was, for a considerable 
 space, thickened, spongy, and irregular ; the coats of the right lateral 
 sinus Avere greatly thickened through its whole extent, and the 
 capacity of the sinus Avas very much diminished by a deposition 
 similar to that Avhich occurs in the cavity of an aneurism. The in- 
 ternal ear contained dark-colored matter ; the left cavity of the 
 pleura contained fully a pound of puriform fluid ; the left lung was 
 collapsed, dense, dark colored, and covered by a coating of coagu- 
 lable lymph. 
 
 From the examination made by me of deposits in the cavity of 
 the lateral sinus, I have no doubt that the matter alluded to in the 
 above case, consisted of coagulated blood mixed with pus. 
 
 The following is one of Dr. Watson's cases : "A boy, 11 years 
 old, had had a discharge of offensive, purulent matter from his ear 
 since the time Avhen, four years before, he had gone through an at- 
 tack of scarlet fever. In August, 1838, he Avent for a Avalk into 
 Kensington Gardens, and there lay doAvn and slept upon the damp 
 grass, . The next day he Avas attacked with headache, shivering, and 
 fever; strong rigors, followed by heat and perspiration, occurred 
 very regularly for tAvo or three days in succession, suggesting the 
 suspicion that his complaint might be ague ; but then pain and swel- 
 ling of some of the joints came on, and AA'cre at first considered 
 rheumatic. However, the true and alarming nature of the com- 
 plaint soon became apparent ; abscesses formed in and about the 
 affected joints, and one of these fluctuating SAvellings Avas opened, 
 and a considerable quantity of foul, grumous, dark-colored matter 
 
336 THE DISEASES OF THE EAR. 
 
 let out. After about a fortnight, the child sank under the con- 
 tinued irritation of the disease. The hip-joint presented a frightful 
 specimen of disorganization ; it was full of unhealthy sanious pus ; 
 the ligamentum teres was destroyed, the articular cartilages were 
 gone ; and matter had burrowed extensively among the surround- 
 ing muscles. The knee and ankle-joints of the same limb were in a 
 similar condition. Unfortunately the head was not examined, but 
 that the fatal disorder had penetrated from the ear to the dura 
 mater, I entertain no doubt; in all probability the inflammation had 
 involved the veins or sinuses of the head." 
 
 Having given another case of a similar natui'e. Dr. Watson 
 says : — 
 
 " I much lament that, in these instances, the direct link of con- 
 nection between the disease of the ear and the disorganization of 
 the joints was not demonstrated, for seeing (they say) is believing. 
 Yet the pain of the ear, the discharge of pus from the external 
 meatus, the subsequent pain in the head, coming on with fever and 
 rigors, and followed, after a short interval, by destructive suppura- 
 tion in several distant parts, and, in the latter case, the actual 
 femoral phlebitis, — these circumstances form a chain of presumptive 
 evidence amounting, in my judgment, to moral certainty, that the ' 
 fatal mischief, in each case, found entrance through the porches of 
 the ear, and that the dura mater underwent inflammation. The 
 same evidence is scarcely less afiirmative of the complication of 
 cerebral phlebitis. Perhaps the veins of the diploe, which, in the 
 cranial bones, are of considerable magnitude, were involved in the 
 inflammatory mischief; perhaps the large sinuses of the brain. The 
 close proximity of the lateral sinus to the diseased bone, and its 
 formation by a duplicature of the dura mater, would seem to render 
 such a complication highly probable." 
 
 The direct link of connection between the disease in the ear and 
 that of the circulating system was pointed out by Dr. Bruce, and 
 also in the case cited by Mr. Wilde. In the latter, " The membra- 
 nous walls of the right lateral sinus, throughout the whole of the 
 mastoid portion of its course, were much thickened, and their lining 
 presented a sloughy appearance, being covered with lymph of a 
 greenish hue, and smeared with unhealthy purulent matter. This 
 condition of the lining membrane extended along the jugular vein 
 and superior vena cava to within a short distance of the entrance of 
 the latter into the auricle. The left cavity of the pleura contained 
 
THE MASTOID CELLS. 337 
 
 about four ounces of a thin fetid matter." In addition to the facts 
 above cited, all tliat is required is, an account of the exact condi- 
 tion of the ear ; and this has been supplied by me in the following 
 case, which occurred to Dr. Heale, at the Free Hospital. 
 
 Case II. Pus in mastoid cells ; caries of the lateral sulcus ; pus 
 in the lateral sinus ; secondary deposits. — Harriet G., aged 20, was 
 admitted into the hospital on the 9th March, 1850. She had great 
 fluttering and irregular vibrating action of the heart, resembling 
 erythismus mercurialis, but which subsided in a day or two. She 
 was deaf in the left ear, and had long been subject to intense ear- 
 ache, with occasional fetid discharge from the meatus. She was 
 restless, sleepless, occasionally delirious, and had no appetite. Soon 
 after her admission, an abscess formed just above the left collar-bone, 
 which discharged large quantities of matter until her decease. The 
 disturbance of the heart's action returned after three doses of hyd. 
 c. creta, six grains having been given every six hours ; but it again 
 subsided in about two days. She then had severe delirium, which 
 abated after a sudden large and fetid discharge from the left ear : 
 finally she had erysipelas, violent delirium, succeeded by coma, and 
 died on the 15th of April. 
 
 Autopsy. — A very large excavated abscess, with sinuses in vari- 
 ous directions, was exposed at the root of the neck on the left side, 
 communicating with and extending through the whole of the carotid 
 sheath. The internal jugular vein was full of matter, Avhich was 
 also found burroAving down in the direction of the vena innominata ; 
 a fibrinous clot was found in that vein extending into the descending 
 vena cava ; and having been examined by the microscope, was found 
 to contain pus globules. The lungs were filled with a frothy and 
 purulent infiltration, without consolidation, and there was a small 
 circumscribed absoess betAveen the pleura pulmonalis and the right 
 lung, which, however, did not extend into the substance of the latter. 
 The heart was healthy ; the liver pale-colored. The cerebrum was 
 healthy ; the arachnoid membrane, in parts, appeared smeared over 
 with pus, more particularly in the posterior part, near the falx, 
 joining the tentorium. The tentorium covering the left lobe of the 
 cerebellum was much inflamed, thickened, and had matter between 
 it and the arachnoid covering that lobe of the cerebellum ; and im- 
 mediately beneath this, on cutting into the cerebellum, a circum- 
 scribed abscess, about the size of a walnut, was discovered. This 
 was nearer to the falx cerebelli than to the outer margin of the 
 
 22 
 
:j38 THE DISEASES OF THE EAR. 
 
 cerebellum : the part of the cerebellum in contact with the cranial 
 bones was healthy. 
 
 The petrous bone was examined by myself, and reported upon as 
 folloAvs : — 
 
 The meatus externus contained purulent matter. The glandular 
 and periosteal portions of the membranous meatus were much softer 
 than natural, and adhered but slightly to the surface of the bone. 
 The bone forming the upper and outer half of the tube was found 
 to present numerous foramina for the transmission of bloodvessels, 
 which were much larger than natural, and some of them surrounded 
 by delicate layers of new bone : through the larger of these fora- 
 mina, good-sized bristles could be passed, and they appeared to com- 
 municate with canals in the interior of the bone, which were them- 
 selves continuous with orifices in the sulcus lateralis at its inner 
 surface. The lateral sinus was of a dark brown color, and the dura 
 mater formins; its exterior wall was entire. The sinus was full of 
 coagulated blood, mixed with purulent matter. The dura mater 
 constituting its anterior wall, and which was in contact with the 
 surface of the bone forming the sulcus lateralis, was very thick and 
 soft ; portions of it were destroyed by ulceration, and the bone Avas 
 exposed. This bone was dark in color, and covered l)y masses of 
 lymph and pus; its surface was rough, presenting throughout nume- 
 rous orifices and tortuous grooves, — an appearance which was pro- 
 duced by the nearly complete absence of the internal table of the 
 skull, that (with the exception of two scales, each measuring about 
 two lines in diameter) having been destroyed by caries. 
 
 A carious orifice existed between the cavity of the cerebellum 
 and the mastoid cells. The bone forming the jugular fossa was also 
 carious. There was an orifice in the posterior part of the merabrana 
 tympani. • 
 
 The tympanic mucous membrane was much thicker than natural, 
 and in the upper osse9us wall were observed a few small foramina 
 for bloodvessels, and a carious orifice of a size sufficient to allow the 
 passage of a small pin. 
 
 The mastoid cells at their upper part formed a cavity about the 
 size of an ordinary horse-bean, and contained pus. This cavity 
 communicated posteriorly with the lateral sulcus by means of an 
 orifice three lines in diameter. Anteriorly, the orifice into the 
 tympanic cavity was not more than two lines in diameter, and was 
 placed above the level of the floor of the cavity containing the pus. 
 
THE MASTOID CELLS. 339 
 
 It lias been already stated that the anterior wall of the mastoid 
 cells is formed by the posterior wall of the osseous external meatus. 
 The latter wall, in some cases, becomes carious, and matter is dis- 
 charged through it, as was the case in the following interesting in- 
 stance, but the orifice was not large enough to be effectual in reliev- 
 ing the symptoms. 
 
 Case III. Pus and scrofulous matter in the mastoid cells ; commu- 
 nication with the lateral sinus by the veins; secondary deposit in pleura. 
 — Kitty D., aged 15, was admitted under my care as an out-patient 
 of St. Mary's Hospital on the IGth of February, 1854. She stated 
 that six months previously she suffered from pain in the left ear, 
 Avhich was followed by dulness of hearing in it, as well as in the 
 right ear, which had remained to the present time, accompanied by 
 a discharge from the left ear. On examining the left ear, a small 
 red polj'pus was seen at the inferior part of the meatus, near to the 
 mcmbrana tympani : the latter membrane Avas white. She did not 
 complain of pain in the head. Gentle counter-irritation was or- 
 dered behind the car, which was to be syringed with a weak astrin- 
 gent lotion. The patient continued much the same until March 
 27th, when she was admitted, in my absence, as an urgent case, 
 imder Dr. Sibson, into the hospital. When admitted, she was par- 
 tially unconscious, extremely prostrate, and could not speak : the 
 skin was parched ; the tongue broAvn and dry ; pulse 140, very small 
 and thready : pupils sluggish — the left rather more contracted than 
 the right. On inquiry, it was found that, three days before, a marked 
 difference was perceived in her manner, and attributed to the pain 
 in the head and left ear, of which she complained greatly. She was 
 unable to do any work. On the 25th, she kept her bed ; on the 26th, 
 she became still worse ; and on the 27th, application was made at 
 the hospital. Upon being Seen by one of the officers, she was at 
 once admitted. Stimulants were freely administered, and the pa- 
 tient somewhat rallied : during the night, she was very restless, and 
 wandered a good deal. 
 
 28th. — Seems quite sensible of all that is done to her, but does 
 not speak, muttering only to herself. Pulse 140 ; skin hot, though 
 some moisture is still apparent. Loud sonorous rhonchus of right 
 lung ; the head is held to the right sidej the mouth also is drawn to 
 the right ; the nostrils are expanded ; and there is partial paralysis 
 of some of the muscles on the left side of the face. She was sup- 
 ported by stimulants at the same time that a leech was applied to 
 
r,40 THE DISEASES OF THE EAR. 
 
 the neck. 10 p.m. — A^ery low, surface cold; skin clammy; face 
 livid ; subsiiltus tendinum ; pulse feeble and irregular. 
 
 2ntli. — Much as yesterday; rambled during the night ; voids urine 
 involuntarily ; tongue brown and moist ; pulse 140, very small. 
 During the evening very low ; voided urine in the bed ; muscles 
 suddenly contracting. 
 
 30th. — Slept badly; at times wandered much; breathing hurried; 
 pulse 140 ; nostrils dilated. She gradually became worse, and died 
 at 2-15 P.M. 
 
 AutojJSi/. — Cerebrum firm ; ventricles dry ; gray substance very 
 dark. Over the left lobe of the cerebellum, at the posterior part of 
 the petrous bone, is a dark bluish portion, of the size of half-a-crown. 
 The gray matter of the cerebellum very blue to the depth of one- 
 eighth of an inch, and beneath the discolored spot the substance of 
 the cerebellum was slightly softened. There were considerable ad- 
 hesions between the lungs and the pleura costalis ; and also tuber- 
 cular deposit covered by an unhealthy plastic, fibrinous exudation ; 
 the pleural cavities contained a pint of fluid. The dura mater form- 
 ing the posterior wall of the lateral sinus (where it is situated in the 
 temporal bone) was of a dark color and soft ; the sinus contained, at 
 its upper part, a firm coagulum of dark-colored fibrin ; at its lower 
 part it was full of dark-colored pus. The anterior Avail of the sinus 
 was attached to the bone much less firmly than natural. The mas- 
 toid cells were full of pus and scrofulous matter ; and their anterior 
 wall presented an orifice, about two lines in diameter, which opened 
 into the meatus externus. The incus and the thick mucous mem- 
 brane around it prevented the pus from escaping. The orifices for 
 the passage of the bloodvessels from the mastoid cells to the lateral 
 sinus were somewhat larger than natural. 
 
 It will be observed that in this case there Avas no caries of the bone 
 towards the cerebellum ; and the only means by which the disease 
 from the nuistoid cells could be propagated to the cavity of the late- 
 ral sinus must have been the veins. 
 
 A sufficient number of facts have now been cited to shoAv how very 
 insidiously disease progresses from the mastoid cells to the cerebellum 
 and lateral sinus, and to prove that the sinus may become influenced, 
 purulent matter developed within it, and secondary abscesses pro- 
 duced, without the occurrence of caries in the bone forming the sinus 
 lateralis. 
 
 It has been alreatlv stated that the cause of disease advancing 
 
THE MASTOID CELLS. 341 
 
 from the mastoid cells to the lateral sinus and the brain, is the 
 retention of the dischai-ge within these cells, instead of its finding a 
 free egress throno-h the external meatus. 
 
 In the cases of death from purulent infection which have been 
 detailed, it will have been observed that there was merely a small 
 aperture in the membrana tympani, so that only part of the matter 
 could be discharged from the mastoid cells ; and it seems to me 
 probable, that if, in any way, a sufficient portion of the membrana 
 tympani had been removed at the beginning of the attack, to permit 
 of a thorough evacuation of the contents of the mastoid cells, the 
 bone Avould have remained free from disease — an opinion which 
 seems corroborated by the following case : for it will be noted that 
 the scarlet fever appears to have attacked the mastoid cells of each 
 ear equally. In each, the lower half of the membrana tympani Avas 
 destroyed ; but in the organ of which the bone became diseased, it will 
 be remarked that the lower margin of the remnant of the membrana 
 tympani fell inwards towards the promontory, to Avhich it became 
 attached, and by this means the escape of matter from the mastoid 
 cells was prevented ; while, in the other ear, the lower margin of 
 the membrane remained free, and the discharge readily escaped. 
 The case, of which the particulars were sent to me by a friend, 
 togetlicr Avith the petrous bones, is of importance on other grounds, 
 since it shoAvs the coexistence of disease in the mastoidal and tym- 
 panic cavities, and the contemporaneous production of disease in the 
 cerebrum and cerebellum. It is further of interest as pointing out 
 how very little relation exists betAveen the condition of the bone 
 forming the lateral sulcus, and the contents of the lateral sinus. 
 In some cases already described, the lateral sinus contained a large 
 quantity of pus, but the bone was not carious ; whereas in the fol- 
 lowing case, where the bone forming the lateral sulcus was so much 
 diseased that a large portion Avas necrosed and completely detached 
 from the surrounding parts, there was no pus in the sinus. The 
 explanation of this circumstance, found also in other cases, is most 
 probably to be sought for in the fact, that Avhen there is extensive 
 caries of the substance of the bone, there is more space for the 
 matter, and hence the pressure upon the sinus is comparatiA'ely 
 slight. 
 
 Case IV. Catarrhal injlammation of the mucous membrane lining 
 the mastoid cells of the ear; retention of the discharge in the right 
 ear by the adhesion of the membrana tympani to the promontory ; 
 
342 THE DISEASES OF THE EAR. 
 
 caries of the right lateral sulcus, and abscesses in the cerebrum and 
 cerebellum. — J. R., aged 12, had an attack of scarlet fever two years 
 previously, since Avhich he has had a discharge of matter from each 
 ear, and a considerable diminution of the hearing power. On the 
 13th of February, 1854, he complained of rigors and general 
 malaise; these were followed by febrile symptoms and pain behind 
 the left ear. On the 15th, a small abscess was observed behind the 
 ear, which, Avhen opened, discharged a sanguineous fluid. There 
 was a slight degree of stupor, and the discharge continued without 
 relief to the pain. On the 20th, he had somcAvhat improved ; pain 
 less ; stupor diminished ; discharge from the meatus as well as from 
 the abscess. On the 21st, another abscess formed over the mastoid 
 process ; pulse small and frequent, discharge very fetid. 22d. — 
 Decidedly improved in every respect ; but the pain and feverish 
 symptoms returned on the 23d, in an aggravated form ; the drowsi- 
 ness much increased, so tliat he had to be roused up to take his 
 food, and he soon fell back ao;ain into the same state. He jiradu- 
 ally became weaker; the urine and fences were passed involuntarily; 
 the stupor was increased ; and the prostration was extreme. On 
 the 4th of March, he had two severe rigors, and constantly cried out 
 on account of the severe pain in the head. The pain gradually in- 
 creased till the 6th of March, Avhen attacks of pain came on every 
 ten minutes, and of so acute a character as to cause him to scream. 
 During the succeeding seven days, he suffered much less pain ; and 
 there was a copious sanious discharge from the ear and from the 
 abscess. On the 15th, the stomach became irritable, and rejected 
 everything introduced into it. The pain, at times, Avas extreme. 
 On the ICtli, at tAventy minutes past twelve, he suddenly became 
 convulsed, the face and chest Avere of a deep blue, the pulse Avas 
 imperceptible at the Avrist, the pupils dilated and fixed, and in this 
 state he died. Upon inquiry, it appeared that, since the fever, the 
 patient had suffered from frequent headaches, languor, and drowsi- 
 ness. 
 
 Autopsy. — The bloodvessels of the dura mater Avere highly con- 
 gested. In the sulcus lateralis Avas a portion of necrosed bone, 
 about three-quarters of an inch long, and half an inch broad, and 
 quite detached from the surrounding bone : its outer part formed a 
 portion of the mastoid process ; between this detached piece of bone 
 and tlie dura mater was a large quantity of purulent matter, Avhich 
 communicated Avith the superficial abscess behind the ear. An ab- 
 
THE MASTOID CELLS. 343 
 
 scess was also found in the substance of the middle lobe of the cere- 
 brum. Upon examining the ear, the lower half of the membrana 
 tympani was found to have been destroyed, and the inferior half of 
 the upper part Avas attached to the promontory, so that the upper 
 portion of the cavity of the tympanum was closed, and the matter 
 secreted there had no exit. The tympanic mucous membrane was 
 thick, and ulcerated in parts, and the mastoid cells presented a 
 large cavity full of pus. In the opposite ear the lower two-thirds 
 of the membrana tympani were absent, but the upper part was not 
 adherent to the promontory ; so that there was ample room for the 
 egress of discharge from the tympanum. The tympanic mucous 
 membrane was thick, but not otherAvise diseased ; the bone was 
 healthy. 
 
 A case very similar to the last cited was brought under my notice 
 by Dr. Ogle, who was so good as to give me the preparation. In 
 this case the disease had made way externally, so that the mastoid 
 process Avas broken up, Avhile the sulcus lateralis Avas by comparison 
 but slightly affected. The veins seem to have been the medium of 
 communication with the lateral sinus, and the cause of the deposit 
 of pus within it. The question Avould probably be asked, Avhy, in 
 these cases of disease in the mastoid cells, does not the matter make 
 its Avay outA\'ards through the external Avail of the mastoid process ? 
 It Avill be observed, that this outAvard advance of the disease has 
 already been noticed in three of the cases ; but while this Avas going 
 on, the internal Avail of the mastoid cells, or of the lateral sinus, 
 became so diseased as to destroy life. It must also be borne in 
 mind that cases are of very frequent occurrence Avhere the disease 
 advances externally, destroying part of the mastoid process, Avhich 
 often comes away en masse, and where the brain and its membranes 
 suffer but slightly. Cases of this kind generally originate in an at- 
 tack of scarlet fever, or of cold ; sometimes the symptoms of cere- 
 bral irritation are but slight, at others, very severe, and usually sub- 
 side Avhen there is a free discharge externally, as will be seen AA'hen 
 speaking of the treatment. 
 
 In the course of the previous observations, it has been stated that 
 in cases of disease Avithin the tympanic cavity catarrh of the dermoid 
 meatus takes place, as the result of sympathetic action, and Avithout 
 the existence of any orifice in the membrana tympani. It is impor- 
 tant to bear this fact in mind, because the attention of the surgeon 
 is apt to be draAvn from the real disease tOAvards the affection of the 
 
344 THE DISEASES OF THE EAR. 
 
 meatus ; indeed, in many cases of irritation of the external meatus, 
 arising from obstruction of the Eustachian tube, the primary disease 
 is often overlooked, and the cause of deafness supposed to reside in 
 the irritation of the meatus. The meatus externus not only sympa- 
 thizes with the condition of the tympanic cavity, by becoming the 
 seat of catarrh, but not unfrequently polypi are developed within it. 
 When tuis happens in cases where there are symptoms of disease of 
 the bone, great care must be taken not to increase the irritation of 
 the ear by interfering with the polypus. The following case is, in 
 this view, worthy of the most attentive consideration. It Avas laid 
 before the Pathological Society in 1851, by the late Mr. Avery, and 
 reported upon by myself. 
 
 Case V. Caries of the mastoid cells ; jpolyiyi in the external mea- 
 tus ; abscess in the cerebellum. — A man, aged 35, had suffered for 
 some years from frequent earache of a severe character, accompa- 
 nied by discharge. About five weeks before his death a large 
 polypus was removed from the external meatus. This was followed 
 soon after by great pain at the back of the head, in the right side, 
 and down the neck and shoulder, of a plunging intermitting cha- 
 racter. 
 
 These pains were treated at first as neuralgic; but they increased 
 in severity and frequency, and rest could only be obtained by the 
 oft-repeated doses of laudanum. The patient appeared generally to 
 be dull, heavy, stupid, and incapable of making any exertion. He 
 several times remarked that people must have thought him intoxi- 
 cated when in the street, as his gait was so very unsteady that he 
 was often obliged to lay hold of the rails to prevent himself from 
 falling. He ultimately became comatose and died. 
 
 Autopsy. — The brain was found to fill the cranial cavity, and tlie 
 convolutions were very closely pressed together. The arachnoid 
 membrane Avas extraordinarily dry ; the lateral ventricles contained 
 a very large quantity of clear limpid fluid, and the fornix and 
 septum lucidum were very white and soft. On separating the cere- 
 bellum from the petrous portion of the temporal bone, a gush of 
 thick creamy pus took place, and an abscess Avas found occupying a 
 cavity in the right lobe, large enough to hohl a pigeon's egg. The 
 contents of this caA-ity Avere very fetid, and the Avails were firm and 
 lined by false membrane, being thin at the point Avhere the cere- 
 bellum rested on the aqufcductus vestibuli of the temporal bone. 
 At this spot there Avas a small ulcerated opening in the dura mater, 
 
THE MASTOID CELLS. 345 
 
 communicating "with a carious portion of temporal bone, and it was 
 here that the disease had been continued to the cerebellum. There 
 was no loose lymph in the cavity of the arachnoid, and only a thin 
 film covering it near the ulcerated opening in the dura mater. The 
 unsteadiness of his gait, in connection with the abscess in the cere- 
 bellum, Avas very remarkable ; but it could not be ascertained, on 
 repeated inquiry, that the want of power over the regulations of his 
 movements affected one side of the body more than the other. 
 
 Upon examining the petrous bone, two small polypi were found 
 attached to the upper and posterior part of the membrana tympani, 
 which was very thick, and presented a small orifice at its anterior 
 part. The membranous meatus was easily detached from the bone, 
 which was darker and rougher than natural. The mastoid cells 
 were carious and full of pus. On removing the dura mater from the 
 posterior surface of the petrous bone, the upper part of the sulcus 
 lateralis Avas found to be carious for a space three lines in diameter, 
 and the orifices in the bone were filled with fibrin. The dura mater 
 coverino; the sulcus lateralis was softened, but the disease had not 
 penetrated to the cavit}^ of the sinus. The dura mater adjacent to 
 the fossa jugularis was soft and partially destroyed by ulceration. 
 The bone beneath it was carious, and Avas found to form part of the 
 posterior Avail of the inner extremity of the mastoid cells, from Avhich 
 the disease had been propagated. 
 
 In addition to the other points of interest in this case, is the fact 
 that disease may be propagated to the jugular vein from the mastoid 
 cells, without the intervention of the lateral sinus. 
 
 I believe it to be rare for disease in the mastoid cells to manifest 
 itself for the first time after the adult period. The folloAving is an 
 instance of the kind. It is impossible to say hoAv long there had 
 been incipient disease ; but from the appearances after death, it is 
 probable that it was of long standing. The case is of great interest, 
 from the fact of the existence of so large an amount of disease, and 
 the presence of formidable symptoms for so short a time only before 
 death. 
 
 CaseNl. Caries of the mastoid cells; destruction of the sulcus 
 lateralis; pus discharged behind the ear. — T. D., aged 29, was under 
 the care of a friend, in May, 1851, on account of diabetes. He 
 remained under treatment for ten Aveeks, during Avhich time he did 
 not complain of pain either in the head or ear. At the expiration 
 of the ten Aveeks he went into the country for a fortnight, and shortly 
 
346 
 
 THE DISEASES OF THE EAR. 
 
 after liis return lie began to speak of pain in the liead, "svhich was 
 principally referred to the right mastoid process. This pain, accom- 
 panied by violent earache, gradually increased, and was attended 
 by a purulent discharge from the ear. Drowsiness, giddiness, and 
 stupor supervened. These symptoms were not relieved by the most 
 active treatment. Six weeks previous to his death, an abscess was 
 opened behind the right ear, from which a large quantity of pus was 
 discharged. No relief followed, the head-symptoms gradually in- 
 creasing until his death. 
 
 Autopsy. — The external meatus contained a large quantity of 
 muco-purulent discharge ; the surface of its dermoid layer was 
 denuded of epidermis, and its substance much tumefied. The meni- 
 brana tympani was entire, but of a dull leaden hue, and much softer 
 than natural. The cavity of the tympanum contained a great quan- 
 tity of j)urulent matter, and its lining membrane was vascular, thick, 
 and flocculent. The incus had disappeared ; the stapes was in situ, 
 but was surrounded 1)Y bands of adhesion. The osseous walls of the 
 
 Fig. 98. 
 
 The Right Petrous Bone, showing the carious condition of the Sulcus Lateralis. 
 
 tympanum were healthy. The mastoid cells were full of purulent 
 matter, and the bony laminix? dividing the cells were extensively 
 carious, large portions of them having been destroyed. The whole 
 of tlie posterior -wall of these cells, usually forming the sulcus late- 
 ralis, was completely destroyed, and in its place was an orifice mea- 
 
THE MASTOID CELLS. 347 
 
 snring an inch and a quarter from above downwards, and more than 
 half an inch in breadth. The orifice in reality corresponded exactly 
 with the sulcus lateralis, as situated in the temporal bone, with the 
 exception of half an inch before it reaches the fossa jugularis. A 
 circular orifice, about the size of a pea, existed at the posterior part 
 of the mastoid process, which communicated with the aperture just 
 mentioned, on the one hand, and with the abscess behind the ear, on 
 the other. The membranous lateral sinus was much attenuated, and 
 beneath it was a large quantity of pus. The state of the cerebellum 
 was not reported. 
 
 From tlie paucity of the notes which accompanied the specimen, 
 the cause of death was not quite clear ; but most probably there was, 
 in addition to the other symptoms, disease of the cerebellum. 
 Probably the life of this patient might have been saved, if a free 
 outlet for the discharge had been effected at an earlier pei-iod. It 
 is important to notice to how great an extent the osseous sulcus 
 lateralis Avas destroyed, without ulceration of the lateral sinus con- 
 tained in it. In this respect the case is analogous to that of P. R. 
 
 A case of a similar character to the last was published by Mr. 
 Gray, of St. George's Hospital, in the Transactions of the Patlio- 
 logkal Society for the Session 1848-9. 
 
 From previous remarks, it will have been gathered that the ex- 
 istence of Ions-continued discharo-e from the ear of the affected side, 
 is one of the most frequent symptoms attendant upon caries of the 
 mastoid portion of the bone. This discharge is usually accompanied 
 by perforation of the membrana tympani, although, as has been 
 pointed out, the discharge usually comes from the surface of the 
 meatus, and is purely sympathetic. The case which follows is of 
 interest, from the fact that the membrana tympani was entire, and 
 yet there was slight discharge from the ear ; and is further remark- 
 able for the short duration of the chronic symptoms. It Avas pub- 
 lished by Dr. Budd, of Bristol, in the year 1851, to whom I am 
 indebted for the preparation, and for several additional particulars. 
 
 Case VII. Catarrh of the mucous membrane lining the mastoid 
 cells ; memhrana tympani entire ; caries of the 2)etroushone ; abscess 
 in the cerebellum. — "' George Bell, aged 13, of spare habit and deli- 
 cate appearance, but never before the subject of serious illness, was 
 laid up, in the beginning of June, 1851, with an attack, which was 
 at first considered to be one of simple fever. Two circumstances 
 were, however, remarked, which the sequel showed to be of great 
 
348 THE DISEASES OF THE EAR. 
 
 importance. These Avere severe lieadaches, chiefly confined to the 
 right temporal region, and a slight discharge from the right ear, 
 with severe deafness on the same side. 
 
 " For the relief of these complaints, leeches were applied to the 
 temple and behind the ear, followed by a blister to the same spot. 
 Salines and a few gentle doses of mercury were given internally. 
 Under this treatment the pain abated, the febrile symptoms entirely 
 subsided, and in the course of a few days the boy was able to return 
 to school, and resume his usual occupations. The pain in the temple, 
 however, never entirely ceased. It was described as a dull pain, 
 occasionally attended with throbbing. Up to this period there had 
 been no vomiting, and no disorder in the motor or other powers of 
 the nervous centres. 
 
 " On the 12th of June, he was again laid up, and on the following 
 day Mr. Tribe, his usual medical attendant, was sent for. The 
 pain in the head had once more become continuous and severe ; and 
 was limited still more strictly than before to the right temple, occu- 
 pying, according to the patient's own description, a space not 
 broader than a crown-piece. It was not either acute or lancinating. 
 There was still great deafness in the right ear, though the discharge 
 had ceased. An entirely new symptom of great significance was 
 now added. Two days previously, the speech had become thick and 
 indistinct, and Avas now at times almost unintelligible. Mental 
 faculties unimpaired ; memory accurate ; no strabismus ; no lateral 
 or other deviation of the tongue ; no sickness ; pupils somewhat 
 dilated, but equal and sensitive ; vision good ; no heat of surface ; 
 no thirst ; extremities rather cold than otherwise ; tongue moist 
 but thickly coated ; bowels torpid. Pulse about 100 in the minute, 
 weak, and fluctuating. Complexion pale, and countenance deeply 
 marked with the stamp of suffering. 
 
 " On the following day, his gait was observed to be insecure, and 
 there was a dragging of the right leg. The face was also drawn, but 
 to wliicli side was not noted. The pain in the licad had extended 
 itself across the forehead, and tlie patient had become drowsy. lie 
 had also vomited several times, rejecting everything as soon as taken, 
 except milk, which sat well on the stomach. The bowels had been 
 freely acted upon by an aperient, given the day before. 
 
 " Under these circumstances, it was decided to put the patient at 
 once under the influence of mercury, and employ extensive counter- 
 
THE MASTOID CELLS. 349 
 
 irritation. With this view, three grains of blue pill were given every 
 four hours, and a blister was applied to the nape of the neck. 
 
 " On the following day, four grains of iodide of potassium Avere 
 given Avith each dose of blue pill, and a blister was applied to the 
 shaven scalp. 
 
 " On the 16th, the pain had extended to the back of the head, and 
 there was at times double vision. The vomiting and drowsiness con- 
 tinued. 
 
 " On the 17th, that is to say, the fifth day after the relapse, marked 
 amendment set in. The pain had much abated, being felt, in fact, 
 only when the head was moved ; the utterance had become more 
 distinct, and the distortion of the features had disappeared ; the 
 drowsiness had ceased, and the vomiting had become much less fre- 
 quent. There was still, however, some slight thickness of speech, 
 occasional double vision, and inequality of pulse. 
 
 "■ On the 19th, he had so much recovered as to come down stairs; 
 and on the 20th, he dressed himself and descended without help. 
 During the greater part of this day, he amused himself with his 
 pencil ; and several complicated heraldic drawings, executed with 
 a firm and clear outline, which are still extant, show, better than 
 any other evidence, how entirely the right arm had recovered its 
 loss of power. 
 
 "Up to the 1st of July, the amendment had suifered no check; 
 and on that day the patient was down stairs, running about and 
 quite cheerful. It is worth notice, that he occupied himself a good 
 part of that day with a box of carpenter's tools, handling them with 
 his usual freedom and effect. 
 
 " As the changes revealed by examination after death, coupled 
 with the history already given, leave no doubt that at this time, one 
 if not two abscesses of considerable size existed between the folds of 
 the right lobes of the cerebellum, such an amount of recovery as this 
 must be looked upon as a very remarkable circumstance ; and as one 
 which might readily lead an incautious practitioner to give a favorable 
 prognosis. The only trace of cerebral disorder still remaining, was 
 some slight thickness of speech. 
 
 " The hopes excited by this favorable change were, however, swept 
 away on the following day, the 2d of July, by a return of the former 
 symptoms in still greater violence than before. 
 
 " On the 3d of July I saw him for the first time, in consultation 
 
350 THE DISEASES OF THE EAR. 
 
 with Mr. Tribe, to whom I am chiefly indebted for the notes of the 
 case. 
 
 " The condition of the patient was then very striking, and charac- 
 teristic of severe intercranial mischief. The pain in the head, at all 
 times severe, was occasionally so acute as to extort moans and cries. 
 A very remarkable characteristic of the pain, was the intense degree 
 to which it was aggravated by any, the slightest, movement of the 
 head, voluntary or otherwise. The dread he showed at every such 
 attempt, could not be readily forgotten by any one who witnessed 
 it. The chief seat of the pain appeared to correspond with the base 
 of the occipital bone on the right side ; although, in less severity, it 
 affected the whole head. His brow was deeply knit, and his whole 
 aspect bore the imprint of great suffering. lie was very drowsy 
 withal, so that his whole time was spent in dozing or acute pain. 
 He yawned frequently ; his pupils were much dilated, but equal and 
 sensitive ; and he was very intolerant of light. There was no dis- 
 charge from the right ear, with Avhich he could hear the ticking of a 
 watch several inches off. Everything in the shape of food or medi- 
 cine was vomited as soon as swallowed ; the pulse varied, being at 
 the time of my visit only forty strokes in the minute. The belly 
 was deeply sunken and retracted ; and the skin peculiarly dry and 
 harsh. The grasp of the right hand seemed to be somewhat less 
 firm than that of the left, but there was no impairment or loss of 
 motor power (in the way of paralysis that is) in an}' other part. His 
 mind was clear, and memory good ; and his speech, though thick, 
 was sufficiently intelligible. There had been no fit or convulsion 
 from the first. The urine was scanty, and of high specific gravity, 
 throwing down on being boiled, a precipitate, which was immediately 
 redissolved on the application of nitric acid. The tongue was coated 
 with a thick yellow paste. From this time to the 7th of July, there 
 was little change, except that the vomiting became gradually less 
 urgent. On that day, to the surprise of all, he began, for the third 
 time, to amend ; the pain in the head abated, the drowsiness lessened, 
 and the sickness became less and less frequent. From this time, he 
 steadily improved, and on the 13th of July was so much better, that 
 it was agreed that I should susj)end my visits for some days. The 
 head was now almost free from pain, he moved with ease and free- 
 dom, and the vomiting had quite ceased. His utterance became 
 much clearer; his tongue much cleaner; he began to take light nou- 
 rishment Avith relish ; and his bowels acted, for the first time, without 
 
THE MASTOID CELLS. 351 
 
 medicine. Although there was no derangement amounting to para- 
 lysis, he had still a more perfect use of the left than of the right 
 arm ; feeding himself, for instance, by preference with the left hand. 
 
 " On the 14th the patient was put in a warm bath, Avhich he 
 much enjoyed ; and, on being taken out, stood for some time lean- 
 ing for support on his father's shoulder. This amendment was, 
 however, of short duration. 
 
 " On the following day he became much worse, and in the course 
 of it was several times seized with severe paroxysms of pain, lasting 
 many minutes. During this time, the eyes were fixed, and the pupils 
 gradually dilated more and more, till the agony passed into uncon- 
 sciousness ; he then remained for some time in a state of deep stupor, 
 from which he slowly recovered. Although there was no convulsion, 
 each of these attacks was followed by great exhaustion. 
 
 " From this period he lingered, with very little change and no 
 new phenomena, until the 17th of July, Avhen he expired rather 
 suddenly, after one of the paroxysms just described. 
 
 " The powers of the left hand and arm were unaffected through- 
 out, with this single exception, that, for a short time on the 9tli of 
 July, the fingers were spasmodically bent on the hand. He helped 
 himself to, a cup of coifee without difficulty with that hand about half 
 an hour before his death. 
 
 " The principal agents employed in his treatment were bitters, 
 and mercury, both internally and by inunction. Latterly opiates 
 were given to lull the pain, and alkalies for the sickness ; but the 
 latter with little or no effect. 
 
 " The body was examined twenty-six hours after death. On open- 
 ing the head, the ventricles of the brain were found to be enormously 
 distended Avitli perfectly transparent serous fluid, the quantity of 
 which was not measured, but must have amounted to at least half a 
 pint ; one of the ventricles was in fact accidentally opened by the 
 saw in removing the skull-cap, although the brain was by no means 
 deeply wounded. The convolutions of both hemispheres were so 
 much flattened by the pressure, that the sulci between them were 
 entirely efi'aced. On pursuing the examination, the explanation of 
 this state of things was found in the condition of the venae Galeni, 
 which were flattened, and contained no blood ; the return of blood 
 through them had been obstructed by the pressure of underlying 
 disease, and dropsy of the ventricles had resulted. A few transpa- 
 rent and very minute granulations, which Avcre only visible when 
 
352 TUE DISEASES OF THE EAR. 
 
 looked at obliquely, -were scattered over the arachnoid at the 
 base of the brain. "With this exception, the state of the cerebral 
 membranes, uhether of the surface or ventricles, was perfectly 
 normal ; they presented no trace of inflammation, and the structure 
 of the brain itself was sound. The inferior surface of the riffht 
 lobe of the cerebellum was attached to the dura mater by slight 
 adhesions. On further examination, this lobe was found to be the 
 seat of three distinct abscesses ; two of which were situated between 
 a duj)lication of the deep folds which traverse the lower surface of 
 the cerebellum. It is important to remark in reference to the his- 
 tory of the case, that their presence involved no breach of fibre or 
 other structure, although from their size they must have exerted 
 severe pressure on the surrounding parts. One of them was about 
 the size of a Spanish nut, the other would easily have contained a 
 large walnut. Both were lined by a distinct membrane, of new for- 
 mation, to which a somewhat thick layer of concrete pus was adhe- 
 rent. These characters were best marked in the smaller of the two 
 abscesses, which, if any inference may be drawn from such appear- 
 ances, appeared to be the older of the two. The third abscess was 
 still larger, and was formed at the expense of the substance of the 
 cerebellum itself. The central part of the right lobe w;\s almost 
 entirely converted into pus, so that the Avhole of this lobe might be 
 represented as a bag of matter whose walls were formed by gray 
 substance. The small portion of white substance still remaining 
 was broken up, and consisted chiefly of diflluent pulp. At one 
 point, corresponding to the root of the rhomboidal body, a small 
 extravasation had occurred. .This abscess was lined by no mem- 
 brane, and had no definite wall, the part in which the suppuration 
 was complete shading off" gradually into brokeu-up nervous tissue. 
 The pus it contained was also much more fluid than that of the 
 other abscesses. From these characters there can be little doubt 
 that it was the most recent of the three. The left lobe and other 
 parts of the cerebellum were free from disease. On examining the 
 interior of the skull itself, a yellow spot, about the size of a pea, 
 was discovered over the petrous portion of the right temporal bone. 
 The dura mater was here separated from the skidl beneath by a thin 
 layer of concrete pus lying upon the carious bone ; but there was 
 no trace of inflammation or other disease in the cerebral aspect of 
 the membrane. Over this space the bone was destroyed in its whole 
 thickness, so that, on lightly scraping it with a scalpel, the cavity 
 
THE MASTOID CELLS. 353 
 
 of the tympanum was brought into view. This cavity was filled 
 with opaque lymph, of a reddish-yellow color, but on its removal 
 the proper bones and muscular apparatus of the ear were seen to 
 be still in place. The membrana tympani Avas slightly thickened 
 and opaque ; but with this exception Avas sound, as was also the 
 meatus externus. It was ascertained that the lungs were free from 
 tubercle, and the heart healthy ; but the other viscera were not 
 minutely examined." 
 
 Upon carefully inspecting the bone, it was evident that this case 
 formed no exception to the general rule laid down b}' me, that when 
 disease, beginning in the mastoid cells after the second or third year 
 of life, injures the brain, the cerebellum is the part affected ; for it 
 is clear that the part principally involved lies posterior to the small 
 bones, and that it is in reality included in the mastoid cells. 
 
 This case gives rise to one or two other important considerations : 
 and first as to the duration of the disease of the ear. Dr. Budd 
 informs me, that the earliest history he had of any affection of the 
 ear was, that two months before the fatal illness, the boy had been 
 kept from school for two days by a slight earache, but the attack 
 seemed to go off. This attack of earache followed an illness sup- 
 posed to be scarlatina, and it is probable that the attack was the 
 exciting cause of the urgent symptoms ; but considering the carious 
 condition of the petrous bone, and the presence of the abscess in the 
 cerebellum, there can, it appears to me, be but little doubt that the 
 disease, in a chronic form, had been in existence for a considerable 
 period. In a letter to me. Dr. Budd says : " It is difficult to find a 
 satisfactory reason why a carious condition of the posterior part of 
 the petrous bone should give rise to abscess in the cerebellum, and 
 caries of the superior part to abscess in the cerebrum ; but it seems 
 to me that the difficulties are fewer under the supposition that the 
 disease is generally propagated by the veins than under any other. 
 In the case of George Bell, the notion of propagation by direct 
 proximity was out of the question ; for not only was the carious 
 bone at a considerable distance from the cerebellum, but no morbid 
 change of any kind could be detected in the cerebral aspect of the 
 dura mater covering the carious part. Many other reasons, if neces- 
 sary, could be given for believing that in this and many similar 
 cases, the veins were the channel of the mischief. That it should 
 have had (as under this supposition it would) to run counter for 
 some distance to the current of the blood is no real diflficulty ; since 
 
 23 
 
354 THE DISEASES OP THE EAR. 
 
 in the inflammation of the femoral vein which is set up by diseased 
 conditions of the uterus, and still more by intestinal ulcer, we have 
 undoubted and frequent examples of such a course : it would at the 
 same time be going too far to deny that in some cases, especially 
 Avhere the abscess is seated in the brain, the disease is propagated 
 by direct continuity." Several cases have been seen by me in 
 which, in a spot exactly corresponding with the cerebral mischief, 
 the dura mater was either ulcerated through, or manifestly diseased. 
 From the peculiar discoloration of the parts in many such cases, I 
 should suppose the putrefactive decomposition of the carious dis- 
 charges has much to do in the extension of the disease. With 
 regard to the mode in which the disease is propagated from the ear, 
 there appears to me no doubt that the dura mater is affected by 
 direct continuity. To the lateral sinus there seems abundant evi- 
 dence that it is communicated by the bloodvessels ; and although it 
 is impossible to disprove the statement of Dr. Budd, that the disease 
 extends to the brain through the blood also, it has always appeared 
 to me probable, that the existence of an abscess in the bone has by 
 sympathy caused a similar disease to be developed in the brain. It 
 is quite certain that it does not take place by continuity, inasmuch 
 as a considerable layer of healthy brain often intervenes between 
 the petrous bone and the abscess in the cerebrum. 
 
 It has been before stated, that disease of the mastoid cells pro- 
 duces death by causing suppuration of the lateral sinus, inflamma- 
 tion of the membranes of the cerebellum, or an abscess in the sub- 
 stance of the latter ; cases are, however, sometimes met Avith in 
 which the pneumo-gastric nerve is affected as it emerges through the 
 foramen laccrum posterius. A case of this kind occurred to Mr. 
 Coe, of Bristol, and was brought before the Bath and Bristol Branch 
 of the Provincial Association, in December, 1854. I give it in Mr. 
 Coe's words : — 
 
 Case VIII. Disease of the mastoid cells, advancing to the lateral 
 sinus and pneumo-gastric nerve. — " An out-patient of the Bristol 
 General Hospital came under my care, complaining of running at 
 the right ear, which had existed for some years, and occasional 
 paroxysms of acute pain in the car and head wlienever the discharge 
 ceased for a time, such being the case at the period of application. 
 Leeches were applied to tlie mastoid process, and warm fomentations 
 to the side of the head, and mercury was given internally. On the 
 next day symptoms of meningitis having come on, the patient was 
 
THE MASTOID CELLS. 6bb 
 
 taken into the house. He progressed favorably for some days ; but 
 afterwards began to complain of stiffness and pain in the right side 
 of the neck, and sudden attacks of difficulty of breathing, as if from 
 spasm of the glottis. There was a distinct rope-like swelling de- 
 scending from the base of the skull, down the side of the neck, in 
 the situation of the carotid sheath : it was very tender to the touch. 
 
 " The diagnosis was caries of the posterior portion of the temporal 
 bone ; meningitis ; obstruction of the right lateral sinus, either from 
 extension of inflammation or from secondary purulent deposit ; sub- 
 sequent coagulation of blood in the internal jugular vein; inflamma- 
 tion of its sheath, with involvement of the pneumo-gastric nerve, 
 especially the inferior laryngeal nerve (the phenomena of the irrita- 
 tion of this branch, being, at any rate, more manifested than of any 
 other portion of the nerve). 
 
 " The correctness of the diagnosis was proved by the 2)ost-mortem 
 examination." 
 
 Mr. Leonard, of Bristol, brought forward a case at the same 
 meeting, in Avhicli the pneumo-gastric nerve was implicated, and it 
 is interesting to find that the cases of these gentlemen are considered 
 by them corroborative of the opinion advanced by me, "that the 
 parts of the encephalon, secondarily affected in caries of the petrous 
 part of the temporal bone, vary according to the situation of the 
 caries." 
 
 In concluding this account of the pathology of the mastoid cells, 
 let me glance at a peculiarity sometimes met with in these cases, 
 viz., their being attended with symptoms exactly resembling remit- 
 tent fever. 
 
 Dr. Griffin, in the Dublin Journal of Science, published two cases 
 of the kind. One of them, which is also cited by Dr. Watson, is as 
 follows : — 
 
 A young man, previously healthy, Avas attacked with fits of shiver- 
 ing, accompanied by pain in the left side of the head. At first the 
 paroxysms were rather irregular, but they soon assumed the form 
 of tertian ague, coming on every other day, at about the same hour : 
 the cold fit commencing at noon, and lasting about half an hour, 
 followed by a hot stage of somewhat longer duration, and termina- 
 ting in a profuse sweat. In the intermissions the pain in the head 
 was trifling ; there was no thirst nor heat of skin, but he did not 
 sleep. A tumor formed over the mastoid process of the left side, 
 and was opened, and a quantity of extremely offensive brownish pus 
 
356 THE DISEASES OF THE EAR. 
 
 sprang out with great force. This gave much relief. The bone 
 was carious over a space as large as a shilling. After about ten 
 days, the pain in the head and in the mastoid process became very 
 severe ; the patient had violent shivering fits many times in the day, 
 great thirst, heat of skin, vomiting, and delirium ; his face was 
 flushed, and his pulse hard ; and he died within a few hours of the 
 accession of these last symptoms. 
 
 (<?.) NECROSIS OF THE MASTOID PROCESS. 
 
 On account of their position and peculiar arrangement, disease of 
 the mastoid cells is usually of a more serious character than disease 
 of the tympanum. The difference between the construction of these 
 cells in childhood and in the adult has been already described, and 
 it will have been seen that in each period of life, during disease, 
 there is scarcely any possibility of the whole of the secreted matter 
 being discharged from the ear. 
 
 In childhood, before the mastoid process is developed, the rudi- 
 mental cells, as stated, are placed posteriorly and superiorly to the 
 tympanic cavity, and are bounded externally by a portion of the 
 squamous bone. In the instances already detailed of disease occur- 
 ring in these cells during childhood, it has been shown that it 
 advanced rapidly until it caused the death of the patient ; indeed, 
 in those cases the brain, or its membranes, were most probably 
 affected long before the patient's friends applied for relief, and be- 
 fore the diseased portion of bone had become detached, or partially 
 detached, so as to admit the free egress of the matter from the 
 mastoid cells. An examination of a specimen illustrative of this 
 branch of the pathology of the subject will show, that had the por- 
 tion of necrosed bone, forming the outer wall of the mastoid cells, 
 been capable of removal during the life of the patient, the progress 
 inwards to the brain would probably have been arrested or averted. 
 In the majority of cases of necrosis of the mastoid process which 
 fall under notice among the out-patients of St. Mary's Hospital, 
 the portion of necrosed bone does become detached before the mem- 
 branes of the brain are affected, and frequently the mass of bone 
 comes away with but very slight cerebral disturbance. Indeed, as 
 a rule, when the portion of necrosed bone is detached, although it 
 
THE MASTOID CELLS. 357 
 
 may be of considerable size, tliere is very little fear of injury to the 
 brain or the dura mater. 
 
 It is not always very easy to distinguish between disease in the 
 tympanic cavity and that occurring in the mastoid cells. As a 
 general rule, Avhen the mastoid cells are affected, the pain is referred 
 to the region of the mastoid process, or to the back of the head ; 
 tenderness is experienced upon gently tapping or pressing upon the 
 mastoid process ; the attacks of pain and giddiness appear more in 
 the shape of sudden paroxysms, and the giddiness is more violent. 
 It not unfrequently occurs that there is no perforation of the mem- 
 brana tympani, though the disease in the mastoid cells causes irrita- 
 tion and catarrh of the dermoid meatus. 
 
 The following particulars relate to what may be considered one 
 of the most favorable eases of caries of the mastoid process. 
 
 Chronie eatarrh of tlie inueous rnemhrane lining the mastoid cells; 
 caries of the hone ; removal of the dead portion ; recovery. — Master 
 W., aged 6, was brought to me on the 4th of September, 1853. 
 His mother said, that four years previously he had an attack of 
 scarlet fever, followed by discharge from both ears, and by dulness 
 of hearing. After the discharge had continued for three months, 
 with pain at the back of the head, and frequent giddiness, an abscess 
 formed behind the right ear, which being laid open, a portion of 
 dead bone was felt, which gradually became detached and was re- 
 moved. The discharge from the ear continued. On examination 
 of the right ear, the membrana tympani was absent, and the meatus 
 contained polypi. In the left ear, the membrana tympani was per- 
 forated ; the mucous membrane of the tympanum was red, and 
 poured out an abundant discharge. Posterior to this ear was a 
 small orifice, through which, by means of a probe, dead bone was 
 felt. This was the upper part of the mastoid process, which, by 
 slow degrees, was detached and removed. After its removal, and 
 the constant use of the syringe and warm water, the discharge dis- 
 appeared. 
 
 A large number of cases, very similar in detail to the above, 
 might be added. Sometimes the head-symptoms are slight, at others 
 very marked. There is usually polypus in the meatus, resulting 
 from the irritation of the dead bone. If it seriously interferes with 
 the outward progress of the dead bone, the polypus may be removed ; 
 otherwise it Avill generally be found to disappear after the discharge 
 of the bone. In many cases which have fallen under my notice, the 
 
358 THE DISEASES OF THE EAR. 
 
 portion of necrosed bone has been removed from the meatus, without 
 any incision being made over the mastoid process : a plan which 
 may usually be adopted, since the membranus meatus is capable of 
 being greatly dilated, and the disfigurement is thus less than •when 
 an incision is made. 
 
 It not unfrequently happens, that the loss of a considerable por- 
 tion of the mastoid cells is unattended with any more serious dimi- 
 nution of the hearing power than that accompanying simple catarrh 
 of the mucous membrane of the tympanum, accompanied by ])artial 
 or complete loss of the membrana tympani. Paralysis of the portio 
 dura nerve is, however, a not uncommon result. This nerve, it will 
 be remembered, passes internal to the mastoid process, and is apt 
 to become involved in the disease of the bone, as in the following 
 cases. 
 
 Catarrh of the mucous membrane of the tympanum and mastoid 
 cells after scarlet fever ; caries of the mastoid pt'ocess; paralysis of 
 the portio dura nerve. — Master C, aged 5, was brought to consult 
 me on the 8th of February, 1853. His history is, that seven 
 months ago he had an attack of scarlet fever, which was followed, 
 a fortnight after, by a discharge from each ear, the loss of the small 
 bones, and complete deafness, so that he does not hear a sound. On 
 examining the right ear, the membrana tympani and ossicles were 
 absent, the mucous membrane of the tympanum Avas red and thick, 
 and pouring out a copious discharge of mucus. 
 
 Left car. — The meatus contains a large polypus, below which is a 
 portion of necrosed mastoid process, that moves on being touched 
 with a probe. The left portio dura nerve is paralyzed. The course 
 of treatment recommended consisted in the use of a syringe and 
 warm Avater daily, and in the administration of tonic medicines. 
 In the course of a fortnight, the portion of dead bone gradually 
 Avorkcd its Avay to the orifice of the meatus, and Avas removed ; it 
 was about half an inch in length, and a quarter of an inch in 
 breadth. After the bone Avas extracted, the polypus disappeared, 
 and the discharge ceased. 
 
 Sometimes, as in the next case, the cerebral symptoms are of 
 great severity. 
 
 Caries of the mastoid cells; severe cerebral sympt07us; paralysis 
 of the jjortio dura nerve. — Miss J. S., aged 6|, pale and sickly, Avas 
 brought to me on the 14th of August, 1850, Her mother stated, 
 that a day or tAvo after her birth a discharge Avas seen to issue from 
 
THE MASTOID CELLS. 359 
 
 the tube of each ear, but more abundantly from the left. The right 
 ear recovered, except a slight occasional discharge, but it was con- 
 stant on the left side ; and at the age of two years was followed by 
 an abscess at the back of the ear, accompanied by violent pain in 
 the back part of the head, giddiness, and partial insensibility. 
 After the abscess had remained open between two and three 
 months, a rounded portion of dead bone, of the size of a large 
 horse-bean, came away, and about this time the child lost the use of 
 the muscles of the left side of the face. When seen by me, there 
 was so great a dulness of hearing that she had to be loudly spoken 
 to within the distance of a yard. The membrana tympani of each 
 ear was absent ; the tympanic mucous membrane was red and thick, 
 and there was a depression behind the left ear, from which the piece 
 of dead bone had been removed. The treatment pursued consisted 
 in the use of frequent injections with warm water, folloAved by mild 
 astringents. Gentle counter-irritation was kept up behind each 
 ear, and tonic medicines administered. Under these plans the 
 discharge gradually subsided, and the power of hearing somewhat 
 improved. 
 
 Treatment in the adult. — In the adult, the mastoid process rarely 
 comes away in a considerable portion ; and the outer surface is so 
 dense, that the only way in Avhich discharge escapes from the inte- 
 rior is through a small fistulous orifice. The inner wall of the mas- 
 toid cells is usually the first to yield, and the sulcus lateralis is 
 partially or wholly destroyed, as has been shown by cases already 
 quoted. The cause of the inward progress of the matter is, doubt- 
 less, the difficulty of its escape outAvards. In some cases where the 
 membrana tympani has been wholly destroyed, and where the 
 mucous membrane of the tympanum is not so thick as to close or 
 very much diminish the aperture from the mastoid cells, a certain 
 quantity of the matter can escape through the tympanum into the 
 meatus ; but often the membrana tympani is either entire, or, as in 
 one case already cited, its lower margin is attached to the promon- 
 tory, and effectually precludes the escape of the discharge. 
 
 It is unnecessary to repeat the remarks already made as to keep- 
 ing an opening in the membrana tympani. When that membrane 
 is evidently preventing the egress of the matter, and where the irri- 
 tation produced by the operation is not to be feared, there can be no 
 harm in trying the effect of a puncture. Perforation of the mastoid 
 process also suggests itself, and this operation may, doubtless, be 
 
360 THE DISEASES OF THE EAR. 
 
 performed in those cases M'licrc the matter is pent up in the cavity 
 of tlie ear, and is causing such urgent and serious symptoms, as are 
 likely, if not relieved, to terminate in death. I have never per- 
 formed this operation, but I should not scruple to do so in a case 
 ■where the life of the patient -was threatened. Considering the large 
 extent of the mastoid cells, it appears to me, that the best plan of 
 operating -would be to use a trephine over the middle and posterior 
 part of the process, and to remove a portion of bone three-quarters 
 of an inch in diameter. It might be imagined, that when the dis- 
 ease has advanced so far as to produce coma, all attempts to give 
 relief by making an outlet for the matter would be ineffectual. 
 Such, however, is not the case ; for in one instance related by Dr. 
 Abercrombie, a young lady, wlio had laid for three or four days in 
 a state of perfect coma, and whose situation was considered to be 
 perfectly hopeless, was immediately and permanently relieved by a 
 sudden discharge of matter from the affected ear. Dr. Abercrom- 
 bie adds, "It is, however, by no means certain, that in such a case 
 as this, the discharge , came from the cavity of the cranium ; for 
 there is reason to believe that extensive suppuration within the 
 cavity of the tympanum is capable of producing symptoms of great 
 urgency, especially if there should be any difficulty of finding an 
 outlet." 
 
 The treatment, however, on which it seems to me safest to rely 
 for promoting the absorption of the matter and preventing its secre- 
 tion, so as to bring back the ear to a more healthy condition, is 
 counter-irritation, combined with plans for improving the general 
 health. The following case thus treated is one of great interest, as 
 from the symptoms manifest when the patient was first seen by me, 
 there is no doubt that both dura mater and bone were affected. 
 
 Disease of the mastoid cells ; giddiness ; great pain in the head ; 
 cured by the use of a scton. — R. D. M., a clergyman, aged 42, tall 
 and thin, and not robust, consulted me on the recommendation of 
 Professor Miller, of Edinburgh. The history of the case is, that 
 since a child, after an attack of earache, has had discharge at times 
 from the left ear until the age of 24 ; from 24 to 82 had but one 
 attack of pain and discharge; between 32 and 35 had several severe 
 attacks of pain at intervals of a few months ; at the age of 35 had 
 a severe attack of pain, after which such attacks became frequent, 
 and the discharge became constant and fetid ; at times serous, at 
 others purulent or bloody. By degrees fits of confusion and giddi- 
 
THE MASTOID CELLS. 3G1 
 
 ness in the head supervened, leading to prostration of nervous 
 energy, and a constant feeling (to use the patient's words) " as if 
 he were on the brink of apoplexy." 
 
 About four months previous to consulting me, he exerted himself 
 greatly in preaching on one occasion. On the same evening, he 
 afterwards sat listening long to a speaker in a public debate, Avith 
 his head resting on his right arm. On rising up, he was seized with 
 giddiness and a numb feeling in the right arm, while his pulse Avas 
 slow and laboring. He got home Avith diflBculty; but, under the in- 
 fluence of rest and gentle purgatives, he speedily recovered. About 
 two months afterAvards the giddiness returned, but in a more persis- 
 tent form, accompanied by double vision. He had a foul tongue, 
 palpitation, and flatulency ; and there Avas a fixed pain in both sides 
 of the forehead over the frontal sinuses. The ordinary discharge 
 from the car continued, and the numb feeling in the right arm re- 
 curred, extending from the elboAv to the fingers, and folloAving accu- 
 rately the course of the ulnar nerve. At this time he Avas treated 
 with blisters behind the ears, but Avithout much relief. A month 
 before the patient came to me he was under the immediate care of 
 Professor Miller, who stated that he Avas then relieved by food and 
 stimuli and the administration of tonics. In a day or two the symp- 
 toms assumed a pericranic character ; they Avere also intermittent, 
 affecting the left side of the forehead, eye, and face, and were unac- 
 companied by stuffing of the nostril on that side. The treatment 
 Avas then changed to FoAvler's solution, Avith an anodyne embroca- 
 tion ; and in ten days the pain, giddiness, and uneasy feelings in 
 the arm all passed away. At the time of my seeing him he com- 
 plained of occasional SAvimming in the head, pain in the ear, and 
 fetid discharge, together Avith a sensation at the back of the left ear 
 when he walked, as if there Avere an empty drum there — a sensation 
 Avhich Avas increased upon tapping the mastoid process. The pain 
 extends over the head from ear to ear, and also over the back part 
 of the head ; and Avhen the discharge is very abundant, he suffers 
 from the extreme sensitiveness of a spot three inches posterior to 
 the upper part of the ear. When he presses upon the left jugular 
 vein, he feels a great Aveight at the back of the ear, as if something 
 would burst. 
 
 On inspection, the surface of the meatus Avas observed to be red 
 and denuded of epidermis ; the upper and only visible part of the 
 membrana tympani Avas also red, and evidently fallen iuAvards to- 
 
362 THE DISEASES OF TUE EAR. 
 
 wards the promontory. The lower half of the memhrana tympani 
 was concealed by a polypus. The discharge was milky and A'ery 
 offensive. Upon slightly blowing the nose with closed nostrils, the 
 air passed through the Eustachian tube into the tympanic cavity ; 
 but it did not pass into the meatus ; so that the memhrana tympani 
 was believed to be entire. The power of hearing was so deterio- 
 rated, that the watch was not heard ; the crack of the nail was, how- 
 ever, distinctly perceived. 
 
 The diagnosis formed by me was, that there was a collection of 
 pus, or of pus and mucus, in the cavity of the mastoid cells ; and 
 that, probably, the dura mater covering their posterior surface was 
 partially affected. I had no doubt that the discharge from the 
 meatus was purely sympathetic, and the result of the internal irri- 
 tation ; it certainly did not come from the seat of the disease. 
 
 Acting on this view of the case, I recommended perfect quiet, 
 tonic medicines, and a bracing air ; while a constant discharge was 
 to be kept up, first behind the ear, and then between the shoulders 
 by means of blisters. This treatment producing but partial benefit, 
 in April, 1852, about four months after first seeing him, I ordered a 
 seton to be placed in the nape of the neck. For a time no good 
 result followed, but in July the fetid discharge began to dry up, the 
 power of hearing greatly improved, and the nervous energ}- much 
 increased. During the two years that the seton has been worn, the 
 patient (to use his own words) has " enjoyed a considerable measure 
 of health and comfort, and feels comparatively well and strong ;" 
 and he preaches regularly once a week. He is annoyed now and 
 then by slight attacks of giddiness, which are supposed, however, 
 to depend upon indigestion ; and are, he adds, "quite different from 
 the oppressed feeling on the brain which I had two years ago." 
 Occasionally the hearing is clogged for a day or two, but this state 
 gives way to the use of the syringe and warm water ; the seton 
 continues to discharge. 
 
 The above case has been cited at some length, because it so fully 
 illustrates the peculiar symptoms of this affection of the mastoid 
 cells, which is far from being uncommon ; and because it shows the 
 decided benefit which is to be obtained by counter-irritation long 
 continued. 
 
 Before concluding the subject of treatment, I will offer a few ob- 
 servations on the relation between the presence of discharge from 
 
THE MASTOID CELLS. 363 
 
 the ear and disease of the bone or brain. Patients sometimes come 
 to comphiin of having been objected to at a Life Insurance Office, 
 on account of a long-standing discharge from one or both ears ; or 
 an opinion is requested whether such a discharge is a valid cause 
 amiinst insurino; a life. No doubt a discharge from the ear should 
 always be regarded with suspicion ; an opinion which is borne out 
 by an inspection of the following table, showing the relation be- 
 tween the duration of the discharge and the acute symptoms. The 
 cases are taken from a paper of mine in the 3Iedico-Chirurgical 
 Transactions for 1851. 
 
364 
 
 THE DISEASES OP THE EAR. 
 
 
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THE MASTOID CELLS. 
 
 365 
 
 
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366 THE DISEASES OF THE EAR. 
 
 It is true that many persons live long, having had, during the 
 Avhole of life, a discharge from the ear -without any disease of the 
 bone : others live many years •with a discharge, but at death the 
 bone and dura mater are found affected, and might under many cir- 
 cumstances have assumed an active form of disease, ending in death. 
 It is important, therefore, to be able to form an opinion respecting 
 cases of the kind. To do this, it is first necessary to decide upon 
 the source of the discharge. If it arises from the dermoid meatus, 
 the membrana tympani being entire, there is, as before stated, most 
 probably irritation in the tympanic cavity or mastoid cells, of which 
 irritation the discharge is the symptom. Unless there •were simply 
 some eczematous state of the meatus to account for the discharge, 
 and unless the hearing power Avere perfect, such a case should be 
 looked upon ■with suspicion, especially if attended ■with any symptoms 
 of brain or cerebral irritation. Again, if the discharge issues from 
 the tympanic cavity through a small or a valvular opening, and it 
 is requisite to blo^w the nose forcibly to clear out the tympanum, 
 there probably is, or ■will be, some affection of the bone, from the 
 accumulation of the discharge. If there is a large orifice in the 
 membrana tympani, or that membrane is absent; if there is no ulcer- 
 ation of the mucous membrane of the tympanum ; if there is some 
 power of hearing remaining ; and if by pressing and tapping the 
 region round the ear, no pain is felt ; and if there are no other symp- 
 toms of disease in the ear or head, I think it may be assumed that 
 there is no disease of the bone ; and that by attention to daily 
 syringing, and the other plans alluded to when speaking of the 
 treatment of these affections of the ear, there is a fair prospect of 
 the disease remaining confined to the mucous membrane of the ear. 
 On the other hand, it becomes a duty to state that any negligence 
 on the part of the patient, by which the discharge should be allowed 
 to collect so as to fill up the orifice in the membrana tympani — a blow 
 on the ear, an attack of fever, or any severe illness, might cause an 
 irritation in the ear, which, if unattended to, might advance to the 
 bone. 
 
CHAPTER XV. 
 
 THE DISEASES OF THE NERVOUS APPARATUS OF THE EAR, PRO- 
 DUCING WHAT IS USUALLY CALLED "NERVOUS DEAFNESS." 
 
 . DISEASES IN WHICH THE EAR ALONE IS AFFECTED : — 1. FROM COXCUSSIOX — THREE 
 MODES — BLOWS ON THE EAR — LOUD SOUNDS — FALLS. 2. FROM THE APPLICATION OF 
 COLD — COLD AIR — COLD WATER. 3. FROM THE EFFECT OF MORBID POISONS — RHEU- 
 MATIC FEVER — TTPHUS FEVER SCARLET FEVER — MUMPS — GOUT. h. DISEASES IN 
 
 WHICH THE BRAIN AS WELL AS THE EAR IS AFFECTED : — 1. MENTAL EXCITEMENT 
 
 OVER-STUDV — SORROW. 2. BODILY DEBILITY WANT OF SLEEP — ACCOUCHEMEXTS — 
 
 OVER-EXHAUSTION IN HOT CLIMATES — FASTING — NEURALGIA. 
 
 The nervous apparatus whicli receives the sonorous undulations 
 from the tympanum, and conveys them to the brain — one of the 
 most delicate structures in the human body — is liable to many func- 
 tional and organic derangements.' As some cases of deafness depen- 
 dent upon the derangement of the nervous apparatus connected with 
 the organ of hearing, appear to be caused by the condition of the 
 brain generally, or of that part in intimate relation with the acoustic 
 nerve, it has seemed desirable to divide the nervous diseases of the 
 ear into two classes : to the first of which belong those cases where 
 the special nervous apparatus of the organ is alone affected ; to the 
 second., those where the brain conjointly with the ear, seems to be 
 injured. 
 
 The first class may be subdivided into diseases arising from — 
 
 (1.) Concussion. 
 
 (2.) The application of cold'. 
 
 (3.) Various poisons : as that of typhus, scarlet, or rheumatic 
 fevers, of measles and mumps, of gout, of an accumulation of bile 
 in the blood, and of quinine in large doses. 
 
 And the secondanto diseases arising from — 
 
 ' As I have nothing to add to the descriptions usually given of the anatomy of the laby- 
 rinth, I have not entered upon the subject. 
 
368 THE DISEASES OF THE EAR. 
 
 (1.) Excess of mental excitement. 
 (2.) Physical debility. 
 
 [a.) DISEASES IN AVIIICH THE EAR ALONE IS AFFECTED. 
 
 This section will be occupied with a revicAv of the various kinds 
 of disease comprehended under the first of the above classes, all of 
 which are usually accompanied by more or less of congestion. 
 
 (1.) I>chHit>j of the JVervous Apparatus of the Ear 2)rodueed hy 
 Concussion. 
 
 Concussion may arise in three ways ; either from a blow on the 
 ear, or from the effect of loud sounds, or from a jar of the whole 
 frame. Affections of the nervous apparatus of the ear, as the 
 result of blows on the external organs, are not very common, !?ince, 
 as a general rule, the membrana tympani gives way and is ruptured, 
 and consequently the shock on the drum is so far modified in its 
 effect on the ossicles and the fenestra ovalis, that the contents of 
 the labyrinth receive no greater injury than that which causes a 
 slight dulness of hearing for a few days. 
 
 Cases of more permanent injury to the acoustic nervous apparatus 
 do, however, sometimes happen from the effects of a blow on the ear, 
 as in the following case. 
 
 Injury to the nervous apparatus of the ear, produced by a hloiv on 
 that organ. — A physician in London, while playing with his little chil- 
 dren, suddenly brought his right ear in contact with the head of 
 one of them, causing a rather severe concussion on that side of his 
 own head. The concussion was instantly followed by a singing in 
 the ears. I saw the patient soon after the accident, but could 
 detect no unnatural appearance in the membrana tymj»ani ; and on 
 carefully testing the hearing power by the watch, there appeared to 
 be no dulness of hearing. This physician has been seen by me from 
 time to time since the accident, and he tells me the singing remains 
 as it was on the day the concussion took place. 
 
 The nervous apparatus of the ear is frequently injured also from 
 the effect of a general concussion of the body, in which case the 
 hearing power is often entirely destroyed. The well known in- 
 
NERVOUS DEAFNESS. 369 
 
 stance of the late Dr. Kitto, wlio Avas rendered wholly deaf by a 
 fall from the top of a house when a boy, may be noticed in illustra- 
 tion, and some others follow which have fallen under my own obser- 
 vation. 
 
 Fatal deafness in the rigid ear, and partial deafness in the left, 
 folloiving a fall from a horse. — The Rev. R. F., aged 53. During 
 many years his hearing has been dull during a cold. Five years 
 before seeing me, he had a fall from his horse, and the fall was fol- 
 lowed by a discharge of blood from the right ear for the space of 
 tAvo days, and subsequently of matter. For some days after the 
 accident, the air whistled out of his right ear whenever the nose was 
 blown. Since the accident, the right ear has been entirely useless, 
 and the left so deaf that he has to be loudly addressed within a 
 yard of that ear. There has also remained a constant singing noise 
 in the head. On inspection, the hearing of the 7'ight car was found 
 to have been wholly destroyed, and the membrana tympani pre- 
 sented an orifice, the margins of Avhich were opaque and uneven. 
 Left ear. — The membrana tympani was dull on its surface, and in 
 parts calcareous. 
 
 In some instances, slight amelioration of the deafness following 
 the accident takes place, as in the next case. 
 
 Total deafness in the right ear folJoioing a fall from a phaeton ; 
 gradual improvement. — The Rev. J. L., aged 35, had a deafness in 
 the right ear during a cold four years ago. In the same year he 
 fell from a phaeton, and was unconscious for some days. When he 
 recovered his sensibility, he found that there was a hissing sound,, 
 like that from a teakettle, in the right ear, which Avas completely 
 deaf. During two years, however, subsequent to the accident, the 
 power of hearing gradually improved, so that the patient is able to 
 hear a loud voice Avith that ear. The noises still continue, and are 
 aggravated by wine, or by bodily or mental fatigue ; when writing 
 or studying, these noises become overpoAvering, but in the morning 
 are much lessened. On inspecting the right ear, the air is distinctly 
 heard by me to enter the tympanic caA'ity, but the patient experi- 
 ences no sensation in the ear Avhen it enters. A loud ticking watch 
 is heard. When spoken to through a trumpet, loudly and slowly, 
 the voice is heard, but not till a second or two after the Avord has 
 been uttered. The membrana tympani Avas opaque. 
 
 The violent shock communicated to the nervous system of the ear 
 (most probably through the medium of the membrana fenestras ro- 
 
 24 
 
370 THE DISEASES OF THE EAR. 
 
 tiindio) in the act of coughing, sometimes produces deafness ; in- 
 deed, in some cases, hooping-cough seems rather to cause deafness 
 by this means than by the agency of poison. 
 
 Nervous system of the ear injured by violent coughing. — Mrs. A. 
 consulted me in 1851, and stated that a week previous to her visit, 
 directly after coughing, she experienced a pain in the left ear, which 
 lasted for two hours, together with a loud singing noise which has 
 never ceased. She complains of an unpleasant sensation as if 
 sounds passed through the ear, and is troubled with a sense of giddi- 
 ness, and a feeling of confusion in the head. Every step she takes 
 sounds like the beating of a drum. Tlie mcmbrana tympani was 
 fallen in, and its surface dull. The watch was heard only when in 
 contact with the ear. Means having been used to diminish the con- 
 gestion of the nervous apparatus of the ear, the distressing symp- 
 toms of nervousness and giddiness disappeared, but the singing 
 sounds remained. 
 
 The concussion upon the nervous system of the ear resulting from 
 loud sounds is a very common cause of deafness. In a previous part 
 of this volume, when speaking of the functions of the ossicles and 
 muscles of the tympanum, it was shoAvn tliat the one use of the 
 tensor tympani muscle is to render tense the membrane of the 
 fenestra rotunda, as well as that of the larger membrane ; and in 
 this tense condition the membrane of the fenestra rotunda is thrown 
 into vibratory movements of much less extent than when it is in a 
 relaxed state. When a loud sound is anticipated, the tensor tym- 
 pani muscle draws the membrana tympani and the membrana fenes- 
 trae rotundne tense ; so that, when the approach of a loud sound is 
 expected, it rarely injures the ear. On the contrary, however, when 
 both membranes are comparatively lax, the same sounds throw them 
 into very extended vibrations, and tlic fluid in the cochlea by the 
 magnified movements of the membrana fenestrjx: rotundi\j is so con- 
 cussed as to injure, and often most seriously, the expansion of the 
 auditory nerve in the laliyrinth. 
 
 Injury to the nervous apparatus of the ear may be produced by a 
 variety of sounds. Cases Jiave been seen by me in which a cannon- 
 ade at laud or sea, or the firing a single cannon, has produced the 
 injury; and others have occurred where an explosion of gas, thunder, 
 a pistol shot, or even loud shouting near the ear, have resulted in 
 the same effect ; but the most common cases are those which follow 
 the long-continued sport of shooting, where the deafness almost in- 
 
NERVOUS DEAFNESS. 371 
 
 variably occurs in the left ear, which is turned towards the gun 
 during its explosion, and consequently receives the direct concussion. 
 
 The treatment in recent cases when the patient is suffering from 
 the immediate effect of the shock, consists in the removal of the con- 
 gestion by the application of leeches, or by cupping : by the admi- 
 nistration of mild aperients ; by strengthening the general nervous 
 system as much as possible, and by securing the ear against the 
 effect of loud sounds. 
 
 Noises in the ears, deafness, and a feeling of deadness in the head, 
 following the sound of a pistol shot; relief. — Mr. C. S., aged 45, a 
 fortnight before consulting me, fired a pistol, for the first time in his 
 life, in the open air on a cold frosty day. The concussion was in- 
 stantaneously followed by a hissing noise in each ear, but more espe- 
 cially in the right, and he also felt a shock throughout the whole of 
 the head, followed by a " feeling of deadness" in it. Since the acci- 
 dent, he has been dull of hearing, and has observed, among other 
 things, that he could not hear the " ring of money." Leeches and 
 mustard plasters were applied behind the ears, and small doses of 
 calomel and colocynth were administered. Immediate relief to the 
 head and ears followed the application of the leeches, and in a week 
 the hearing had improved, and the noises diminished. 
 
 Nervous apparatus injured hy the report of a cannon. — ^Y. L. C, 
 Esq., aged 73, about four months before consulting me, his hearing 
 being then perfect, was sitting in the open air at Brighton, looking 
 upon the sea, when a cannon near where he sat was fired, without 
 his having any idea of such a proceeding being about to take place. 
 The concussion was immediately followed by a singing in the ears, 
 or rather about two yards from them, and a sensation as if water 
 were rushing through them. Since the accident, he has heard a 
 whisper very distinctly, but a loud voice causes unpleasant jarring 
 sensations in the ears, and deafness to all sounds. In another case, 
 the ear was "benumbed" for some time after the patient's child had 
 shouted into it. 
 
 Nervous apparatus of the ear injured by very loud shouting ; very 
 distressing noises ; great relief. — When surgeon to the St. George's 
 and St. James's Dispensary, a poor man applied to me for relief 
 from deafness and very distressing noises in the left ear. The 
 latter had lasted several years, and the patient, a strong muscular 
 man, thinks they were caused by the loud shouting he is obliged to 
 
372 THE DISEASES OF THE EAR. 
 
 practice as a hawker of fish. These noises came on in the left ear, 
 and after remaining there some time advanced to the left side of 
 the head ; they have increased lately, sometimes resembling " a 
 rapid tinkling," at others being like the driving of a sledge ham- 
 mer ; but most commonly they resemble the roaring of the sea. 
 When at their loudest, as after exertion, the house seems to go 
 round with him. The ear is quite insensible to any sound but that 
 of these noises. The right ear is healthy. On examination, the 
 membrana tympani of the affected ear "vvas found to be opaque, and 
 the air passed through the Eustachian tube Mith a loud crackling. 
 As this was a local affection, as the patient was a strong man, and 
 as the symptoms were increased by any cause which increased a flow 
 of blood to the organ, I determined to treat the case as one of con- 
 gestion, and accordingly ordered the patient to apply twelve leeches 
 below the ear, followed by a cantharidine cerate dressed with ungu- 
 entum hydrargyra, at the same time that the outer half of the 
 meatus was washed with a solution of nitrate of silver suflBciently 
 strong to produce desquamation. This was followed by the use of 
 a solution of chloride of zinc (six grains to the ounce) to the mea- 
 tus, so as to cause a discharge. The result of this treatment was 
 satisfactory. The noises, the patient says, " have not been so loud 
 or nearly like it :" and ten days subsequently to this report, he 
 said that his head was much better, and " he could do his work with- 
 out being obliged to give up." 
 
 Nervous apparatus of the ear injured by the explosion of bladders 
 of gas. — J. B., aged 64, was admitted under my care at St. Mary's 
 Hospital in 1853. He stated that nine months previously, directly 
 after the explosion of two bladders of gas at the distance of a yard 
 from his head, he suddenly became so hard of hearing, that he could 
 not hear a voice except when spoken to distinctly at a distance of 
 two yards from the head. The explosion was followed by a singing 
 sound in the ears, which gradually subsided. The watch could not 
 be heard at a distance of more than two inches from the right ear, 
 and only when in contact with the left. The treatment consisted in 
 the application of leeches. below the ears, but the patient did not 
 return to report progress. 
 
 The following is a well-marked case in which the nervous appa- 
 ratus was injured by shooting. 
 
 Deafness in the left ear following shooting, and temporarily in- 
 creased by a days sport. — F. F., Esq., aged 23, accustomed to 
 
NERVOUS DEAFNESS. 373 
 
 shoot, has been gradually becoming dull in the left ear. For two 
 years he has not been able to hear general conversation distinctly, 
 and the striking of the clock seems no longer attended by the natural 
 sound. Is more dull of hearing during a cold. Is not aware of 
 any cause that could have produced the deafness. The right ear 
 was in a natui-al state ; by the left the watch was only heard at the 
 distance of half an inch. The treatment consisted in the use of 
 gentle counter-irritants over and around the ear, and in doing all 
 that could be suggested for diminishing local and general conges- 
 tion. This treatment was followed by great improvement at the end 
 of about three weeks, when the watch could be heard at a distance 
 of four inches — an improvement which continued, with the excep- 
 tion of a considerably increased amount of deafness which ensued 
 upon a morning's shooting. This increased deafness continued for 
 some days, and then gradually diminished. The last time the patient 
 was seen by me, the hearing had not regained the previously im- 
 proved state, for the watch could only be heard in contact with the 
 ear. 
 
 Not having had the opportunity of ascertaining the condition of 
 the ear by the aid of dissection, I have assumed that in these cases, 
 arising from shooting, the nervous system of the ear is defective. 
 The grounds of this conclusion are, that the noises and defective 
 hearing followed immediately on the concussion, and all the symp- 
 toms indicated that a shock had been given to the nervous system. 
 The secondary effect of this concussion, it can scarcely be doubted, 
 may be anchylosis of the stapes to the fenestra ovalis. In cases, 
 indeed, when the nervous system of the ear has received a very 
 severe concussion, and deafness has subsequently slowly come on, I 
 have convinced myself of this anchylosis by dissection, and will 
 now relate one or two cases of the kind. 
 
 Concussion of the nervous apparatus of the car hy thunder ; com- 
 plete deafness. — T. D., aged 80, is so completely deaf that he can- 
 not hear any sound. He states that, fifteen years ago, when in a 
 thunder-storm on the coast of Guinea, he was rendered thoroughly 
 deaf by a clap of thunder, and since then has not heard a sound. 
 On examination, an orifice was observed in each membrana tym- 
 pani. No treatment was attempted, but about two years after the 
 examination, the opportunity was given me of dissecting his ears, 
 which were in the following morbid condition. 
 
 lUght ear. — At the posterior part of the membrana tympani was 
 
374 THE DISEASES OF THE EAR. 
 
 an orifice about two lines in diameter, the remaining portion of tlie 
 membrane being white, thick, and tense, and more concave exter- 
 nally than natural : parts were also calcareous. In the centre of 
 the remnant of the membrana tympani is a space about lialf a line 
 in diameter, in Avhich the epidermoid, dermoid, and nmcous layers 
 alone remain. The long process of the incus and the crura of the 
 stapes are gone, and the expanded base of the stapes is attached to 
 the fenestra ovalis more firmly than natural. The membranous 
 labyrinth was atrophied, and the nervous fibrillte of the cochlea 
 appeared the same. 
 
 Left ear. — Like the right ; except that the crura of the stapes 
 were only partially absorbed. 
 
 In another case of total deafness produced by a loud cannonading, 
 the only morbid condition that could be detected by me, on dissec- 
 tion, was that the otoconie was more abundant than natural, while 
 in the vestibule there was a deposit of oval-shaped cells. 
 
 Results similar to those noticed as following the practice of shoot- 
 ing, also occur to operatives engaged in occupations involving very 
 loud sounds. Thus in a large factory for making steam-boilers, I 
 found a great number of men engaged in riveting the bolts, and 
 therefore obliged to work inside the boiler, who were very deaf. It 
 will be very interesting to ascertain by post-mortem inspection the 
 pathological condition of the ear when subjected to such loud 
 sounds, and some day perhaps the opportunity will be afforded me 
 of doing so. 
 
 (2.) The effect of the application of cold on the nervous apparatus 
 
 of the ear. 
 
 There are two classes of cases in Avhich a diminution of the tem- 
 perature is found to be injurious to the ear : in the one cold air, in 
 the other cold water, is the agent producing the effect. I have 
 known engine-drivers to suff'er from deafness after being exposed to 
 a cold blast, and huntsmen also who have had a sudden " check" 
 when very hot, and have then stood about while a bitter east wind 
 was blowing upon them. The effect of the application of cold 
 seems, in the first instance, to produce congestion ; and then to 
 lead to the symptoms of noise in the ear and of deafness, which 
 appear to depend upon a depressed or depraved action, subsequent 
 
NERVOUS DEAFNESS. 375 
 
 to and resulting from the congestion. In what the depraved action 
 consists, it is, however, difficult to determine. The congestion often 
 yields to the application of leeches ; and the depraved action is fre- 
 quently diminished, sometimes wholly removed, by the use of gentle 
 counter-irritants, tonics, shower-baths, &c. 
 
 The first series of cases consists of those in wliich the injury fol- 
 lowed exposure to cold air. 
 
 Total deafness in both ears following exposure to cold hy sleeping 
 in the open air. — A farm-laborer, aged 28, Avas admitted under my 
 care at the St. George's and St. James's Dispensary, in June, 1850, 
 on account of complete deafness in both ears. He said that eighteen 
 months previously, after sleeping in an open cart in which he was 
 riding in the winter, a usual practice with him, intense pain came 
 on between the right temple and ear, Avhich was relieved by the use 
 of veratrine ointment. About three weeks after the exposure to 
 cold the deafness made its appearance, at first for a day or two 
 only, and then disappeared : in the course of a few days, however, 
 it recurred with increasing intensity and once more disappeared. 
 This recurrence and disappearance of the deafness ended after a few 
 more days in total and permanent loss of hearing. At the present 
 time he cannot hear a gun, even if fired close to the head. He 
 complains of loud noises in the hfead, and of great heaviness and 
 sleepiness. All kinds of empirical treatment had been tried on 
 him ; oils of various kinds had been dropped into the ears, Avith 
 brandy and salt, and then hot baked salt behind them ; every 
 species of medicine had been given, and he had been cupped and 
 blistered at the nape of the neck, but without producing any good 
 effect. On examination, the upper part of each membrana tympani 
 was found to be red, the lower part being concave and white ; air 
 entered through the Eustachian tube and caused a loud crackino; 
 sound. Some relief to the head-symptoms followed a discharge 
 from each meatus, which was kept up by the application from time 
 to time of the chloride of zinc. 
 
 Deafness and singing in the ears following exposure to cold while 
 skating. — J. V., Esq., aged 49, consulted me in March, 1852. His 
 health was good, and his constitution strong. He stated that twelve 
 or fourteen years previously, while skating on a bitterly cold day, a 
 singing sound suddenly came on in the left ear, which has remained 
 ever since ; being at times very loud, and then much subdued. A 
 few years after this exposure, the left ear became gradually dull of 
 
376 THE DISEASES OF THE EAR. 
 
 hearinff, and receutlv Lotli the sin";infi and dulness of hearing have in- 
 creased. The power of hearing varies, but is not worse after fatigue 
 or excitement. With the right ear the hearing distance was three 
 inches ; with the left, half an inch only. Two leeches were ordered 
 to be applied below each ear, and the ears to be syringed with warm 
 water, the object being to remove congestion. This treatment was 
 followed by relief; but with the further progress of the case I am 
 unacquainted. 
 
 Two other cases of injury produced by the application of cold air 
 to the ear may be briefly alluded to. The first was that of a gentle- 
 man, aged 21, who ten months before my seeing him, being exposed 
 to a very cold February wind blowing in the left ear, had a singing 
 and pulsation ensue within that organ ; these sensations are unaccom- 
 panied Avith deafness, and are worse while in bed or reading. At 
 times they wholly disappear. The second case is that of a clergy- 
 man, aged ^^^ who having been exposed to cold in a railway car- 
 riage, three years before my seeing him, was subsequently attacked 
 by a whizzing sound in the left ear, which has never ceased. By 
 sitting up late at night, or by entering a warm room from the cold 
 air, the sound is increased, but is better rather than worse after 
 dinner. Complains of dulness of hearing, as general conversation 
 is not heard. 
 
 The following are cases whore the application of cold Avater re- 
 sulted in injury to the ear : — 
 
 Deafness foUoicing bathing in cold water. — T. F., aged ll>, saAv 
 me on account of his deafness. He said, that more than a year pre- 
 viously deafness came on sloAvly, after bathing daily in cold fresh 
 Avater, and in a month or six Aveeks he became as deaf as at present. 
 The affection has been stationary for some months. He requires 
 speaking to loudly__Avitliin the distance of a yard, and at times suffers 
 from a buzzing in the ears. He is not deafer during a cold, and 
 docs not hear better in a carriage. The right ear is rather Avorse 
 than the left. The previous treatment consisted in dropping oils 
 into the ears, and in syringing them Avith Avarm Avater. In each ear 
 the Avatch Avas heard only Avhen in contact. The mombrana tympani 
 appeared to be slightly more concave than natural, and its surface 
 Avas dull and congested. The treatment consisted in the application 
 of a vesicating paper behind each ear, and in taking small doses of 
 blue-pill and iodide of potassium, a treatment Avhich Avas followed by 
 a slight amelioration of the symptoms. 
 
NERVOUS DEAFNESS. 377 
 
 Deafness produced in two days by dipping the head in cold water. 
 — A girl, aged 14, the daughter of a farmer consulted mc in 1853. 
 She stated, that two years previously^ when very much heated, she 
 plunged her head into cold water, and two days afterwards became 
 so deaf that she required to be loudly spoken to close to the head. 
 The deafness varies slightly, being worse during a cold, and at times, 
 from no assignable cause, better. The treatment consisted in keep- 
 ing up a slight discharge from the surface of each mastoid process, 
 and in giving small doses of the bichloride of mercury (one-thirtieth 
 of a grain) with gentian, daily. The treatment, pursued during two 
 months, resulted in decided improvement. 
 
 Deafness and noises in the ears after bathing. — A man, aged 29, 
 was admitted under my care at St. Mary's Hospital, in July, 1853. 
 He said, that six years before, after bathing in a canal of cold fresh 
 water, he became rapidly deaf in both ears, and in the course of a 
 week was so deaf as to require to be distinctly spoken to quite close 
 to him ; complained from the first of buzzing noises and pulsations. 
 The deafness and the noises increase in damp weather, or when he is 
 tired ; and he also hears worse in a carriage and amid loud sounds. 
 The treatment consisted in the application of gentle counter-irritants 
 over each mastoid process, and in taking alteratives, but without any 
 beneficial effect. 
 
 (3.) Deafness produced by the action of morbid poisons on the 
 7iervous apparatus of the ear. 
 
 As has been stated, in addition to the causes just detailed, the 
 nervous apparatus of the ear often suffers from the action of the 
 poisons of gout, typhus fever, scarlatina, measles, or mumps. Though 
 unable to furnish any information of the modus operandi of the 
 several poisons enumerated, in some cases where the functions of the 
 organ have been wholly destroyed, the nervous apparatus of the ear, 
 on dissection, has been found by me completely disorganized, and 
 the fluid in the cochlea and vestibule dark-colored, and occasionally 
 tinged with blood. Many of the cases of acquired deaf-dumbness 
 originate in the effect of poisons of various kinds. A careful con- 
 sideration of the symptoms attendant upon these cases, and the re- 
 sults of treatment, indicate that whatever may be the immediate 
 effect of the poison on the nervous tissue, the secondary effect is to 
 produce congestion of that tissue. 
 
378 THE DISEASES OF THE EAR. 
 
 Noises and deafness after rheumatic fever. — Miss. B., aged 36, 
 consulted me in 1851. She stated, that ten years previously she 
 had an attack of rheumatic fever, which "svas followed by dulness of 
 hearing in the right ear, and accompanied by a constant whizzing 
 sound and a pulsation which extended over the head. The left ear 
 has lately become dull. The watch was heard only when pressed 
 upon the right ear, or at a distance of six inches from the left. 
 Neither ear presented any appearance of disease, except a slight 
 dulness of the surface of the left membrana tympani. The treat- 
 ment consisted in applying mustard plasters and stimulating lini- 
 ments to the nape of the neck, and the etherial solution of cantha- 
 rides behind the ears. The result of two months' perseverance was 
 such an improvement of the hearing power, that conversation could 
 be more distinctly perceived, and the watch could be heard at half 
 an inch from the right ear. 
 
 Totid deafness foUou'ing an attack of rheumatic fever. — ^Ir. M. 
 G., aged 17, a year and a quarter before consulting me, had a bad 
 attack of rheumatic fever, which was followed by noises in both ears 
 and gradually increasing deafness, so that in a month after the fever 
 he could not hear any sounds. Since the attack, has now and then 
 heard loud sounds for a very short time : but when he saw me he 
 was so deaf that he could not hear anything, even when the poker 
 and tonfrs were knocked ao^ainst each other. The ears had been 
 
 o o 
 
 syringed, blistered, and galvanized without any effect. There was 
 no appearance of disease in either ear. The case was at once re- 
 garded by me as incurable. 
 
 Partial deafness folloiving an attack of typhus fever. — Miss A. 
 M., aged 16, saw me on March 1st, 1851. Eleven years previously 
 she had an attack of typhus fever, and during the illness became so 
 deaf as not to be able to hear the human voice. After the symp- 
 toms of fever had disappeared, the power of hearing slowly returned, 
 until she was able to hear when loudly spoken to close to the head. 
 There was no appearance of disease in either ear. 
 
 Partial deafness folloiving fever. — V. A., Esq., aged 40, consulted 
 me in December, 1853. Twenty years before, he had an attack of 
 fever, during and for some time after which he was so deaf as to 
 re(jnire to be spoken to close to the car. The hearing gradually 
 returned, and at the end of two years he heard perfectly well for a 
 very short time, when the deafness as gradually returning, he soon 
 had to be loudly spoken to within a yard of the head. Does not 
 
NERVOUS DEAFNESS. 379 
 
 now complain of noises, but lias had a ticking sound in the ears. 
 The deafness is worse after flurry, excitement, or fatigue, after 
 dinner, wine or beer ; a single glass of either of the latter increases 
 the deafness instantaneously. Is better after a discharge from the 
 nose, and while riding in a carriage. The hearing power of the left 
 ear is gone. On examination, no unnatural appearance was detected 
 in either ear, and the watch was heard when pressed upon the right 
 ear. 
 
 Total deafness foUowing an attack of fever. — Miss C. J., aged 
 21, when a child had an attack of fever, since which time she has 
 gradually become deaf, and at the present Mioment cannot hear 
 even a loud clapping of the hands. Five years ago both tonsils 
 Avere partially removed, and tlieir remnants have recently been 
 snipped, with no effect except that of producing great mental de- 
 pression. There was no appearance of disease in any part of the 
 organ. 
 
 The poison oi scarlet fever, like that of typhus, sometimes injures 
 the nervous apparatus of the ear, and not unfrequently complete 
 deafness is the result. The following are illustrative cases. 
 
 Didness of hearing folloiving an attack of scarlet fever. — Mrs. S., 
 aged 26, had an attack of scarlet fever, eight years previous to 
 consulting me, and since that time has been troubled with a dul- 
 ness of hearing, especially during a cold. A year ago, after having 
 suffered much trouble, and after being in weakly health, the power of 
 hearing gradually decreased, and this decline Avas accompanied for 
 the first time by pain, with irritation and discharge in both ears, 
 together with constant noises like the bloAving of bellows. Is un- 
 able to hear general conversation, but a single voice is heard dis- 
 tinctly. The left ear is worse than the right. On examination of 
 the right ear, the surface of the meatus was found to be dry and to 
 contain small portions of epidermis ; the membrana tympani was 
 opaque, and the Eustachian tube pervious. The left car was in a 
 similar condition. 
 
 Complete deafness in the right ear p>roduced by the p)oison of 
 scarlet fever. — Mr. H., aged 20, had an attack of scarlet fever at 
 four years of age, since which time the right ear has been so deaf 
 as not to be able to hear even the slightest sound. On examina- 
 tion, the right membrana tympani was observed to be more opaque 
 than natural, and the left ear was perfect in every respect. 
 
 Mumps. — The peculiar poison which causes the disease generally 
 
380 THE DISEASES OF THE EAR, 
 
 known by the name of mumps is very often the source of complete 
 deafness, -whicli, however, usually occurs in one ear only. In these 
 cases, the nervous apparatus is evidently affected, as the deafness 
 comes on suddenly, is usually complete, and, as a general rule, no 
 appearance of disease can be detected in the meatus, membrana 
 tympani, or tympanic cavity. When the nerve is not wholly para- 
 lyzed, and some, although it may be a very slight degree of, hear- 
 ing remains, the only plan of treatment which can be recommended, 
 is the use of gentle counter-irritation over and around the ears, at 
 the same time that the ear is exercised by means of the elastic speak- 
 ing-tube. 
 
 The circulation of bile mixed with the blood is sometimes a cause 
 of deafness, and it is also well knoAvn that large doses of quinine 
 are also liable to be followed by temporary deafness. I have met 
 with only one case in which permanent injury to the ear was 
 assigned to the use of large doses of quinine. 
 
 The poison o^ gont may also give rise to deafness and other pecu- 
 liar symptoms in the head. In two cases of this affection which 
 came under my notice, it is interesting to observe that the head- 
 symptom complained of, viz., a feeling of vacancy, was at once 
 relieved by pressure upon the air contained in the external meatus. 
 
 Distressing sensations produced in the ears by gout. — D. T., Esq., 
 aged 54, consulted me in June, 1857. He said that for the last 
 four or five years he had ])een subject to attacks of gout, Avhich had 
 at times caused him great inconvenience, and the disease had recently 
 made so much progress as to make him fearful that his brain was 
 weakened by its influence. lie added that he was never really clear- 
 headed, excepting just after an attack of gout, when he supposed 
 his blood was temporarily freed from the poison. lie had rapidly 
 aged in the course of the previous two years. An extremely dis- 
 tressing symptom had lately presented itself in the form of a pecu- 
 liar sensation of vacancy in the ears, accompanied sometimes by a 
 low hinnming sound. There was no deafness, and the patient 
 applied to me only on account of the sensations in the ear. On 
 examination, small deposits of gouty matter were oliscrved in the 
 sul)stance of the right upper eyelid ; the surface of the meatus ex- 
 ternus was of a bright red color ; the circumference of the mem- 
 br:ina tympani and of the long process of tlie malleus were also red; 
 while the surface of the tympanic membrane was very bright. Air 
 passed freely, and with the natural sound, into the tympanic cavity. 
 
NERVOUS DEAFNESS. 381 
 
 The hearing power -was perfect. By -what, therefore, coukl the dis- 
 tressing symptoms be caused ? Were they the result of congestion 
 of the nerve ? — a condition which, it seemed to me probable, might 
 render the nerve so exquisitely sensitive, that the ordinary sounds 
 ever floatinor in the air niiglit become a source of excitement to the 
 ear. Being aware also, from previous experience in similar cases, 
 that pressure upon the external meatus so as to shut out or diminish 
 the sound in the meatus would remove the symptom complained of, 
 I closed with my fingers each external meatus, and the unpleasant 
 symptoms at once disappeared. On subsequently exerting a gentle 
 pressure on the ears by the introduction of cotton steeped in water 
 into each, the patient was enabled to leave in comparative comfort. 
 For the purpose of preventing the recurrence of the symptoms, it 
 was of course requisite to diminish the congestion, for which pur- 
 pose two leeches Avere applied below each ear, small doses of colchi- 
 cum administered, and strict attention to diet enjoined. The quan- 
 tity of wine was decreased from four to two glasses daily, and in 
 lieu of beef and mutton, of which he had been in the habit of partak- 
 ing very abundantly, he was ordered to live principally on poultry, 
 game, and fish, with abundance of farinaceous food and vegetables. 
 The result of this treatment was the removal of the distressing 
 symptoms in the ears, and the gradual disappearance of the attacks 
 of gout. 
 
 (b.) DISEASES IN WHICH THE BRAIN AS WELL AS THE EAR, 
 APPEARS TO BE AFFECTED. 
 
 (1.) Debility of the nervous apparatus arising from mental 
 excitement, 
 
 A young lady, of about 25 years of age, is brought to me by her 
 mother, on account of deafness in both ears, one being much deafer 
 than the other. The patient is pale, rather thin, and has a look of 
 depression. She complains of humming noises in both ears, and 
 hears better in a carriage. Upon examination her pulse is feebler 
 than natural, and the deafness is so considerable that she requires 
 to be loudly spoken to within a yard of her ears. There is no mor- 
 bid appearance in any part of the ear, and the Eustachian tube is 
 in a natural state. On inquiring as to the origin of the deafness, 
 the parent states that they had not been able to detect any cause. 
 
382 THE DISEASES OF THE EAR. 
 
 The ilcafnc-ss came on three years previously, when the young lady 
 was in good health, and gradually increased, till in four months the 
 patient had become as deaf as now. She is rather deafer after ex- 
 citement and during fatigue. There is no hereditary tendency to 
 deafness. The young lady has remained at home with her mother, 
 has taken plenty of exercise in the open air daily, and retired to 
 bed early ; but, for some reason or other, her nervous system was 
 not strong, and she was easily excited. On further questioning, 
 it is found, that about the period when the deafness came on, the 
 patient Avas particularly nervous, and ultimately it turns out, by her 
 confession, that she had been deeply grieved by the conduct of one 
 of her friends, and had often lain awake at night indulfrinij in sor- 
 row, and that, at such periods, the noises came on in increased 
 force. 
 
 Another young lady, aged 10, is brought just after leaving school, 
 where she was well taken care of, and so liked l)y all, that she even 
 preferred school to home. Iler parents stated that six months 
 before, without any apparent cause, their daughter had grown gra- 
 dually deaf, and can at present hear only when very distinctly spoken 
 to, Avithin a distance of tAvo or three yards. The deafness is Avorse 
 during excitement. There is no appearance of disease in the ears, 
 and the girl is strong, active, and healthy ; her nerA'ous system is, 
 hoAvever, very sensitive, her feelings most acute, and she broods in 
 silence over slight mental troubles Avhicli Avould pass unheeded by 
 ordinary persons. Perhaps all attempts to find out the cause of the 
 deafness are in vain ; and the parents go away Avith the assurance 
 from the medical man, that at the time the deafness first appeared 
 there must have been some cause of mental excitement to call it 
 forth. After the lapse of a shorter or longer period, the medical 
 man learns, perhaps, that at the time in question the young lady at 
 school suffered a great deal of mental anxiety, OAving to her reli- 
 gious vicAAs being in an unsettled state. 
 
 These tAvo cases are good t^'pcs of the class of nervous deafness 
 now under consideration. The causes may be very numerous, and 
 in some instances are but slight, compared Avith the distressing 
 symptoms Avhich ensue ; but it must be borne in mind that, as a 
 general rule, the nervous system has, from a variety of causes, been 
 alloAved to sink into a Aveakened condition. Thus the child may have 
 been overworked, liave suffered from indigestion, had too little exer- 
 cise or not enough sleep : ventilation also may liave been defectiA'c. 
 
NERVOUS DEAFNESS. 383 
 
 In a depressed state of health from any of these causes, an appa- 
 rently slight additional cause may produce the injurious efi'ect on 
 the nervous system which hag been indicated Sometimes there is 
 no diminution of the hearing power, and the patients complain not 
 of deafness, but rather of singing noises, which are increased by 
 any mental excitement. In some cases the noises are not constant, 
 but only appear after mental emotion ; the slightest unpleasant 
 thoughts are sometimes sufficient at once to induce the noises. 
 
 The deafness and noises in this class of cases, if slight, can be 
 cured by removing the cause (a depressed state of health), and by 
 giving tone to the nervous system by tonics and by local applica- 
 tions to the ear. In some cases, however, of this species of nervous 
 deafness, the symptoms of noises become so greatly aggravated, 
 that unless their peculiar character had been detailed by several 
 patients, it would be difficult to credit their existence. They may 
 commence with a gentle singing, then increase to a hissing or wiz- 
 zing sound, that suddenly changes to a series of sharp cracks, like 
 pistol-shots, followed by a rushing sound like the wind, or the escape 
 of steam from a boiler, after which a rolling may ensue like thunder. 
 These sounds vary much in intensity, being increased in some by 
 rainy weather, in others by an easterly wind ; bodily fatigue may 
 sometimes cause them to be magnified, but the source of increase is 
 usually some discomfort or excitement of mind. A young lady, for 
 instance, comes into my room with her mother to consult me, and 
 she says that the noises became rather worse than usual when told 
 that she was going to see a medical man ; that they Avere accelerated 
 when entering my house and waiting in the dining-room ; and that 
 they reached their acme of intensity after the excitement attendant 
 upon my examination of the ears, and questioning her about the 
 symptoms. The important problem for consideration is, can the 
 ears be improved ? So far as my present experience extends, I may 
 say that a large number of the worst cases can be but slightly in- 
 fluenced by treatment; but there is still a large number which may 
 be very greatly benefited by measures calculated to brace the nerv- 
 ous system ; as tonics, fresh air, exercise, and mental repose. In 
 these cases I am giving electricity a trial. 
 
 Dchility of the nervous apparatus of the car, produced hy over- 
 study. — Lady D. brought her child to me in June, 1852. The young 
 lady was twelve years of age, thin, rather tall of her age, and pale. 
 The pulse was weak ; the tonsils large and red ; the mucous mem- 
 
384 THE DISEASES OF THE EAR. 
 
 brane of the fauces red, thick, and rugous. The sub-maxillary 
 glands were somewhat enlarged, and she had been subject to glandu- 
 lar swellings in the neck. The appetite was good, and she partook 
 freelv of meat twice daily. She was taught at home with her sister 
 by two governesses, one being for languages. She devoted between 
 eight and nine hours daily to her studies. The history given me 
 was, that during the last two years, without any assignable cause, 
 the power of hearing had gradually diminished, and there had been 
 slight noises in the ears at times. On inquiry, it was elicited that 
 she was greatly interested in her studies, and very anxious to make 
 progress in them, never much tiring of her lessons. Her interest 
 in them increased to excitement, and she was often agitated and 
 distressed at not being able to accomplish as much as she desired. 
 On examining the ears, a slight dulness was observable in each 
 membrana tympani ; the Eustachian tubes were pervious, but the 
 hearing power was so diminished, that she required to be loudly 
 spoken to within a yard of the head. 
 
 This deafness was at times so greatly aggravated, that consider- 
 able difficulty was experienced in making the patient hear at all. 
 It was, therefore, palpable that there was considerable debility of 
 the nervous apparatus of each ear, for which tonics were prescribed, 
 also a gentl^^-stimulating embrocation ; fewer hours were to be de- 
 voted to study, and light nutritious food, as game, poultry, fish, 
 was to be taken instead of so much meat. All this resulted in 
 some slight amelioration ; but still the deafness was very con- 
 siderable, and increased greatly at times. Under the circum- 
 stances, another consultation took place, at which I clearly traced 
 the attacks of increased deafness to more than usual nervous ex- 
 citement following more than usual mental work. In addition to 
 the previous tonic measures, entire rest from study in any shape 
 was enjoined for three months, during the whole of which time the 
 hearing gradually improved, and at the end of six months the 
 patient was declared to be perfectly well ; and, although she has 
 resumed her previous plans of study, moderated according to 
 circumstances, the case remains satisfactory. 
 
 To the above case the details of several others might be added, 
 were not a brief allusion sufficient. Thus a lady, aged 27, consults 
 me for deafness accompanied by noises Avhich gradually came on 
 during the previous four years. The nervous system never was 
 strong, but underwent a severe shock, about the commencement of 
 
NERVOUS DEAFNESS. 385 
 
 the period mentioned, from the breaking off of a matrimonial en- 
 gagement. With the continuance of the mental sorrow the deaf- 
 ness and noises had gradually increased, and were always accelerated 
 after much mental dejection. 
 
 Another lady of nervous temperament and' warm feelings, was 
 sitting at home awaiting the return of a brother to whom she was 
 greatly attached, when he was brought home dead from a fall in 
 the street. For the space of a year the sister gave way to despon- 
 dency, and, as she told me, the thought of her brother during the 
 whole year was scarcely a moment absent from her mind. At the 
 end of that time, as her spirits began to improve, noises appeared 
 in the ears and head, dulness of hearing followed, and both noises 
 and deafness so greatly increased, that in the course of another 
 year, when seen by me, she was so hard of hearing as to require to 
 be loudly addressed at the distance of a yard or two, while the 
 noises had reached a pitch of extraordinary excitement. There 
 was scarcely any conceivable sound, whether of thunder, cannon, 
 firing guns, bells, hissing, rolling of the sea against the beach in a 
 storm, or winds howling, to which this lady was not subject. These 
 sounds intermixed and alternated in a manner quite indescribable. 
 They remained of the same general intensity, varying somewhat 
 according to the weather, for several years ; when another severe 
 domestic bereavement occurred, followed by some new noises of a 
 still more intense character, but her deafness remained much the 
 same. 
 
 Another lady, who married at about 26 years of age, was sub- 
 jected to severe domestic trials, which, after preying upon her mind 
 for some years, ended in such total deafness, that she could not hear 
 a pistol-shot fired close to her head. 
 
 The variable amount of deafness in this class of cases is sometimes 
 very marked. Thus, I had for a long while a patient under my care 
 who, when perfectly tranquil, could distinctly hear his daughter 
 reading to him at about the distance of a yard ; but if his daughter 
 told him anything which excited his interest, he became so thoroughly 
 deaf as not to be able to hear a sound, and would remain so until the 
 excitement vanished, when his hearing would return. 
 
 25 
 
386 THE DISEASES OF THE EAR. 
 
 (2.) DehiUty of the nervous apparatus of the ear produced hy 
 general bodily debility. 
 
 It is difficult to th'aw a correct comparison between the number 
 of cases of deafness dependent upon excess of mental excitement, 
 and those arising from overtasking the body ; but from the data 
 before me, perhaps those of the class now to be considered arc 
 the most common. They occur in both sexes, but are more fre- 
 quently met with in the female ; and present great variety of form 
 as well as cause. Sometimes they are temporary, and produced by 
 a long walk, heated, rooms, late hours, &c., when noises, with di- 
 minished hearing power, come on, but disappear after rest. Other 
 cases, and even some of those which come on suddenly, may, how- 
 ever, remain more or less permanent. Thus, cases have been met 
 with in my experience, in which patients have become totally deaf 
 after the administration of too violent a purgative, or after an attack 
 of diarrhoea or cholera, and after the nervous exhaustion attendant 
 upon childbirth ; in some instances of the latter, the deafness has 
 begun with the birth of the first child, and increased with each 
 successive birth, until at last the nervous power was wholly lost. 
 Perhaps the most common cause of nervous deafness from physical 
 debility is the want of proper care in the management of young 
 persons, and particularly girls, when they are growing fast. In 
 hospital practice, young nursemaids who carry heavy children, and 
 whose night's rest is often disturbed, and youths just entering 
 laborious situations, are found to suffer. Any cause, in fact, which 
 reduces the nervous energy of the body to a state too low for the 
 due regulation of the functions of the various orf!;ans of the frame, 
 may be followed by a manifest depression of the nervous power of 
 the ears, which shows itself not merely in diminished power of hear- 
 ing, but often by singing and other sensations in the ear, and some- 
 times by severe pain, like tic doloureux. In cases where debility of 
 the nervous system of the ear is the result of a debilitated state of 
 the body, the pulse, as a general rule, is weak, and there are symp- 
 tt)ms of previous or present indigestion. Generally, no unhealthy 
 condition of the organ itself is apparent ; though, in recent cases, 
 the cerumen may be softer and more abundant than usual, and in 
 old standing cases may even be absent. 
 
 The treatment of cases of debility of the nervous apparatus of the 
 
NERVOUS DEAFNESS. 387 
 
 ear arising from bodily debility, consists in imparting, by every 
 possible means, strength to the general system. Exercise in the 
 open air, a due amount of rest and sleep, -well-ventilated rooms by 
 day and night, abundance of nutritious food, stimulants in modera- 
 tion, tonics in the shape of quinine, bark, strychnine, creasote, &c., 
 should be prescribed ; Avhilc locally, gentle stimulants should be 
 applied over and around the car. I have never found the vapor 
 of ether applied to the tympanic cavity by means of the Eustachian 
 catheter of any service ; nor has my limited experience of the use 
 of galvanism and electricity hitherto been favorable to their em- 
 ployment. Some cases are decidedly amenable to treatment, and 
 the noises diminish or disappear, while the deafness is greatly 
 diminished ; but if the cause in Avhich the deafness originated be 
 allo\yed to continue, or if any debilitating influence be present, total 
 deafness may ensue in spite of every remedial effort. The following 
 cases are all interesting. 
 
 Deafness produced by want of sufficient sleep ; cure. — In the earl}^ 
 part of 1855, a young gentleman, aged 14, was brought to me by 
 his father, on account of gradually increasing deafness. lie ap- 
 peared to be in tolerable health, and was at school in the neighbor- 
 hood of London. No cause could be assigned for the afiection, which 
 had so far advanced as to cause him great discomfort from his ina- 
 bility to hear what his masters said to him. On examination, it 
 became apparent that the deafness depended upon debility of the 
 nervous system, for there was no history of any other disease, nor 
 was there any appearance indicative of disease. The patient had, 
 however, occasional noises in the ears, following over-exertion, and 
 he certainly was deafer when he was tired. On inquiry, I could 
 discover no special cause for the deafness, as he followed the same 
 rules and regulations which Avere pursued by all the boys in the 
 school. I prescribed internally quinine, and a stimulating liniment 
 externally, giving directions that he should not be over-Avorked. 
 In a month's time the boy Avas seen again, but remained in much 
 the same state, so I requested to be alloAved to see the lady with 
 Avliom he boarded, in order to ascertain further particulars as to his 
 mode of living. On the most minute questioning no sufficient cause 
 could be detected, except that, being very desirous to prepare his 
 lessons Avell, he sat up so late that Avlien the time arrived for getting 
 up, he Avas so sleepy as to be roused Avith difficulty. It Avas at once 
 rendered probable, that the debility of the nervous apparatus of the 
 
388 THE DISEASES OF THE EAR. 
 
 ear might be dependent upon the want of sleep ; and I therefore 
 recjuested his friends to see that his duties were so relaxed that he 
 could take as much sleep as he required, and gave directions that 
 he should go to bed at eight o'clock, and sleep until he awoke of his 
 own accord. The result was, that for several successive nights, he 
 slept for fourteen hours, and by degrees the number was reduced to 
 ten, which was his usual allowance for three weeks, at the end of 
 which time he returned to me, when, to the gratification of all, it 
 was found that his hearing was nearly restored, and he was no longer 
 styled " the deaf boy" at school. This patient has been seen by me 
 twice or thrice since, at considerable intervals, in consequence of 
 the deafness returning ; but each time it was evident that the ner- 
 vous system had been too much exhausted, and the administration 
 of quinine, with less work, and an increase in the amount of sleep, 
 soon restored the hearing. 
 
 Total deafness produced hy the nervous shock consequent upon 
 successive accouche j?ients. — Mrs. B., aged 40, pale, and of a nervous 
 temperament, consulted me in 1850, on account of complete deaf- 
 ness in both ears. She stated that she had married in India ten 
 years previously, and at the time of her marriage she could hear 
 perfectly well. On the occasion of her first confinement, previous 
 to which her hearing was still perfect, she sufiered a good deal from 
 exhaustion, and this was followed by a great degree of deafness, so 
 that she could scarcely hear what was said to her, even when the 
 voice was much raised. Upon getting up, and growing stronger, 
 the deafness was so much relieved that she merely required to be 
 spoken to a little louder than usual. During each successive con- 
 finement in India, amounting in all to four, the deafness greatly in- 
 creased, and after each recovery became more permanent, until, on 
 the last occasion, she remained as deaf as at present, when she is 
 oblir'ed to have recourse to signs. Indeed, she has never heard the 
 voices of her younger children, and can only by the movements of 
 their lips understand their words. 
 
 Debility of the nervous apparatus of the ear arising from over- 
 exhaustion in India. — Captain T., aged 40, came home from India 
 in 18')8, having undergone great fatigue, and his health having been 
 greatly shattered, while his hearing power had so much diminished, 
 that when he consulted me I was obliged to speak very distinctly 
 within a yard of his head. He complained of constant loud singing 
 in the ears, which was increased by the slightest exertion. On ex- 
 
NERVOUS DEAFNESS. 389 
 
 amining the ears, no alteration from tlie normal condition could be 
 detected, and the Eustachian tubes Avere in a natural state. The 
 treatment consisted in sending the patient to the seaside and in 
 giving him quinine, using at the same time a stimulating liniment 
 over the ears and at the back of the neck. In two months his 
 strength had greatly increased, with a corresponding improvement 
 in the hearing. He returned to the seaside to pursue the treatment 
 in capital spirits, and was induced to go out on two consecutive days 
 to evening parties, at which he stayed till very late. Nervous ex- 
 haustion followed, and his hearing sank to the same low ebb as when 
 he first consulted me : nor was it until after two months of very 
 quiet life and steady keeping to the prescribed treatment, that he 
 again began to improve. 
 
 Nervous deaftiess produced hy over-exertion. — E. Clarke, aged 31, 
 a tall muscular carter, was admitted under my care at St. Mary's 
 Hospital, on January 27th, 1859. He stated, that fourteen years 
 before, when out of health, deafness came on in the left ear, accom- 
 panied by noises, sometimes like a kettle singing, at others, like the 
 ringing of bells. On recovering his health, he found himself per- 
 fectly deaf in the left ear, which has remained so ever since. Eleven 
 weeks ago, when a good deal exhausted by hard work, he took a bad 
 cold, daring which singing came on in the right ear, with loud noises, 
 like the ringing of bells, and were accompanied with so serious an 
 amount of deafness, that he required to be spoken to in a loud voice, 
 within a yard of his head. The patient's pulse Avas weak, and he 
 had a worn aspect, as from exhaustion of the nervous system. On 
 examination, no appearance of disease Avas visible in either ear, and 
 the Eustachian tubes Avere pervious. Two grains of quinine were 
 ordered to be taken tAvice daily, and a stimulating liniment to be 
 rubbed over the surface of the ears, at the back of the neck, and 
 doAvn the spine. In the course of a Aveek the noises decreased 
 greatly, and in a fortnight they had Avholly disappeared, while the 
 hearing poAver gradually increased ; so that Avhen he left the hospi- 
 tal, at the end of six Aveeks, to use his oaa'u words, he " at times 
 hears quite nicely." 
 
 Several cases of a similar character might be cited, in Avhich equally 
 favorable results folloAved the administration of strychnine, in doses 
 varying from one-thirtieth to one-tAventieth of a grain, tAvice or thrice 
 daily ; and in some instances, Avhere neither quinine nor strychnine 
 
390 THE DISEASES OF THE EAR. 
 
 were of any benefit, doses of creasote, or of morphia, or of both to- 
 gether, "vvere productive of great improvement. 
 
 Kervous deafness relieved by creasote and morphia. — Miss M., 
 aged 29, in good health, but very easily excited, consulted me in 
 January, 1859, on account of deafness. Four years previously her 
 left car gradually became deaf, accompanied with noises very diffi- 
 cult to describe, but something like a whizzing, and these noises 
 were increased by any external noise, or if she felt nervous, tired, 
 or excited, and were worse at night. In a few months the right 
 ear was also affected in the same way. In both the deafness was 
 gradually increasing. This deafness was also accompanied by a 
 sudden loss of voice after she had spoken a few words. The only 
 cause to which she can ascribe the deafness was the habit of going 
 for many hours without food, and then eating very rapidly. She 
 had been treated by blisters, whose use had been followed by a rapid 
 advance of the deafness, and she had been told that her case was in- 
 curable. At the time of her first consulting me, it was requisite to 
 speak loud Avithin a yard of her head, and she was deaf to all gene- 
 ral conversation. On examination, each membrana tympani had a 
 perfectly natural appearance, and the Eustachian tubes were healthy. 
 The treatment consisted in using gentle counter-irritation over each 
 ear, the back of the neck, and down the spine, and in administering 
 creasote and morphia, in doses of two or three minims of the former 
 to one-twelfth of a grain of the latter, twice daily. This treatment 
 was continued perseveringly for four months, at the same time that 
 every measure for restoring the general health as respects food, ex- 
 ercise, and diet, were resorted to, and at the end of the treatment 
 the hearing power was so greatly improved that she could both hear 
 and take part in general conversation. 
 
 Cases of nervous affection of the ear sometimes occur in which the 
 chief symptom is i)ain ; the treatment does not differ from that of 
 the last class of cases. 
 
 Pain in the left ear, accompanied hy diminished power of hearing, 
 folloiving overfatigue. — Miss T., aged 25, pale and not strong, was 
 brought to consult me, in May, 185G, on account of a pain in the 
 left ear ; this pain had made its first appearance about a year before 
 after the patient had undergone considerable fatigue by attending 
 several evening parties in succession, and remaining very late; and 
 the pain Avas much accelerated by any cause which produced fatigue. 
 The hearing power was very slightly affected ; and as the other ear 
 
NERVOUS DEAFNESS. 391 
 
 was perfect, no complaint Avas made respecting the hearing. On 
 examination, the organ appeared to he quite healthy ; and feeling 
 that the pain arose from deranged action of the nerve consequent 
 upon dehility, quinine "was prescribed internally, and mild stimulants 
 applied over the ear and down the spine. This treatment was fol- 
 lowed by considerable success, as the pain disappeared in the course 
 of a month, but returned slightly upon the patient having to undergo 
 great fatigue. 
 
CHAPTER XVI. 
 
 THE DISEASES OF THE NERVOUS APPARATUS {concluded). 
 
 ULCERATION OK TUE MEMBRANOUS LABYRINTH — CARIES AND NECROSIS OF THE 
 PETROUS BONE. 
 
 In the cases hitherto described of disease extending from the tym- 
 panic cavity to the brain, tlie upper osseous wall of the tympanum 
 was the part affected, and the medium through which disease ad- 
 vanced to the middle cerebral cavity. There is, however, another 
 medium by which disease may be conveyed from the tympanic cavity 
 to the brain ; and that is through the labyrinth. When it is re- 
 membered that at the inner wall of the tympanum a delicate mem- 
 brane (membrana fenestrre rotunda?) is all that separates it from the 
 cochlea, and that the base of the stapes with its fine ligaments form 
 the only septum between that wall and the vestibule, it will natu- 
 rally be inferred that disease in the tympanic cavity would fre- 
 quently advance to the labyrinth. The occurrence is, however, in 
 fact, very rare, for this reason, that ulceration of the mucous mem- 
 brane of the tympanum is far from a common disease, while, under 
 the influence of chronic inflammation and of the secretion collected 
 in the tympanum, the membranes both of the fenestra rotunda and 
 ovalis become thickened and turgid. 
 
 I am not aware that any case has been recorded in which disease 
 had made its way through the fenestra rotunda to the labyrinth ; 
 but in the course of my dissections I have found the medium of 
 communication to have been, in one instance, the fenestra ovalis, 
 and, in the other, a carious aperture in the outer arm of the ex- 
 ternal semicircular canal, where it bulges into the tympanic cavity, 
 and is covered by the tympanic mucous membrane. "When suppu- 
 ration takes place in the labyrinth, the disease readily advances 
 through the cribriform floor of the meatus auditorius internus to the 
 auditory nerve, and thence to the base of the brain and medulla ob- 
 
NERVOUS DEAFNESS. 393 
 
 longata. In certain cases purulent matter is efTused beneath the 
 arachnoid over the whole surface of the base of the brain, surround- 
 ing the nerves in their cranial course; and the substance of the pons 
 Varolii or medulla oblongata may be destroyed by ulceration, or an 
 abscess may form between the arachnoid and pia mater. In some 
 cases the disease extends a considerable distance down the medulla 
 spinalis. 
 
 In some cases the labyrinth becomes carious or necrosed, and the 
 dead bone is discharged without the production of any symptoms 
 of cerebral disturbance, as in the following cases. The first oc- 
 curred to my friend Mr. Hinton, who kindly placed the preparation 
 in my museum. It was of a man net. 55, who suifered from a dis- 
 charge from the right ear for some years, and at last the cochlea 
 was discharged entire. The second case occurred to Mr. Shaw, and 
 the following report is extracted from the seventh volume of the 
 Transactions of the Pathological Society of London : — 
 
 Extraction from the left ear of a hoy of the greater jJart of the jJetrosal 
 portion of the temporal bone, including the meatus auditorius in- 
 ternus and labyrinth, separated by necrosis. 
 
 "A boy from the country, net. 7, Avas admitted into the Middlesex 
 Hospital on the 31st of July, 1855, under Mr. Shaw, for otorrhoea 
 aifecting both ears. The disease succeeded a severe attack of scar- 
 let fever, Avhich he had two years and a half ago. From the right 
 ear the discharge of pus was not of great amount. The left ex- 
 ternal ear projected considerably beyond its proper level, and an 
 irregular piece of bone, surrounded with fungous granulations, pro- 
 truded from the meatus into the concha. He had paralysis of the 
 muscles of the left side of the face ; for a year he had been com- 
 pletely deaf in both ears. 
 
 " On the 3d of August, he was put under the influence of chlo- 
 roform, when Mr. Shaw first extracted the piece of bone which 
 projected into the concha ; this appeared to have been the posterior 
 border of the external meatus of the temporal bone. 
 
 " The cartilaginous tube having been ulcerated by the pressure of 
 the loose fragment, the point of the little finger could now be passed 
 inwards to some depth ; when another larger piece of bone was felt 
 rolling freely in the cavity. This was seized by the dressing 
 
394 THE DISEASES OF THE EAR. 
 
 forceps ; and after it liad slipped once or twice, owing to its hard- 
 ness and smoothness, it was extracted by employing force and a 
 twisting motion, so as to favor its coming in a proper direction. For 
 a few seconds after the removal dark venous blood flowed rather 
 freely. As a precaution, he was kept in bed for a week ; by degrees 
 the discharge lessened, and the ulcer of the tube cicatrized. No 
 outward symptoms arose ; and in the end of September, except from 
 the paralysis of the face, the deafness, and a trifling discharge from 
 both ears, he left the hospital in good health." 
 
 Description of the Specimen. — The density of structure, Aveight, 
 and shape of the portion of bone last removed, at once showed that 
 it formed nearly the whole of the petrous portion of the temporal 
 bone. It was of irregular cylindrical, or rhomboidal figure ; it mea- 
 sured one inch in length ; its average thickness in various directions 
 was half an inch ; it weighed twenty-two grains. On one side, 
 nearly in its centre, was an opening and cavity with well-defined 
 borders and walls, which was recognized to be the meatus audito- 
 rius internus. The depth of the meatus, from the margin to the 
 thin perforated plate through which the auditory nerve penetrates 
 into the labyrinth, was three-fifths of an inch ; and, as that is the 
 full depth of the cavity in its normal state, it was thereby shown 
 that the whole of the internal meatus was included in the specimen. 
 At the bottom of the meatus could be seen the commencement of 
 the canal for the portio dura. On the side of the specimen in rela- 
 tion with the brain, the surface presented the cancellated appearance 
 peculiar to the diploe ; whence it was concluded that, in the detach- 
 ing of the necrosed part, the process of separation had taken place 
 in the diploe — that the cortical layer had retained its vitality, and, 
 remaining in contact with the dura mater, had served as a barrier to 
 prevent disease from extending to the cerebrum. On turning the 
 bone around to view it in its opposite aspect, the side then exposed 
 was seen to be the internal wall or boundary of the tympanic cavity; 
 it was easy to distinguish the ''promontory," having above it the 
 "fenestra ovalis," and below it the "fenestra rotuTida;" the two 
 latter openings were broken and irregular, and through tlie enlarged 
 holes thus produced the interior of the "vestibule," with its fossae, 
 the cochlea, modiolus, and lamina spiralis, somewhat injured, were 
 seen. At the posterior part of the specimen portions of the semi- 
 circular canals, broken ofi" near their junction with the vestibule, 
 stood up distinctly into view. 
 
NERVOUS DEAFNESS. 395 
 
 In other instances, although the brain is seriously implicated, the 
 patients recover, as in the following case quoted from Mr. Wilde. 
 He says: "I am indebted to Sir Philip Crampton for an examina- 
 tion of one of the most extraodinary pathological dissections of 
 diseased bones perhaps in existence, consisting of the entire in- 
 ternal ear, cochlea, vestibulum, and semicircular canals, "with a 
 small portion of the inner -wall of the tympanum, -which he drew 
 forth from the meatus of a young lady who, after the most urgent 
 symptoms of inflammation of the brain, with paralysis of the face, 
 arm, and leg, and total deafness of one side, recovered from the bad 
 symptoms and the paralysis of the extremities after a copious dis- 
 charge from the ear. This discharge, the paralysis of the face, and 
 deafness, continued some time, accompanied by occasional attacks 
 of pain in the ear, till one day Sir Philip, perceiving a portion of 
 loose bone lying deep in the cavity of the meatus, drew forth the 
 specimen from which the illustration in the volume was made. It 
 does not appear that the hard external enamel of the bone was 
 affected, but the scala cochleae is far more beautifully displayed 
 than could possibly have been done by art." 
 
 In the following case, which, on several grounds, is one of great 
 interest, the disease advanced through a carious orifice in the semi- 
 circular canal to the labyrinth. 
 
 Disease in the tympanic cavity, extending through a carious orifice 
 in one of the semicircular canals to the labyrinth, and thence hy the 
 auditory and facial nerves to the brain. — On the 28th of March, 
 1851, I was called in by Mr. Such, of Dalby Terrace, City Road, at 
 the request of Mr. Coulson, who had also seen the patient, to see a 
 German gcntleniffti, aged 26, the history of whose case I found to 
 be as follows : — He was of a robust constitution, and had generally 
 enjoyed the best of health: indeed, even when first seen by me, he 
 had the appearance of a stout, hcaltliy man. Between four and 
 five years previously, he complained of occasional pain in the right 
 ear, which was usually followed by a discharge that by degrees be- 
 came constant. Three weeks before my seeing him, he suifered 
 from a severe attack of pain in the head, which ceased on the 
 occurrence of an increased quantity of discharge. Nothing par- 
 ticular happened further until ten days previous to my visit (except- 
 ing a sleepless state at night), when he was suddenly seized with a 
 violent pain in the head, whicli the ordinary remedies failed to 
 relieve ; and by degrees this pain extended to the back of the neck, 
 
396 THE DISEASES OF THE EAR. 
 
 and as low as the sixth dorsal vertebra. About the same time 
 there Avas paralysis of the right facial nerve. For several days 
 there had been a continual shivering fit about two o'clock P.M. On 
 the evening of the 28th, at whicli time I saw him, he was suffering 
 from great pain at the back of the neck ; was very restless, par- 
 ticularly at times, but talked quite sensibly ; the right facial nerve 
 was paralyzed ; he squinted, and the pulse was 85. The external 
 meatus was nearly filled by a polypus : the discharge was very 
 fetid and abundant. A large blister was ordered to be applied to 
 the nape of the neck ; the car to be frequently syringed with hot 
 water ; and, as the patient was very sensitive to the action of 
 mercury, a quarter of a grain of gray powder, Avith three grains of 
 extract of henbane, were administered every two hours. 
 
 March 20th, 9 p.m. — The mercury has already caused great ten- 
 derness of the gums. The symptoms have materially increased ; 
 the pain at the back of the head was very violent this morning, the 
 squinting continues, and he sees double. At three o'clock to-day 
 he became insensible, but was roused by a loud noise, and spoke 
 rationally for a minute or two, but then relapsed into a state of 
 incoherency. Pulse as yesterday ; respiration oppressed and low ; 
 face and head congested and blue ; discharge from the car abundant 
 and fetid. Leeches were applied below the ear. 
 
 March 30th. — Slight relief followed the application of the leeches, 
 but the patient soon grew rapidly worse. The right side of the 
 body became paralyzed, the breathing stertorous, and the face livid. 
 Insensibility gradually came on, and he died at 6 p.m. 
 
 Autopsy, tivclve hours after death. — With the exception of a large 
 quantity of chocolate-colored fluid in the lateral ventricles, the 
 cerebrum was healthy, as was also the cerebellum. The arachnoidal 
 surface of the dura mater, covering the superior and mastoid sur- 
 faces of the petrous bone, was in a healthy state ; but upon removing 
 it from the bone, over two small portions of both surfaces, it was 
 found to be softer than natural, and these soft portions covered 
 apertures in the diseased bone. The appearance of disease was, 
 however, so slight, that it was quite manifest that the affection of 
 the ear had not made its way inwards at either of the two points. 
 On removing the brain, there was evidence of very extensive disease 
 at its base. Purulent matter was deposited beneath the arachnoid, 
 from the roots of the olfactory bulbs, anteriorly, to the medulla ob- 
 longata, posteriorly. In some parts this pus was of a dark color ; 
 
NERVOUS DEAFNESS. 397 
 
 in others, as in the pons Varolii, the arachnoid membrane was 
 ulcerated. The principal seat of the disease "was the right side of 
 the pons Varolii, the substance of which was ulcerated to the depth 
 of a line to a line and a half, over a surface as large as a sixpence. 
 All the nei'ves, at their origins, were surrounded Avith pus, and the 
 substance of the facial and auditory nerves of the right side Avas so 
 soft as to be scarcely distinguishable from purulent matter. On 
 examining the petrous bone, the dura mater around the orifice of the 
 meatus auditorious internus Avas observed to be softened and de- 
 tached from the denuded bone. The portions of the auditory and 
 facial nerves Avithin the meatus Avere also in a state of suppuration. 
 The Avhole of the petrous bone being removed for the purpose of 
 careful dissection, the following was the condition of the parts 
 detected. The external meatus contained tAA'O polypi, one of Avhich, 
 as large as a small pea, A\'as attached, by a broad base, to the poste- 
 rior wall of the meatus, about its middle ; the other, and smaller, 
 about the size of a grape seed, was also attached to the meatus near 
 the former. When the membranous meatus Avas separated from the 
 bone, there Avas found in the latter an orifice between tAvo and three 
 lines in diameter, so that a communication existed betAveen the 
 meatus and the mastoid cells ; there Avas, hoAvevcr, no orifice in the 
 membranous meatus, and consequently the discharge from the ear 
 came not from the mastoid cells, but from the surface of the meatus 
 only. The membrana tympani was entire, but quite Avhite and 
 much thicker than natural. The tympanic cavity contained a large 
 quantity of fetid pus, and its lining fibro-mucous membrane was 
 ulcerated at several points. Within the cavity there were also tAvo 
 portions of carious bone, one projecting towards the cavity of the 
 cerebrum and in contact Avitli the outer surface of the dura mater ; 
 the other, looking towards the cavity of the cerebellum and also in 
 contact Avith the dura mater, Avhich membrane, as before stated, 
 Avas, at the points referred to, thick and soft. The ossicles Avere 
 present, and the stapes adhered Avith its usual degree of firmness to 
 the circumference of the fenestra ovalis. On laying open the cavity 
 of the vestibule, it Avas found to be full of a dark-colored pus, having 
 a fetid odor; the semicircular canals were also full of similar mat- 
 ter, and the osseous Avail of the superior canal Avas carious at tAvo or 
 three points. This purulent matter extended from the vestibule 
 and cochlea to the meatus auditorious internus. While carefully 
 examining the external semicircular canal, Avhere it makes a bulging 
 
398 
 
 THE DISEASES OF THE EAR. 
 
 in the tympanic cavity, a small carious aperture, not larger than a 
 small pin's head, ^vas detected in it, which contained fetid pus, and 
 was the only medium through ■which disease could have been trans- 
 mitted from the tympanic cavity to the vestibule. 
 
 Fig. 99. 
 
 Caries of the External Semicircular Canal. A bristle is iilaced through the aperture 
 in the Semicircular Canal, showing the conimunieation between the Vestibule and the 
 Tympanic Cavity ; the upper wall of the Tymi)anum has been cut away. 
 
 I have described this case as one of disease orifrinatinor in the 
 tympanic cavity, and extending thence to the vestibide, inwards, 
 and to the meatus, outwards. The grounds for my belief that the 
 disease originated in the tympanic cavity are various. In the first 
 place, it is very rare for suppuration to originate in the labyrinth, 
 nor do I recollect ever to have met with a well-marked case of the 
 kind : and had it, in this instance, originated in the labyrinth, it 
 would most probably have produced death before it reached the 
 tympanum. In the second place, the tympanum is, as has been 
 stated, a frequent seat of disease ; and the presence of the un- 
 detached portions of necrosed bone indicates long-standing disease. 
 
 The nature and progress of the disease would appear to have been 
 the following : — AVhen it first made its appearance, it was probably 
 one of catarrh of the mucous membrane ; the quantity of mucus 
 secreted was too large to admit of its entire escape through the 
 Eustachian tube ; the membrana tympani was consequently pressed 
 
NERVOUS DEAFNESS. 399 
 
 upon, and, instead of ulcerating and allowing the matter to escape 
 externally, became itself much thickened and very rigid ; the secre- 
 tion being thus confined in the tympanic cavity, produced caries of 
 the bone and penetrated the labyrinth. There can, it seems to me, 
 be no doubt, that had the membrana tympani been partially de- 
 stroyed, and free egress been in that way afforded to the secreted 
 matter, the disease in the bone might have been prevented, and the 
 life of the patient by that means saved. 
 
 Another opportunity Avas kindly given to me, by the late Mr. 
 Avery, of seeing the post-mortem, and making a careful dissection 
 of the ear, in a second case of disease advancing from the tympa- 
 num to the labyrinth. In this instance, the medium of communica- 
 tion Avas the fenestra ovalis, Avhich had been left open after the 
 removal of the stapes by ulceration. 
 
 Ulceration of the tympanic mucous membrane; extension of dis- 
 ease to the labyrinth through the fenestra ovalis. — James Warner 
 Smith, aged 17, a sailor, was admitted into the Charing Cross Hos- 
 pital, on the 14th of January, 1846. The history of his case was, 
 that at five years of age he had an attack of measles, followed by 
 an abundant discharge from the left ear, from which he has never 
 since been perfectly free, although occasionally the quantity was 
 very small. He had usually enjoyed good health. Three months 
 previously, Avhen off the Cape of Good Hope, he was up aloft during 
 a gale, and lost his cap. Great pain in the ear followed this acci- 
 dent, and the quantity of discharge increased. There have been 
 many attacks of pain since, and occasionally a sanguineous dis- 
 charge. When he came on shore, he took a fresh cold, and the 
 pain in the head and ear became very violent. He now consulted 
 a surgeon, Avho ordered him injections, drops, and ointments ; but 
 not obtaining any relief, he applied to Charing Cross Hospital. At 
 the time of his admission, he complained of constant pain in the left 
 ear, and in the left side of the head as high as the vertex, with a 
 certain degree of pain also on the right side. The muscles on the 
 right side of the face were constantly twitching, and the mouth was 
 as constantly drawn to that side. Some intolerance of light was 
 also observed. An abundant offensive discharge proceeded from 
 the left ear ; but there was no tenderness over the mastoid process. 
 January 16th. — Has had a violent paroxysm of pain in the night, 
 but is better this morning, and the twitching has subsided, except 
 in the right eyelid. Calomel and opium were administered. 
 
400 THE DISEASES OF TUE EAR. 
 
 January 22(1. — Much better ; slept well ; pain abated. 
 
 January 24th. — Pain returned as violently as ever. 
 
 January 27th. — Delirious during the whole of the day. 
 
 January 29th. — Delirium continues : complains of intense pain 
 in both sides of the head ; discharge from the ear abundant ; head 
 drawn backwards. 
 
 January 30th. — The delirium has left him, but he is exceedingly 
 drowsy, and is roused with great difficulty. The movements of 
 the limbs and their sensation unaifccted. The pupils acted pro- 
 perly. 
 
 February 1st. — The drowsiness has vanished ; has liad no deli- 
 rium ; and has passed a good night ; but still complains of consi- 
 derable pain in tlie ear and over the eyes. He remained in this 
 state until the 5th, when he gradually sank, without coma or 
 cerebral symptoms of any marked character. The retraction of 
 the head continued to the last. He was quite sensible before he 
 died. 
 
 Autopsy, tliirty-six liours after death. — On removing the dura 
 mater, the surface of the arachnoid was observed to be remarkably 
 dry ; the vessels of the pia mater were more than usually injected 
 on the convex surface of the hemispheres ; there were two or three 
 small yellow patches beneath the arachnoid. Each lateral ventricle 
 contained at least three ounces of clear fluid ; in the posterior 
 corner of the right, and in the inferior of the left, Avere two patches 
 of bright yellow lymph, as large as half-a-crown, which were covered 
 by a thick creamy purulent fluid. The third ventricle contained a 
 dark clot of blood, of the size of a small walnut, which could be 
 traced into the fourth ventricle, where there was also a small coagu- 
 lum. The commissura mollis was broken down. Surrounding the 
 lower part of the commissure of the optic nerves, and covering the 
 pons Varolii, crura cerebri, medulla oblongata, and upper part of 
 of the medulla spinalis, was a layer of pure yellow pus and lymph, 
 nearly h;ilf an inch thick ; it embraced the nerves at the base of 
 the brain to their passage through their several foramina. The 
 parts in direct contact with this layer were very soft. Under the 
 pia mater, where the right anterior lobe rests on the orbital plate 
 of the frontal bone, there was a patch of effused blood, the size of a 
 shilling. The dura mater covering each petrous bone was healthy, 
 and the exterior of the bone did not present any appearance of dis- 
 ease. On examining the cavity of the ear, the membrana tympani 
 
NERVOUS DEAFNESS. 401 
 
 was found to have been destroyed by ulceration, and all the ossicles 
 had disappeared. The tympanic cavity was full of the most offen- 
 sive secretion, and its lining membrane was ulcerated. The fenestra 
 ovalis was open, and, in tiic cavity of the vestibule, similar matter 
 was found to that in the tympanum. The whole of the natural 
 membranous labyrinth had been destroyed. The auditory nerve 
 was tumefied, and of a dull livid color, the disease having evidently 
 advanced to it through the cribriform floor of the internal aiulitory 
 meatus, and thence to the base of the brain. 
 
 It is to be remarked, that in this case there appeared to be no 
 obstacle to the free egress of the matter, except the accinnulation 
 of thick masses of it in the cavity of the tympanum. It is far from 
 improbable that, in cases of ulceration of the mucous membrane of 
 the tympanum and loss of the stapes, the thick secretion in the 
 tympanum may be quite sufficient to cause the disease to advance 
 inwards. The case is also another illustration of the necessity there 
 exists for frequently washing out the tympanic cavity with Avarm 
 water. It is, however, no doubt possible, ere the stapes is removed, 
 for the disease to advance to the vestibule without the agency of the 
 pent-up matter in the tympanum. 
 
 Besides the two cases just described, I have met with two others ; 
 and as these four cases are the only instances I have found on re- 
 cord of this peculiar form of the disease, brief particulars of the two 
 latter are subjoiiied. 
 
 The first of these cases occurred in the practice of Mr. Streeter, 
 and was laid by him before the Westminster Medical Society on the 
 13th January, 1844. 
 
 Disease extending from the tymjianic cavity to the labyrinth, and 
 thence to the medulla oblongata and the base of tlie brain. — The 
 patient was a lady, aged 42, who had been deaf in the right ear 
 since the age of seven, but from what cause Avas not known. Two 
 or three months previous to her death, she became affected with a 
 severe headache, for which a blister was applied at the back of the 
 neck. Nothing serious, however, was thought of the matter until 
 the 17th December, Avheu the severity of the pain so increased as to 
 become of a maddening character, and almost to produce delirium. 
 The right portio dura nerve was paralyzed, and there was severe 
 pain doAvn the spine, Avhich was attributed to a fall received when 
 getting out of bed. The pulse did not warrant active depletion, but 
 two or three leeches were applied behind the affected ear ; a large 
 
 26 
 
402 THE DISEASES OF THE EAR. 
 
 poultice was applied over the face ; the ear was gently syringed 
 with warm water, and saline medicines were ordered. On the 18th 
 she had some sleep in the night, but complained of an almost intoler- 
 able pain in the back. The catamenia now appeared, and the cause 
 of tlie i)ain remained obscure. She was quite sensible, the pupils 
 acted, but the cornea on the affected side had begun to ulcerate. 
 There was a slight discharge from the right ear, and the left had 
 become somewhat deaf. It was thought that a hole could be ob- 
 served in the membrana tympani : calomel and opium were admi- 
 nistered. 
 
 December 19th. — She has slept better and remained somewhat 
 improved until five or six in the evening of the 21st, when she was 
 suddenly seized with coma, and continued in that state until the 
 following morning, when she died. 
 
 Autopsi/. — On examining the brain, slight sub-araclinoid effusion 
 and vascularity of its surface were found, as also some increase of 
 vascularity in the interior ; but there was no effusion in the ventri- 
 cles. An abscess was discovered in the tympanum and labyrinth, 
 and there was a counter-abscess, about the size of a large pea, in 
 the condensed araclmoid and pia mater, occupying the fossa where 
 the facial and auditory nerves proceed, from the junction of the 
 medulla oblongata with the pons Varolii and cerebellum. Pus was 
 effused beneath the arachnoid and pia mater, investing the right 
 side of the upper portion of the medulla oblongata, and the adjoin- 
 ing part of the right lobe of the cerebellum, to about the extent of a 
 square inch ; but there was neither softening nor apparent lesion of 
 the proper cerebral tissue beneath. 
 
 The exact condition of the tympanic cavity and labyrinth is not 
 detailed in the al)Ove notes by Mr. Streeter ; but there can be no 
 doubt that tlie disease (most probably ulceration of the mucous 
 membrane) had extended from the tympanum to the vestibule, 
 either through the fenestra rotunda or ovalis, or by means of an 
 orifice in the osseous wall of the labyrinth. The state of the portio 
 dura and portio mollis nerves is not stated; but judging from the 
 records of other cases of a similar character to the present, these 
 nerves must have undergone some morbid change and communicated 
 the disease to the base of the brain. 
 
 Tbe remaining case is taken from M. Itards work,' and is as 
 
 ' Trnite des Maladies de I'Oreille. 1821. Tome i, p. 254, Obs. 22. 
 
NERVOUS DEAFNESS. 403 
 
 follows : A man, aged 22, five weeks before his death, complained 
 of toothache: this was followed by febrile symptoms. On the 
 twelfth day after the attack, discharge took place from the left ear, 
 but symptoms of cerebral irritation increased until lii.s death. 
 
 Autojjsy. — Over the convex surface of the brain, and in its sub- 
 stance, were a number of small purulent deposits. The cerebellum 
 was similarly affected, but in a less degree. The auditory and facial 
 nerves were in a state of suppuration, and almost wholly destroyed : 
 pus was also found in the internal auditory meatus, the vestibule, 
 cochlea, and semicircular canals, and the tympanic cavity. 
 
 The treatment to be pursued in these cases is similar to that 
 recommended in cases of disease of the tympanum and the mastoid 
 cells. 
 
CHAPTER XVII. 
 
 MALIGNANT DISEASE OF THE EAR. 
 
 ORIGIN IN THE MCCOCS MKMBRANE OF THE TYMPANUM — DESTRUCTION OF THE PETROUS 
 BONE — SOMETIMES MISTAKEN FOR POLYPUS — OPERATIONS TO BE AVOIDED — BRAIN 
 AND DURA MATEU INVOLVED — TREATMENT. 
 
 Cases of malignant disease, advancing from the ear towards the 
 brain, appear to be of rare occurrence. So far as my own expe- 
 rience and tlie aid of published cases permit me to judge, it appears 
 most probable that the part of the ear in which malignant disease 
 usually originates, is the mucous membrane lining the cavity of the 
 tympanum. After the diseased growth has destroyed the merabrana 
 tyuipani, it advances through the external meatus to the outer orifice, 
 where it shows itself in the shape of a small tumor, Avhich has 
 sometimes been mistaken for a polypus, and the removal of which 
 has caused hemorrhage and an aggravation of the symptoms. At 
 the same time that the disease advances outwards, it also encroaches 
 upon the whole of the parts surrounding the organ of hearing. The 
 osseous walls of the meatus externus and of the tympanic cavity are 
 wholly destroyed ; the outer part, and even the whole of the petrous 
 bone, are converted into a mass of disease ; the lower part of the 
 squamous bone also disappears, and the tumor ailvanccs into the 
 cavity of the skull, where it destroys life, cither by its pressure upon 
 the brain or its bloodvessels, or by involving the brain itself in the 
 disease. 
 
 This malignant disease is sometimes of the nature of fungus 
 hsematodes ; at other times it has the characters of encephaloid 
 disease. This affection occurs at various periods of life: the ages 
 of the three patients to whose cases reference is about to be made, 
 were respectively 3, 18, and 35 ; the progress is very rapid gene- 
 rally, and forms a marked contrast with those cases of chronic 
 
MALIGNANT DISEASE OF THE EAR. 405 
 
 disease of the ear advancing to the brain, to which attention has 
 hitherto been drawn. 
 
 Sophia W., aged 35, a single woman, was admitted under my care 
 into St. Mary's Hospital, on the 14th July, 1854, The history, as 
 given by herself, is, that after a severe cold, a year previously, the 
 right ear suddenly became painful, though the pain was not very 
 severe. Since the above period, the pain has been gradually in- 
 creasing, accompanied by a tumefxction of the right side of the face. 
 Six months ago a red growth Avas removed from the tube of the ear, 
 which the surgeon considered to be a polypus, and since then she 
 has had at times a good deal of bleeding from the ear. Lately the 
 pain has greatly increased, and has extended over the side of the 
 head and the face ; a small round swelling has also appeared at the 
 orifice of the ear. On examination, the external ear was observed 
 to be much redder than natural, and somewhat hypertrophied ; and 
 the orifice of the meatus was closed by a red tumor, about the size 
 of an almond, upon pressing one side of which a small quantity of 
 sanious discharge issued from the meatus. The inteo;uments around 
 the ear, for the distance of an inch and a half, were red, soft, and 
 somewhat elevated above the surrounding parts by a tumor beneath 
 them. The left portio dura nerve Avas completely paralyzed ; there 
 was much pain of a pricking and shooting character complained of 
 in the region of the tumor, and this at times extended inwards to 
 the brain. The treatment consisted in occasional'y applying a leech 
 or two in the region of the ear, so as by diminishing the congestion, 
 to relieve the pain ; small doses of morphia were frequently admin- 
 istered, and the general health supported ; the meatus was frequently 
 syringed with warm water, and emollient applications made to the 
 tumor. These remedies, however, led to very transient amelioration 
 of the symptoms ; though the pain would sometimes subside, the 
 patient was subject to frequent and severe relapses. She was able, 
 however, to walk about the ward, and a few days previous to her 
 death expressed a wish to leave the hospital in order to visit her 
 friends in the country. On the 23d of October, she did not com- 
 plain more than usual of the pain in the face and head, but on the 
 24th and 25th there were symptoms of considerable cerebral conges- 
 tion, she Avandered a good deal, and the head was evidently a source 
 of great distress to her. The symptoms of congestion gradually in- 
 creased, and she died on the 28th of October. 
 
 Autopsy. — The integuments of the external ear, and those cover- 
 
406 THE DISEASES OF THE EAR. 
 
 ing the tumor, ■were red and tumefied. Upon reflecting the ear and 
 the integuments from the tumor, a large mass was exposed, Avliich 
 extended from the posterior part of the mastoid process, posteriorly, 
 to the body of the malar bone anteriorly, and also from half an inch 
 below the squamous suture to the angle of the inferior maxilla 
 below. The tumor was intimately connected with the integuments, 
 and of a reddish-white color. It presented different degrees of con- 
 sistence, being in front, where it surrounded the ascending ramus of 
 the lower maxilla, quite hard and firm like the pancreas, while more 
 posteriorly it was softer ; and deeper towards the styloid process, 
 there was a large quantity of a white creamy fluid. Both anterior 
 and posterior to the external auditory meatus, the tumor contained 
 small spicuUx! of bone. The mastoid process was involved in the 
 disease, and Avas deduced to some detached masses of bone in the 
 middle of a portion of the tumor. The osseous meatus had wholly 
 disappeared, and the remains of the , membranous meatus could 
 scarcely be distinguished, its walls having become so much involved 
 in the diseased mass. The only remains of the tympanic cavity 
 were some portions of the mucous membrane, having a dark livid 
 hue, with distended bloodvessels, and small red growths attached to 
 it. Not a remnant was left of the bony cavity. The whole of the 
 squamous bone, from an inch below the squamous suture, and the 
 whole of the outer part of the petrous bone had been destroyed, so 
 that the apex of the petrous bone had no connection with the squa- 
 mous. The tumor had advanced inwards to the cavities of the 
 cerebrum and cerebellum, through the aperture formed by the 
 destruction of the squamous and petrous bones. In the middle 
 cerebral fossa was a reddish-white tumor, of about the size of a small 
 pear, which consisted of two portions, one below, and the other 
 above, the dura mater. The part below the dura mater was directly 
 continuous with the external tumor, while the large portion above 
 seemed to be an indejjendent growth from the free surface of the 
 dura mater, and connected to the larger mass of the tumor by 
 bloodvessels only. The upper part of this portion of the tumor 
 was adherent to the lower surfiice of the left middle cerebral lobe, 
 which was softened to the depth of half an inch. The part of the 
 tumor posterior to the petrous bone, and beneath the tentorium, was 
 somewhat smaller and less prominent than that just described in the 
 middle cerebral fossa, was wholly confined to the interior surface of 
 the dura mater, and must have almost entirely arrested the circula- 
 
MALIGNANT DISEASE OF TUB EAR. 407 
 
 tion of tlie lateral sinus. The Avholc of the cerehral veins and 
 sinuses were very much distentled with dark-colored blood, but 
 there was no appearance of disease in any other part of the cerebral 
 substance than the softened portion of the inferior lobe. 
 
 On examining the tumor by the aid of the microscope, the harder 
 portions were found to consist of very delicate fibres and nucleated 
 cells, Avhile the softer parts and creamy fluid were almost wholly 
 composed of nucleated cells, circular, fusiform, and angular. 
 
 There appears every reason to believe that, in this case, the dis- 
 ease originated in the tympanic cavity. It will have been seen that 
 the seat of the pain when first complained of, was the car. This 
 was followed by a growth from the meatus, similar to a polypus, and 
 then by paralysis of the portio dura nerve. From this centre the 
 disease seems to have spread in all directions, destroying every 
 structure which it approached. In the preparation, a large portion 
 of the osseous Avail of the cranium is seen to be absent, so that, by 
 pressing upon the tumor during life, the contents of the cerebral 
 cavity were also subject to pressure. Unfortunately in these cases, 
 little can be done even to alleviate the sufferings of the patient. 
 Local depiction by leeches applied to the vicinity of the tumor, hot 
 fomentations and the administration of opiates, appear to be the 
 only remedies capable of doing any service. It is nevertheless of 
 the utmost importance to be able to decide upon the nature of the 
 disease whenever it does occur, since measures Avill at least be re- 
 frained from that are calculated to aggravate the disease, and no 
 operation Avill be attempted. In the case in question, it is possible 
 that the removal of part of the tumor, which was thought to be 
 a polypus, did material injury, by causing the disease to advance 
 more rapidly. Those Avho are careful will have no difiiculty in dis- 
 tinguishing between an ordinary polypus growing from the walls of 
 the meatus, and a portion of tumor similar to that of the case under 
 discussion. The polypus is smooth and globular, and not covered 
 by epidermis ; neither does it present an ulcerated surface, such as 
 Avould be disclosed by a portion of encephaloid tumor when it exists 
 and gives off secretion. Again, in cases of polypus growing from 
 the external meatus, there is very rarely any tumefaction of the 
 ear or integuments, such as is found in malignant disease. The ob- 
 servation, so frequently made by me, may here be repeated, that as 
 polypoid growths are so often symptomatic of the existence of irri- 
 tation within the tympanic cavity, aiul are sometimes coexistent 
 
408 THE DISEASES OF THE EAR. 
 
 with disease of the bone, great caution shouUl always be used pre- 
 vious to ])roceeding to extirpation. By referring to a very interest- 
 ing case of malignant disease of the ear, published by Mr. AVilde at 
 page 20G of his treatise on Aural Surgery, it will be found that he 
 also lays much stress upon the necessity of being careful " in med- 
 dling with morbid growths of long standing, without being fully 
 satisfied as to their nature, and the place from which they grow." 
 The cause of death in the patient whose case has here been con- 
 sidered, appears to have been congestion of the brain, produced by 
 the pressure of the tumor on its substance, as well as upon the 
 lateral sinus. 
 
 The second preparation illustrative of the effects of malignant 
 disease of the ear extending to the brain, Avhich has to be described, 
 was laid before the Pathological Society of London, in 1850, by 
 Mr. Cooper Forster, to whom I am indebted for the specimen. The 
 particulars, copied from the Transactions of the Pathological So- 
 ciety, are as follow : — 
 
 "• A strumous lad, aged 19, was knocked down by a cab nineteen 
 months before his death, and struck on the right side of his head. 
 He soon afterwards became deaf, and suffered severe pain in the 
 right ear ; the part became slightly swollen and excessively tender, 
 especially over the mastoid process. The swelling did not increase, 
 but the pain in the head was most intense, and paralysis of the 
 right portio dura nerve took place. No great change occurred until 
 within the last six months, when, from another blow on the same 
 spot, the disease seemed to become more active ; the side of the 
 head, from above the temporal ridge to two inches below the ear, 
 became enormously enlarged and tender ; and the external ear ap- 
 peared as though pushed away from the side of the head. He ex- 
 perienced great difficulty in swallowing solid food, and was also 
 unable to speak. 
 
 " About two months before his death, the swelling began to fun- 
 gate and slough, profuse hemorrhage occurred at intervals, and 
 sloughing very rapidly took })lace, and at last laid bare the pharynx. 
 To such an extent, ultimately, had the destructive action taken 
 place, that a large chasm formed around the ear, leaving that organ 
 completely isolated. Xo brain symptoms occurred. The profuse 
 hemorrhage and constant drain of pus (juickly destroyed him. 
 
 ^''Autopsy. — The brain appeared perfectly healthy except at the 
 lower part of the right hemisphere, wliich was pulpy and very soft. 
 
MALIGNANT DISEASE OF THE EAR. 
 
 409 
 
 The softening was, without doubt, occasioned by the upward pres- 
 sure of a hard scrofulous-looking mass, attached to the petrous 
 portion of the temporal bone, through the intei'vention of the dura 
 mater, from which it seemed to spring. The mass pressed upon the 
 bone below, and appeared as though inclined to force its way down- 
 wards, through the temporal bone, at the junction of the squamous 
 Avith the petrous portion, a great part of the latter being completely 
 absorbed. Some new bone had formed at the inner side, and the 
 whole of the exterior was occupied by a sloughy nwss and carious 
 bone (as seen below), the surrounding parts being very hypertrophied ; 
 no vestige of meatus or mastoid cells could be discovered ; the lateral 
 sinus was filled by a coagulum." 
 
 Fig. ion. 
 
 ^-1:; 
 
 
 From the history of the case just cited, and an examination of 
 the preparation, there is no doubt on my mind but that the nature 
 of the disease was malignant, very probably encephaloid, and that 
 it commenced in the tympanic cavity. It will have been observed, 
 that the early symptoms indicated that the disease was in the ear, 
 both by the pain experienced there, and by the presence of deaf- 
 ness. If the preparation be carefully inspected, it Avill be seen that 
 
410 THE DISEASES OF THE EAR. 
 
 the largest amount of destruction, and the most marked appearance 
 of disease, are around the tympanic cavity ; from which the progress 
 seems to have been downwards to the pharynx, upwards to the 
 outer surface of the squamous bone, and histly, inAvards and up- 
 wards to the cavity of the skull. The orifice communicating between 
 the disease without and that within, is, however, very small in com- 
 parison to the extent of the disease externally, and the internal 
 surface of the bone is much less affected than the outer. That the 
 disease was malignant is shown, I think, by the bleeding and fungoid 
 character of the soft growth, and tlie peculiar expanded and spicu- 
 lated state of the bone. 
 
 The third case is one published in the eleventh volume of the 
 Edinburgh Medical and Surgical Journal, by Mr. Wishart, and 
 called by him a case of fungus hfcmatodes. The subject was a child 
 three years old, in whom, after suffering for some weeks from severe 
 pain in the right ear, followed by discharge, a tumor appeared 
 surrounding the ear, and which speedily ulcerated, discharging a 
 large quantity of fetid bloody matter ; hemorrhage also fre(|uently 
 occurred. The child died within fifteen weeks after the appearance 
 of the disease. On a post-mortem examination, the tumor was 
 found to be as large as the child's head ; externally it had caused 
 the destruction of the condyloid process of the lower jaw ; the 
 zygomatic process was also gone. The tumor had advanced inwards, 
 destroying the whole of the petrous bone, and extended upwards, 
 through a large orifice in the squamous bone, so as to form a de- 
 pression on the middle lobe of the brain, which was in other respects 
 quite sound. 
 
 As bearing upon the subjent, I may as well give briefly the par- 
 ticulars of a case of disease of the petrous bone which occurred in 
 the practice of Mr. Part, of Camden Town, to whom I am indebted 
 for the preparation. The patient was a clergyman, aged twenty- 
 five, subject for five years to a discharge from the right ear, with 
 occasional pain. A year before his death an abscess broke behind 
 the ear, wliich discharged at times. About a fortnight before his 
 death he suftercd from severe pain in the head and vomiting, and 
 had paralysis of tlie right ])ortio dura nerve. lie was not relieved 
 by Jvny treatment, and the head-symptoms increased until his death. 
 On a post-mortem inspection, a cavity was found in front of the ear, 
 and another beneath the temporal muscles ; both contained a soft 
 caseous substance. Tlie whole of the petrous bone, a portion of the 
 
MALIGNANT DISEASE OF THE EAR. 411 
 
 basilar process of the occipital and of the sphenoid, were found de- 
 generated into a soft cheesy mass. The malar bone was destroyed, 
 and the mastoid process occupied by the disease. The ventricles 
 contained three ounces of bloody serum ; the arachnoid was much 
 injected ; while between it and the pia mater was a layer of very 
 yellow pus, extending along the base of the brain. In the middle 
 lobe of the brain was an abscess containing upwards of an ounce of 
 very fetid greenish pus ; and a second abscess existed in the middle 
 of the posterior lobe. If the preparation be examined, as in the 
 preceding cases, there will be found to be a large aperture in the 
 squamous bone, and the petrous and mastoid bones are wholly con- 
 verted into the white cheesy-looking matter. On examination by 
 the microscope, this matter is discovered to consist of cells, varying 
 in form, only few of which have any distinct nuclei ; granular 
 matter is also interspersed among the cells. The case may be con- 
 sidered as one of degeneration of the petrous bone, originating in 
 the tympanic cavity. 
 
 The ulceration at times proceeds most rapidly, extending to the 
 bone, which is soon destroyed. Sometimes the greater part of the 
 squamous bone disappears. A case of the kind has been published 
 by Dr. Russell, of Birmingham, in the Association Journal, for March 
 31st, 1852, of which I will give a few particulars. 
 
 Mrs. P., aged 66, was attacked, about nine months before her de- 
 cease, Avith pain in the right ear, attended with swelling. A fort- 
 night afterAvards, she struck it against a bracket ; the swelling broke, 
 and the ear discharged. The discharge and pain continued, and 
 paralysis of the portio dura ensued, while the power of hearing dis- 
 appeared. xVt the time she was seen by Dr. Russell, there was in- 
 tense pain in the ear ; mania, coma, and ultimately death, ensued. 
 There was no history of early disease in the ear, but she had been 
 accustomed to pick it with a pin, for a certain degree of itching. On 
 an autopsy, tlie entire S(|uamous portion of the temporal bone was 
 found to have been destroyed, and tlic disease had encroached 
 upon the mastoid process, laying open the cells. Tlu petrous 
 bone was also almost entirely destroyed. The dura mater was not 
 injured, except in one spot, where there was a sloughy opening, the 
 size of a crown-piece. Opposite the orifice in the dura mater, the 
 brain was in a state of suppuration ; and both ventricles were full 
 of the ddbris of sloughy cerebral tissue. There were about two 
 drachms of thin, purulent fluid at the base of the brain. This spe- 
 
412 THE DISEASES OF THE EAR. 
 
 cimen, which through the kindness of Dr. Russell I had an oppor- 
 tunity of inspecting, presented a very similar appearance to the one 
 previously described. In each case all vestiges of the tympanic 
 cavity had disappeared. They differ from the great majority of 
 cases of disease in the tympanum, in extending outwards instead of 
 upwards. 
 
 The treatment in these cases consists in diminishing the symptoms 
 of congestion of the brain, by the occasional application of leeches, 
 and in attempting to allay the pain by the administration of mor- 
 phia. 
 
CHAPTER XVIII. 
 
 ON THE DEAF AND DUMB. 
 
 DISEASES PRODUCING DEAF-MUTISM — THE CONDITION OF THE EARS IN THE DEAF AND 
 DUMB, AS ASCERTAINED BY EXAMINATION DURING LIFE — THE CONDITION OF THE 
 EAR IN THE DEAF AND DUMB, AS REVEALED BY DISSECTION — THE MODE OF EXA- 
 MINING A CHILD SUPPOSED TO BE DEAF AND DUMB ON THE MEDICAL TREATMENT 
 
 OF THE EARS OF THE DEAF AND DUMB — THE AMOUNT OF HEARING POSSESSED BY 
 CHILDREN USUALLY ACCOUNTED DEAF AiND DUMB — ON THE EDUCATION OF THE 
 DEAF AND DUMB; WITH CASES. 
 
 TuE number of deaf-mute children examined, and from whom 
 the facts in this chapter were obtained, amounted to 411. Of these, 
 313 were congenital cases, and 98 were the eflfect of different dis- 
 eases acquired subsequent to birth. 
 
 I. THE DISEASES PRODUCING DEAF-MUTISM. 
 
 On the causes producing congenital deaf-mutism I am unable to 
 oifer a decided opinion ; but the results of dissection, as detailed in 
 a subsequent part of this chapter, show that the nervous apparatus 
 is very frequently affected. If regard be also paid to the other 
 cases I shall refer to, and the non-appearance of an efficient cause 
 of any other kind, together with the analogy to be drawn from the 
 cases in the chapter on Nervous Deafness, it would be no very 
 violent assumption to suppose that early derangement of the nervous 
 apparatus is at the root of most of the instances of deaf-mutism. 
 
 Of the causes of acquired deaf-mutisra a more accurate estimate 
 may be formed. Thus in the 98 cases of acquired deafness the 
 causes were as follows : — 
 
 Scarlet Fever 30 
 
 Fever, 23 
 
 Measles, ............. 4 
 
 Various diseases, as teething, convulsions, hydrocephalus, a full, fits, a 
 
 fright, Ac, 35 
 
 98 
 
414 THE DISEASES OF THE EAR. 
 
 II. THE CONDITION OF THE EARS IN THE DEAF AND DUMB, AS 
 ASCERTAINED BY EXAMINATION DURING LIFE. 
 
 The condition of the ears in the deaf and dumb is very various, 
 and in the majority of the ears there is some abnormal appearance, 
 although it is often very slight. Thus, in only 197 out of 411 
 patients were the ears healthy. The following table shows the con- 
 dition of those ears that were not healthy: — 
 
 In GQ the surface of the membrana tympani was dull. 
 38 the membrana tympani was opaque. 
 12 the membrana tympani was more concave than natural. 
 3 the membrana tympani was very concave and opaque. 
 
 1 the membrana tympani was shrivelled. 
 
 10 the mem])rana tympani had fallen inwards. 
 
 9 the membrana tympani was perforated. 
 18 the membrana tympani was absent, from ulceration. 
 
 2 the meatus was full of cerumen. 
 
 35 the meatus was full of cerumen, and the membrana tympani 
 opaque. 
 
 3 the meatus externus formed a cul-de-sac half an inch from the 
 
 orifice. 
 
 1 the meatus contained a polypus. 
 
 3 the membrana tympani of one ear was opaque, and in the 
 other it had fallen inwards. 
 
 2 the membrana tympani was opaque in one car and absent in 
 
 the other. 
 1 the membrana tympani was normal in one ear and absent in 
 the other. 
 
 3 the membrana tympani was fallen in in one car and perforated 
 
 in the other. 
 1 the membrana tympani was natural in one ear and the meatus 
 
 full of cerumen in the other. 
 1 the meml)rana tympani was fallen in in one car and dull in 
 
 the other. 
 1 the membrana tympani was absent in one ear and the meatus 
 
 contained a polypus in the other. 
 1 the membrana tympani was very concave in one ear and had 
 
 fallen inwards in the other. 
 
ON THE DEAF AND DUMB. 415 
 
 In 1 the membrana tympani was natural in one ear and very con- 
 cave in the other. 
 
 1 the memhrana tympani was perforated in one ear and opaque 
 in the other. 
 
 1 the membrana tympani was very concave in one ear and absent 
 in the other. 
 
 It is interestinjr to observe the difference between the condition 
 of the ears in the acquired and congenital cases. 
 
 The condition of the ears in the 313 congenital cases : — 
 
 172, or nearly three-fifths, had a natural appearance. 
 
 In the 172 cases of absolute deafness the folloAving was the con- 
 dition of the ears : — 
 
 96 had a healthy appearance. 
 In 37 each membrana tympani was dull. 
 
 20 there was an accumulation of cerumen, and each membrana 
 
 tympani Avas dull. 
 12 each membrana tympani was opaque. 
 
 1 each membrana tympani had been destroyed by ulceration. 
 
 2 one membrana tympani was opaque, the other had fallen in. 
 1 one membrana tympani Avas opaque, the other Avas absent. 
 
 1 one membrana tympani Avas natural, the other Avas opaque. 
 1 one membrana tympani was natural and the other was absent. 
 1 one membrana tympani Avas fallen in and the other was per- 
 forated. 
 
 172 
 
 The following was the condition of the ears in the 141 congenital 
 cases, in Avhich certain sounds Avere heard : — 
 
 [a.) In 11 Avho heard a clapping of the hands, 7 had a normal 
 aspect. 
 In 2 each membrana tympani Avas opaque. 
 
 1 each meatus was distended by cerumen, and the membrana 
 
 tympani Avas opaque. 
 1 each membrana tympani Avas concave. 
 
416 THE DISEASES OF THE EAR. 
 
 (6.) In the 44 who heard a shout : — 
 
 21 "vvere apparently natural. 
 In 7 each inembrana tympani ■was dull. 
 
 4 " " " " and the meatus full of 
 
 cerumen. 
 4 " " " opaque. 
 
 4 " " " concave 
 
 2 " " " concave and opaque. 
 
 2 " " " perforated. 
 
 (('.) In the 30 -who heard a loud voice : — 
 
 24 were apparently normal. 
 In 7 each membrana tympani was dull. 
 
 3 " " " " and the meatus full of 
 
 cerumen. 
 3 " " " opaque. 
 
 1 " " " concave. 
 
 1 in one car the membrana tympani was normal ; in the other 
 it was opaque, and the meatus full of cerumen. 
 
 ((?.) In the 43 who heard the vowels and repeated them after 
 me: — 
 
 24 appeared to be normal. 
 In G each membrana tympani was dull. 
 
 5 " " " " and the meatus was full of 
 
 cerumen. 
 5 " " " opaque. 
 
 1 " " " concave and opaque. 
 
 (r.) In the 5 who heard words and repeated them: — 
 
 2 appeared normal. 
 
 In 1 each membrana tympani was dull. 
 
 1 " " " " and the meatus was full of 
 
 cerumen. 
 1 in one ear the membrana tympani was opaque and concave, 
 
 an<l in tlio other it had fallen in towards the promontory. 
 
 (/.) In the single instance in wliieh short sentences were heard 
 and repeated, the membrana tympani was dull. 
 
ON THE DEAF AND DUMB. 417 
 
 The condition of the ear in the 98 acquired cases of deafness. 
 
 Of the entire number, only 23, or about one-fourth, had a natural 
 appearance ; of the 75 cases of acquired deafness, in which there 
 Avas no power of hearing, 19, or about one-quarter, Avere apparently 
 normal ; including those instances in which the surface of the mem- 
 brana tvmpani was only slightly dull, 27, or about one-third of the 
 whole, had a natural appearance. Of the 25 acquired cases in which 
 there was a certain amount of hearing power, 5, or one-fifth, were 
 apparently healthy. 
 
 Scarlet Fever. 
 
 In the 36 cases of scarlet fever, only two patients had the ears in 
 a healthy state ; in 15 each mcmbrana tympani was absent, and in 
 5 each membrana tympani was perforated ; in 3 each meatus formed 
 a cul-de-sac about half an inch from the orifice. It is clear, there- 
 fore, that in the majority of cases of deafness from scarlet fever, the 
 effects of very active disease were apparent ; this disease was usually 
 catarrhal inflammation of the tympanic mucous membrane, ending in 
 an ulceration of that membrane, which extended to the labyrinth. 
 As it is interesting; to observe the relation between the amount of 
 hearing possessed by a patient, and the condition of the ears, I have 
 arranged the results in the following forms : — 
 
 (a.) Condition of the ears in the 27 patients who were entirely 
 deaf : — 
 
 In 1 each ear was apparently healthy. 
 
 4 the surface of each membrana tympani was dull. 
 
 1 each membrana tympani was concave. 
 
 2 " " " fallen in. 
 
 3 " " " perforated. 
 
 13 " " " absent, and there was catarrh 
 
 of the tympanic mucous membrane. 
 3 each meatus formed a cul-de-sac about half an inch from its 
 orifice. 
 
 [b.) Condition of the 9 patients by whom certain sounds are 
 heard : — 
 
 27 
 
418 THE DISEASES OF THE EAR. 
 
 In tlic single individual who heard a clapping of the hands, each 
 
 membrana tympani was absent. 
 Of the fee who heard a loud voice : — 
 In 1 the membrana tympani was fallen in. 
 
 2 " " " perforated, and there was a poly- 
 
 pus in the meatus. 
 
 2 " " " absent in each ear. 
 Of the two who pronounced the vowels : — 
 
 In 1 the membrana tympani was dull and opaque. 
 
 1 in the right ear the membrana tympani was fallen in ; in the 
 
 left ear it was absent. 
 In the 0)ic child who pronounced short words both ears were appa- 
 rently natural. 
 
 Condition of the ears in the 23 cases of deaf ness from fever : — 
 
 (a.) In the 17 who did not hear any sound : — 
 
 3 were apparently healthy. 
 
 In 2 each meatus was distended by cerumen. 
 3 each membrana tympani was opaque. 
 1 
 1 
 
 2 " 
 1 
 1 
 1 each meatus full of paper, each membrana tympani fallen in 
 
 and red. 
 1 right ear, the membrana tympani concave and thick ; left ear. 
 
 membrana tympani perforated and fallen in. 
 1 right ear contained a polypus ; in left ear the membrana 
 
 tympani was absent. 
 
 (h.) In the 6 who heard sounds. 
 In the four who heard a shout : — 
 
 1 each membrana tympani was dull and opaque. 
 1 " " " perforated; the mucous mem- 
 
 brane of the tympanum being thick. 
 1 each membrana tympani was dull. 
 
 1 right ear, the membrana tympani was perforated ; left ear, 
 the membrana tympani fallen in and corrugated. 
 
 
 
 dull. 
 
 
 
 white and shrivelled. 
 
 
 
 fallen in. 
 
 
 
 perforated. 
 
 
 
 destroyed by ulceration 
 
ON THE DEAF AND DUMB. 419 
 
 In the single instance in whicli a loud voice was heard, each mem- 
 brana tympani was opaque ; and in the case Avhere the patient tried 
 to articulate "words after the speaker, each ear was apparently 
 normal. 
 
 Condition of the ear in the four cases of measles: — 
 
 (a.) Of the three who were deaf: — 
 
 In 1 each ear was apparently normal. 
 
 1 each membrana tympani white and thick. 
 
 1 right ear, the membrana tympani dull ; left ear, membrana 
 tympani dull, and fallen in. 
 
 (5.) In the patient who heard a clap of the hands, each membrana 
 tympani was thick and white. 
 
 Condition of the ear in the 35 cases of deafness produced hy va- 
 rious diseases, as teething, convulsions, hydrocephalus, a fall, Jits, a 
 fright, ^c. : 
 
 In seventeen cases each ear appeared to be normal. In several of 
 the others the membrana tympani was dull on the surface, opaque, 
 or concave. In three cases it had fallen in ; but in only two was it 
 perforated : thus showing a marked difference between the effects of 
 these diseases and those of scarlet fever ; where it will be remem- 
 bered that, in 20 out of 36 cases, each membrana tympani was 
 either absent or perforated. I will give, first, the condition of the 
 ears in the patients entirely deaf, and then the condition of those 
 having various degrees of hearing. 
 
 (a.) Condition of the ears in the 26 patients who were entirely 
 deaf: — 
 
 14 appeared natural. 
 In 2 each membrana tympani was dull. 
 
 3 " " opaque. 
 
 4 " " concave. 
 1 " " fallen in. 
 
420 THE DISEASES OF THE EAR. 
 
 1 one ear appeared natural ; in the other the membrana tympani 
 
 was fallen in. 
 1 in one ear the membrana tympani was opaque ; in the other it 
 
 was absent. 
 In the case where the clap of the hands was lieard, each ear ap- 
 peared to be natural. 
 
 (b.) Of the three who heard a shout : — 
 
 1 appeared to be natural. 
 In 1 each membrana tympani was opaque. 
 
 1 the membrana tympani of one ear was concave, and it was na- 
 
 tural in the other. 
 
 (<?.) Of the four who heard a loud voice : — 
 
 1 appeared natural. 
 In 1 each membrana tympani was opaque. 
 
 2 the membrana tympani of each ear had fallen in. 
 
 In the single case where the vowels were heard, the membrana 
 tympani of one ear was opaque, and it was perforated in the other. 
 
 III. ox THE CONDITION OF THE EAR IN THE DEAF AXD DUMB, AS 
 REVEALED BY DISSECTION. 
 
 It is highly desirable that careful dissections should be made of 
 the ears of deaf and dumb patients whose cases have been carefully 
 noted during life, in order that tlie condition of the organ may be 
 compared with the amount of hearing possessed by the patient. Pa- 
 thological investigations into the condition of the ear in the deaf and 
 dumb have, however, been too seldom conducted, to enable us to 
 draw any conclusive general deductions as to the condition of the 
 ear in deaf-mutes. I purpose now to give the details of five dissec- 
 tions performed by myself, and to follow them with a tabular view 
 of the morbid appearances found in all the other dissections of simi- 
 lar cases that have been met with by me. 
 
 Dissection 1. — A woman, xt. 40, deaf, and consequently dumb, 
 from birth. For the last ten years of her life she was insane, and 
 was confined in a lunatic asylum. The petrous bones were sent to 
 
ON THE DEAF AND DUMB. 421 
 
 me, immediately after tlie death of the patient, by tlie late Mr. 
 Crosse, of NorAvich. 
 
 Right ear. — The meatus externus, membrana tympani, and the 
 tympanic cavity were in a healthy state. Labyrinth. — The anterior 
 limb of the superior semicircular canal commvmicatcd "with the ves- 
 tibule, but was rather larger than natural, and its shape somewhat 
 irregular. Examined as it passes inwards, it was observed to ter- 
 minate in a cul-de-sac, after having attained only half its usual 
 length. The portion of bone in the situation usually occupied by 
 the inner part of the canal was of an ivoid whiteness, and could be 
 distinctly distinguished from the surrounding bone. The greater 
 part of the posterior semicircular canal Avas absent, its anterior and 
 posterior extremities presenting tAVO cul-de-sacs, half a line in length. 
 The external semicircular canal, the vestibule, and cochlea, were in 
 a normal state. 
 
 Left ear. — The superior semicircular canal is in the same incom- 
 plete state as that of the right ear. 
 
 Dissection 2. — J. C, set. 50, died from fever. He was born 
 deaf, and had been educated as a deaf-mute. 
 
 Right ear. — Meatus externus in a natural state, excepting that 
 one part of the osseous parietes Avas quite rough. Membrana tym- 
 pani thicker than natural, and perforated : a small red polypus was 
 attached to its dermoid layer. A membranous band connected the 
 stapes, incus, and tensor tympani muscle. The osseous semicircular 
 canals Avere large ; but they did not contain any membranous tubes. 
 The cochlea AA-as in a normal state, as Avere also the tympanic muscles 
 and nerves. 
 
 Left ear. — The osseous semicircular canals did not contain any 
 membranous tubes. One of the osseous canals Avas so contracted as 
 to admit of the passage through it of a fine wire only. 
 
 Dissection 3. — R. B., ?et. 16, a girl, sharp and intelligent. 
 Her parents stated that she was born deaf; but the child, on the 
 contrary, said that she had heard sounds. Her teacher thought 
 the child's statement to be more likely to be correct, as she pro- 
 nounced many AA'ords according to their proper sounds. None of 
 her relatives AAxre deaf-mutes. Upon making a careful dissection of 
 each car, no deviation from the normal condition could be detected 
 in the meatus externus, membrana tympani, or tympanic cavity. 
 The stapes adhered to the fenestra ovalis Avith its usual degree of 
 firmness. The membranous labyrinth in the vestibule was healthy, 
 
422 THE DISEASES OF THE EAR. 
 
 as also was that in the semicircuhir canals, Avith this exception, that 
 in the middle of the superior semicircular canal in the right ear ■svas 
 a quantity of otoconie (ear crystals), Avhich completely obstructed 
 the tube. 
 
 From the occurrence of an accident to the left ear, it was not 
 possible to ascertain its condition. 
 
 Dissection 4. — A boy, set. 15, -who had been wholly deaf from 
 his birth. No deviation from the normal state in either ear could 
 be detected by me. 
 
 Dissection 5. — For the opportunity of making this dissection, I 
 am indebted to Dr. Ormerod, of Brighton. The ears were taken 
 from a young woman deaf and dumb, with discharge from each ear. 
 She died with tubercular inflammation of the brain. 
 
 Right ear. — The membrana tympani was absent ; the mucous 
 membrane of the tympanum red, and of extreme thickness, so as to 
 fill the whole of the tympanic cavity and to conceal the stapes ; the 
 tympanum was distended with dark-colored blood. The petrous 
 bone was so intensely hard, that it could with difficulty be cut by 
 the bone forceps. The cochlea, to the naked eye, had a natural 
 appearance, and submitted to microscopic examination, no deviation 
 from the normal structure could be detected, excepting in that por- 
 tion of the lamina spiralis which is near to the vestibule. This, 
 instead of being composed of a delicate osseous lamina and a fine 
 membrane, the two making a delicate septum between the scala 
 tympani and scala vestibuli, presented a mass of solid bone filling 
 up the scala tympani, and concealing from view the membrana 
 fenestra) rotundac ; the inner surface of which it wholly covered. 
 The outer surface of this membrane could, however, be distinctly 
 seen from the tympanic cavity, and it appeared natural. 
 
 The semicircular canals contained more otoconie than natural. 
 
 Lrft ear. — The membrana tympani absent. The mucous mem- 
 brane of the tympanum thick and red, as in the right ear. The 
 semicircular canals containcMl more otoconie than natural, and espe- 
 cially the posterior one, which, at its junction with the posterior 
 limb of the superior canal, was wholly distended with crystals for 
 the extent of half a line. The lamina spiralis of the cochlea was 
 of a deep red color, and blood was effused in both scahe. The part 
 of the lamina spiralis near to the vestibule was in the same state as 
 the same portion in the right ear. 
 
 In the subjoined table the condition of the ears in deaf-mutes, as 
 revealed by various reported dissections, is shown. 
 
ON THE DEAF AND DUMB. 
 
 423 
 
 A TABULAR VIEW OF THE CONDITION OF THE EAR IN THIRTY-SIX 
 DISSECTIONS OF DEAF-MUTES. 
 
 Meatus 
 ExterDUS. 
 
 Membrana 
 Tympani. 
 
 Tympanum. 
 
 Labyrinth. 
 
 Nerve. 
 
 Name of 
 Observer. 
 
 Absent. 
 
 .* 
 
 
 
 As soft us 
 mucus. 
 
 Iliud. 
 
 Absent. 
 
 
 
 
 
 Fabricius. 
 
 Absent. 
 
 
 
 
 
 Do. 
 Itard. 
 
 
 Destroyed. 
 
 Containing vege- 
 tations from the 
 mucous mem- 
 brane ; ossicles 
 absent. 
 
 
 
 Do. 
 
 
 Do. 
 
 Do. 
 
 
 
 Do. 
 
 
 Partially 
 destroyed. 
 
 Containing scrofu- 
 lous matter. 
 
 
 
 Mr. Cock. 
 
 
 Do. 
 
 
 
 
 Do. 
 
 ... 
 
 Do. 
 
 Containing calca- 
 reous concre- 
 tions. 
 
 
 
 Do. 
 Itard. 
 
 
 
 Full of gelatinous 
 matter. 
 
 Full of gelatinous 
 matter. 
 
 
 Do. 
 
 
 
 Containing a yel- 
 low fluid. 
 
 
 Harder 
 
 than 
 natural. 
 
 Rosenthal. 
 
 
 
 Anchylosis of 
 stapes to fenestra 
 ovalis. 
 
 
 
 Valsalva. 
 
 
 . . . 
 
 All the ossicles 
 wanting. 
 
 Vestibule full of 
 caseous matter. 
 
 Cochlea consisting 
 of only one turn 
 and a half. 
 
 Vestibule, coch- 
 lea, and semicir- 
 cular canals ab- 
 sent. 
 
 Semicircular ca- 
 nals wanting. 
 
 
 Reimarus. 
 Dr. Haighton. 
 
 Mundini. 
 
 Meckel. 
 Murer. 
 
 * Where no entry is made, it is to be assumed that the part of the organ was in a 
 healthy state. 
 
424 
 
 THE DISEASES Of TU£ EAR. 
 
 Meatus 
 Externum. I 
 
 Membrana 
 Tympani. 
 
 Tympanum. 
 
 Labyrinth. 
 
 Name of 
 
 Obscrrer. 
 
 Partially 
 destroyed. 
 
 Destroyed. 
 
 All the ossicles 
 wanting. 
 
 Mucous 
 membrane thick. 
 
 Two of the semi- 
 circular canals 
 imperfect. j 
 
 Do. I 
 
 Atrophied. 
 Indurated. 
 Wanting. 
 
 Fenestra rotunda 
 closed by bone in 
 each ear. 
 
 One semicircular 
 canal incomplete 
 in one ear only ; 
 the other ear 
 healthy. 
 
 Aquaeductus vesti- 
 buli very large. 
 
 Semicircular < 
 nals absent in one 
 ear. 
 
 Filled with caseous 
 matter. 
 
 A portion of one of 
 the membranous 
 semicircular ca- 
 nals filled with 
 otoconie. 
 
 The superior and 
 posterior semicir- 
 cular canals in- 
 complete in right 
 ear ; the superior 
 incomplete in the 
 left ear. 
 
 Membranous semi- 
 circular canals 
 absent. 
 
 Lamina sjiiralis Otoconie ob- 
 I near the vestibule structing 
 
 filling the scala the canals. 
 I tympani. | 
 
 Very hard. 
 
 naif its 
 usual size. 
 
 Atrophied. 
 
 Compressed 
 by a tumor. 
 
 Mr. Cock. 
 
 Do. 
 
 Sylvius. 
 
 Ameman. 
 Morgagni. 
 Mr. Cock. 
 
 Dr. Thurnam. 
 
 Dalrymple. 
 
 Rosenthal. 
 Murer. 
 
 Dr. Haighton. 
 
 Hoffman. 
 Duverney. 
 
 Author. 
 Do. 
 
 Do. 
 
 Do. 
 Do. 
 
ON THE DEAF AND DUMB. 425 
 
 IV. ON THE MODE OF EXAMINING A CHILD SUPPOSED TO BE DEAF 
 
 AND DUMB. 
 
 From the absence of precise experiments from which accurate 
 conclusions could be dra-\vn, great difference of opinion frequently 
 exists, even among medical men, as to whether a child suspected of 
 being deaf and dumb really is so. 
 
 It frequently happens, therefore, that a child is reported not to 
 be deaf, because it always starts or looks up Avhen the door of the 
 room is loudly knocked, or the floor over the room is tapped with 
 considerable force, or the fire-irons in the room are permitted to 
 fall, or the piano is played. A similar opinion is often formed 
 because a child can utter some short syllables, as "Mam," "Pa," 
 &c., it being argued that no child could learn to utter these sounds 
 unless it had heard them. It is also asserted, that a child could 
 not have been born deaf, because the defect was not discovered until 
 it had reached the age of a year and a half or two years. 
 
 In reply to the above arguments in favor of a child's being able 
 to hear, it must be borne in mind that loud sounds are always 
 accompanied by more or less vibration of the walls and floor of the 
 apartment, which can be felt by a person whose attention may thus 
 be attracted, although totally deaf. A child may also learn to utter 
 short words by simply imitating the movements of the lips of the 
 parent, or nurse, without the exercise of the sense of hearing. The 
 plan adopted by me to ascertain Avhether a young child is deaf, con- 
 sists, in the first place, of allowing it to sit on the knee of the 
 nurse or parent, and be amused by something, and then while its 
 eyes are fixed upon the object, to speak loudly, or shout, taking 
 especial care that the breath does not reach the patient. Again, 
 let the child, its attention distracted as before, be placed with its 
 back towards the surgeon, who should, when near it, clap his hands 
 loudly, ring a large bell, or blow a powerful Avhistle, always taking 
 care that his OAvn shadoAV is not seen, and that the child is screened 
 from the movements of the air, while the nurse is warned not to 
 start or suddenly look up ; or the surgeon may come into a room, 
 the door of which has been some time open, and wliere the child is 
 seated with its back toAvards him surrounded by toys, and perform 
 similar experiments. If the child does not evince any symptom of 
 hearing, by suddenly lifting up its eyes, turning round, or starting, 
 
426 THE DISEASES OF THE EAR. 
 
 it must be concluded that it is wholly deaf ; but if, on the contrary, 
 it looks up each time the surgeon shouts, or turns round quickly the 
 instant the hands are clapped, it is evident that some power of 
 hearing exists, and steps should be taken to ascertain the extent of 
 such power, and how far it may enable the child to be orally taught. 
 
 V. ON THE MEDICAL TREATMENT OF THE DEAF AND DUMB. 
 
 It is of great importance that the surgeon should be able to decide 
 what treatment, if any, should be pursued when deaf and dumb 
 children are brought to him. 
 
 The first rule which may be laid down is, that in those cases 
 where there is no hearing power whatever, and in which it is sup- 
 posed that the nervous apparatus is either incomplete or much dis- 
 organized, no treatment for the purpose of improving the hearing 
 should be resorted to. The friends of the child should be told that 
 there is no hope of any change, and that it will have to be educated 
 as a deaf-mute. 
 
 On the contrary, should there be a certain decided amount of 
 hearing power, some attempt, it is obvious, should be made to de- 
 velop it. Where the child is evidently born deaf, general medicinal 
 treatment is not required ; and the only remedy is the use of means 
 to excite the nervous system of the ears to natural action. By the 
 persevering use of the long elastic tube, the hearing power has, in 
 some cases, been decidedly increased. 
 
 In cases where by disease subsequent to birth, either the mem- 
 brana tympani, or the mucous membrane lining the tympanum, has 
 been thickened, counter-irritation over the mastoid process will aid 
 the use of trumpets ; and in those where the membrana tympani has 
 been partially or wholly destroyed by ulceration, and where there 
 is a constant discharge of mucus from the surface of the tympanic 
 mucous membrane, it is desirable for the ears to be syringed, and 
 occasionally with a weak astringent, so as to prevent the membrane 
 becoming idcerated, and the bone which it covers, carious. The 
 artificial drum may also be resorted to. 
 
ON THE DEAF AND DUMB. 427 
 
 VI. THE AMOUNT OF HEARING POSSESSED BY CHILDREN EDUCATED 
 AS DEAF AND DUMB. 
 
 The examination of a large number of children usually considered 
 to be wholly deaf, and consequently educated as deaf-mutes, shows 
 that a large proportion are not totally deaf, but that, on the contrary, 
 certain sounds are distinctly heard. Thus, it will be observed, that 
 of the 411 children examined at the Deaf and Dumb Asylum, 245, 
 or three-fifths, were quite deaf, not hearing any sound ; while 166, 
 or two-fifths, heard certain sounds. The 166 cases in which certain 
 sounds were perceptible, may be classified as follows : — 
 
 14 heard a clapping of the hands. 
 
 51 heard a shout close to the ears. 
 
 50 heard a loud voice close to the ears. 
 
 44 distinguished vowels, and repeated them. 
 
 6 repeated short words. 
 
 1 repeated short sentences. 
 
 166 
 
 Of the 411 children it has already been stated that 313 were cases 
 of congenital deafness, while 98 were acquired cases. 
 
 Of the 313 congenital cases — 
 172, or about five-ninths, were deaf — i. e., no sounds were heard 
 
 by them. 
 141 heard certain sounds. 
 
 313 congenital cases. 
 
 The 141 cases in which certain sounds were heard may be classi- 
 fied as follows : — 
 
 11 heard a clapping of the hands near to the head. 
 
 44 heard a shout. 
 
 39 heard a loud voice. 
 
 41 heard the vowels, and repeated them. 
 
 5 heard words, and repeated them. 
 
 1 heard short sentences, and repeated them. 
 
428 THE DISEASES OF THE EAR. 
 
 Of the 98 acquired cases — 
 73, or about three-fourths were deaf. 
 25 heard certain sounds. 
 
 The 25 acquired cases in which certain sounds ^Ycre heard may be 
 particularized as follows : — 
 
 Arising from scarlet fever, 9 : — 
 
 1 hears a clapping of the hands. 
 5 hears a loud voice. 
 
 2 pronounce the vowels. 
 
 1 pronounces short words. 
 
 Fever, 6 : — 
 
 4 hear a loud shout. 
 
 1 hears the voice. 
 
 1 hears the voice, and tries to imitate it. 
 
 Measles, 1 : — 
 
 1 hears a loud clapping of the hands. 
 
 Various Diseases, 9 : — 
 1 hears a loud clapping of the hands. 
 
 3 hear a shout. 
 
 4 hear a loud voice. 
 1 repeats the vowels. 
 
 VII. ON THE EDUCATION OF THE DEAF AND DUMB. 
 
 The observations to be offered upon the system usually adopted 
 for the education of the deaf and dumb, have reference to two points : 
 first, the improvement of the power of hearing ; second, the use of 
 the vocal organs. 
 
 1. Of the improvement of the j^oiver of Jicaring. 
 
 It would be very interesting to know how far the facts respecting 
 the hearing power of so-called deaf and dumb children, cited in a 
 
ON THE DEAF AND DUMB. 429 
 
 previous part of this chapter, are corroborated by the observations 
 of others. Itard hazarded the opinion that one-half of the pupils 
 at the Deaf and Dumb Institution at Paris were -wholly deaf, and 
 that the other half heard some sounds. It is assumed by the writer 
 of the very interesting article on the Deaf and Dumb, in the " Penny 
 Cyclopjedia," that the same proportion of the totally deaf to those 
 who hear a little, will be met with in our English institutions. If 
 there exist throughout the deaf and dumb in England relatively, as 
 many cases of a large amount of hearing as in the London Institu- 
 tion, steps taken to improve the hearing power might be productive 
 of the most valuable results ; especially as my own limited experi- 
 ence warrants the assertion that this power is capable of considerable 
 development, as may be seen by the cases appended. Though one 
 of these does not belong to the category of the deaf and dumb, yet 
 the long duration of nearly total deafness in one ear, followed by so 
 great a restoration of its dormant power, renders the case of great 
 interest in the present inquiry. The treatment calculated to im- 
 prove the hearing, consists in the use of trumpets, whereby the 
 nervous apparatus may be gradually excited, as to become sensitive 
 to ordinary sonorous undulations and external stimulants. While 
 quite agreeing with Mr. "Wilde, that we cannot hope to cure cases 
 of deaf-mutism, I still think, when there already exists the power 
 to hear the vowels so distinctly as to distinguish and repeat them, 
 that from the exercise of the ear considerable improvement may 
 reasonably be anticipated ; suflBcient, in fact, to aid in carrying out 
 the end above all things to be desired, viz., the exercise of the organs 
 of speech. 
 
 The influence of the use of the vocal organs upon the general 
 health has, it seems to me, scarcely been sufficiently considered in 
 the education of the deaf and dumb. Sir H. Holland, with his 
 usual acuteness, has placed the subject in its just light. He says : 
 " Might not more be done in practice towards the prevention of 
 pulmonary diseases, as well as for the improvement of the general 
 health, by expressly exercising the organs of respiration ; that is, 
 by practising, according to some method, those actions of the body, 
 through which the chest is alternately in part filled or emptied of 
 air ? Though suggestions to this efiect occur in some of our best 
 works on Consumption, as well as in the writings of certain conti- 
 nental physicians, they have hitherto had less than their due in- 
 fluence, and the principle as such is little recognized or brought 
 
430 TUE DISEASES OF THE EAR. 
 
 into general application. In truth, common usage takes, for the 
 most part, a directly opposite course, and, under the notion or 
 pretext of quiet, seeks to repress all direct exercise of this impor- 
 tant function in those who are presumed to have a tendency to 
 pulmonary disorders." — 3Iedieal Notes, c. xx, b. 422. 
 
 To this, I may be allowed to add, in reference to the deaf and 
 dumb, that in those cases where the organs of speech are not used, 
 and where, consequently, the lungs, and the muscles of the chest, 
 and heart, are not duly exercised by the act of articulation, the 
 general health always suffers. 
 
 But the great advantage of calling forth the auditory power of 
 so-called deaf-mutes is, that they may be enabled to hear their own 
 voices, and to modulate them ; for the extreme harshness and 
 monotony of the sounds produced by deaf-mutes, arise from the im- 
 possibility of regulating the tones of a voice which they cannot 
 distinguish. 
 
 CASES. 
 
 Miss L. L., get. 23, consulted me in the early part of the year 
 1857. Her history was, that since childhood she had heard only 
 certain loud sounds, and was quite deaf to all conversation. Iler 
 means of comprehending what was spoken Avere derived from 
 watching the movements of the lips, and the sounds she uttered 
 appeared to be the result of her attempts at imitating the move- 
 ments she saw. Upon examination, having found that the voice 
 was heard Avhen spoken into the ears, I recommended counter- 
 irritation and the use of a long elastic tube. At first she could 
 hear only for from three to five minutes at a time. In a fortnight 
 there was decided improvement in the hearing power, and she began 
 to experience a painful sensation in the ears when too loudly spoken 
 to. To use the words of her sister (who devoted herself to the 
 poor patient in a way that only a sister or parent could), " During 
 the third week the improvement was wonderful. This was not so 
 perceptible with the tul)e as in her hearing generally. Everything 
 was so much louder to her, but not more distinct. The noise in 
 the street now quite annoyed her : she called it dreadful, although, 
 when we arrived in town, she did not notice it.'" She left me at 
 the end of a month's treatment, and I directed her to be spoken to 
 daily, but only in words of one syllable, which she was to repeat to 
 
ON THE DEAF AND DUMB. 431 
 
 herself. Then very simple sentences were tried ; which she heard 
 and understood when spoken to through the tube in the ordinary 
 way of conversing, and replied by speaking through the tube her- 
 self, so that she was able to hear her own voice and modulate it. 
 Her sister writes : " In October, 1857, she spent three weeks at 
 
 , and there she was seen by people Avho saw her just before 
 
 she came to consult you: they said they should not have believed 
 it possible for her to have improved so much in hearing and articu- 
 lation; her mind, too, had come out so. During the three weeks 
 she was from home, she had a complete holiday (e. e., the tube was 
 not used), and when she came back, the hearing had not retrograded 
 generally, but she did not hear so well through the tube. Since 
 her return from a visit, she has gone steadily on Avith the use of the 
 tube. Latterly," — this was written on February 2d, — " for some 
 weeks, I have talked through the tube daily an hour divided into 
 three or four intervals. Two or three times, when much amused, 
 she bore its use, without fatigue, half an hour at a time, and she 
 said she could have borne it longer. Even when she has had a 
 difficulty in comprehending what was said, I have never allowed her 
 once to see my lips while talking through the tube. We spelt the 
 words which she could not make out, and she never once failed to 
 find them out by tlie aid of the ear alone. One afternoon she could 
 not understand a single word of sentences she had distinctly heard 
 in the morning. By degrees, however, she made out a word here 
 and there, and in a few minutes heard everything I said. She had 
 been absorbed in writing a letter till a minute or so before the use 
 of the tube. Several times now, I observed that she heard far 
 more easily at the end of our talk than at the beginning. To her 
 best ear I am obliged to talk in a high treble, not loud. The left 
 ear requires a deeper, stronger voice. Great distinctness and slow- 
 ness are necessary — a monotonous tone suits her best. The final 
 consonants must be strongly uttered. She says she now hears them, 
 but she never did so before. She notices the difierence of touch in 
 persons playing on the piano, and can often understand much that 
 is said without seeing the mouth. A few days since she exclaimed, 
 ' You are talking French.' Lately she has gained many new 
 phrases, trying to apply those she hears in conversation, very often 
 making wonderful mistakes. Not long ago she said, ' That tree is 
 a great assortment for the birds,' meaning ' resort for.' At another 
 time she said, ' I hope you will not think me liberty,' meaning, ' I 
 
432 THE DISEASES OF THE EAR. 
 
 hope YOU will not think I take a liberty.' She began to read half 
 an hour a day ; it was hard work, although the book was written 
 for a child. As hearing improyed, articulation and intelligence 
 improyed, and lately I haye often wondered at the change. We 
 increased the reading to an hour, my sister constantly saying, ' I 
 feel as if something were coming to my mind,' and expressing sur- 
 prise that she could understand what she'neyer could comprehend 
 before. She noAV quite distinguished between my mode of pro- 
 nouncing and her own, and we never had the tube while reading to 
 her, as I knew its use would have distracted her thoughts from her 
 book. Occasionally, when the word was a yery difficult one, she 
 made it out, and then had the tube used to convince her of her 
 correctness. Numbers of people have remarked my sister's im- 
 provement. A lady saw her the first time in the beginning of 
 August last, and she saw her no more till November, when she said 
 to me in astonishment, ' I could not understand a word your sister 
 said in August ; now I can understand everything she says.' "When 
 I began your plans, I had to ask my sister, as a favor to myself, to 
 allow me to talk to her sometimes ; she was annoyed, and then did 
 not hear so well. Now, things are very different. She very often 
 proposes the use of the tube, and says she wishes you could know 
 what we had done for her." 
 
 Another case, very similar to the above, also occurred to me lately. 
 
 A young lady, ret. between twenty and thirty, like the case above 
 cited, had never heard sounds so as to be able to speak or read with 
 any degree of distinctness. I subjected her to a treatment similar 
 to that pursued in the above case, and the result was also satisfac- 
 tory. In about four months I received the following report in a 
 letter from her sister: "I do think she (the patient) is improving; 
 a good many of her friends also think so." In another letter the 
 same sister writes : "■ I really do think the improvement gradu- 
 ally continues, although slowly, which perhaps is the best and 
 surest." The patient herself writes : " I cannot tell how much I 
 have improved in hearing, reading, and speaking ; but I now read 
 much better, and I knoAv the numbers very well by the tube. I 
 hear everything continually. The G.'s, during my visit there, and 
 Aunt F., say my improvement is much in speaking ; they under- 
 stand me very well, and I am very glad of it." 
 
ON THE DEAF AND DUMB. 433 
 
 Tlie right ear useless for xixty years ; at the age of seventy so greatly 
 improved as to hear conversation all over the room, by means of a 
 trumpet. 
 
 I was called into the country in great haste in tlic spring of 1856, 
 to see a nohleman, «?t. 70, who was suffering from an attack of in- 
 tense inflammation of the mucous membrane lining the left tympanic 
 cavity. At the time of my seeing the patient, the inflammation had 
 extended internally as far as the labyrinth, and the power of hear- 
 ing was destroyed. The only means of communication with my 
 patient was by writing. Having but slight hope of doing anything 
 towards the improvement of the hearing power of the left ear, I 
 turned my attention to the right, the drum of which had, I found, 
 been inflamed and damaged in early life. I proposed, amid opposi- 
 tion at the supposed utter uselessness of the experiment, to try the 
 effect of a loud voice spoken into the right ear. The result was 
 decided, the sound of the voice was distinctly heard, and some 
 words were understood. Feeling that the nervous system of this 
 ear was lying torpid, from the circumstance that ordinary sonorous 
 undulations had not been able to reach it through the diseased con- 
 dition of the membrana tympani and mucous membrane of the tym- 
 panum, and also from the w^eak state of the nerve itself, I determined 
 to try a plan of treatment having a twofold object, — the excitement 
 of the nervous apparatus of the ear by the healthy stimulus of 
 sonorous vibrations, through the use of ear-trumpets, and an im- 
 provement of the condition of the drum, as also of the mucous 
 membrane of the tympanum, by remedial applications. The former 
 of these objects was attempted at once with a most satisfactory re- 
 sult, for the hearing power gradually increased. In short, by the 
 means in question, the latter of the two being principally gentle 
 counter-irritation, the patient's power of hearing in this ear, which 
 had been so defective during sixty years that its faculty was con- 
 sidered "lost," became, in the course of eighteen months, so im- 
 proved, that for a long time previous to his death, he could hear a 
 voice speaking near to the ear, and with the aid of a trumpet on his 
 table could carry on a conversation with persons sitting in different 
 parts of an ordinary sized room. In this case I am confident that 
 
 28 
 
434 
 
 THE DISEASES OF THE EAR. 
 
 no good would have resulted from the treatment, if the nervous ap- 
 paratus of the ear had not been stimulated at the same time by the 
 influence of sounds ; and my experience tells me that liundreds of 
 persons are living with one ear supposed to be perfectly deaf, and 
 in reality useless, but which might be made very serviceable, were 
 the sonorous undulations conveyed to it by artificial means. 
 
CHAPTER XIX. 
 
 EAR-TRUMPETS AND THEIR USE. 
 
 In some cases of climinislied power of hearing, there can be no 
 doubt that ear-trumpets afford great assistance, and arc a source of 
 much comfort to the sufferers. On the other hand, if imprudently 
 used, they are apt to increase the deafness and to cause additional 
 distress. They are decidedly injurious, for instance, in the early 
 stages of deafness arising from debility of the nervous apparatus, 
 and the noises are likely to be increased by their use ; Avhile in the 
 old standing cases of the same disease they often prove most service- 
 able : they are also equally advantageous in cases of partial anch}'- 
 losis of the stapes to the fenestra ovalis. 
 
 Ear-trumpets may be considered under three different classes, 
 according to their use, in as many degrees of deafness. 
 
 The first class consists of instruments to be worn on or in the 
 ears, without the aid of the hand ; and by means of which more 
 voices than one, or even general conversation, can be heard. 
 
 The most useful of this class of instruments are the small cornets 
 made by Mr. Rein, which are connected by a spring passing over 
 the head, that serves also to hold them in the ears. The cornets 
 can be concealed by the hair or worn under the bonnet. A variety 
 of this class is a small cornet, which can equally be concealed by the 
 liair, and which fits into the ear, where it is retained by a convolu- 
 tion which passes around the ear and dispenses with the spring. 
 
 The second class consists of instruments held in the hand, by 
 means of Avhich one voice, and sometimes more, spoken near the 
 extremity, can be heard. 
 
 To this class belong all the varieties of trumpet of different 
 lengths and shapes, Vhether made of tin, gutta-percha, &c., and 
 consisting of a narrow portion inserted into the eai-, which graduallv 
 
436 THE DISEASES OF THE EAR. 
 
 expands into a Avide mouth. These trumpets must be held in the 
 hand, and the expanded portion can be directed to any person or 
 persons whose voices are desired to be heard. 
 
 The tliird class embraces a variety of elastic tubes, one end being 
 placed in or on the patient's ear, and the other held in the hand of 
 the speaker, whose mouth being applied near or in its free extremity, 
 his single voice is heard. 
 
APPENDIX. 
 
 LIST OF PUBLISHED PAPERS ON THE STRUCTURE, FUNCTIONS, 
 AND DISEASES OF THE EAR. 
 
 On the structure of the membrana tympani in the human ear. With 
 numerous engravings. Pidlosoplucal Transactions, 1851. Parti. 
 
 On the functions of the membrana tympani. Proceedings of the 
 Royal Societg, 1852. 
 
 On the muscles -which open the Eustachian tube. Proceedings of the 
 Royal Society, 1853. 
 
 On the mode in which sonorous undulations are conducted from the 
 membrana tympani to the labyrinth, in the human ear. Pro- 
 ceedings of the Royal Society, 1859. 
 
 Pathological researches into the diseases of the ear. Medico-Chirur- 
 
 gical Transactions, vol. xxiv, 1841. 
 Pathological researches into the diseases of the ear. Second series. 
 
 3Iedico-Chiriirgical Transactions, vol. xxvi, 1843. 
 Pathological researches into the diseases of the ear. Third series. 
 
 Medico- Chii'urgical Transactions, vol. xxxii, 1849. 
 Pathological researches into the diseases of the ear. Fourth series. 
 
 Medico-Chirurgical Transactions, vol. xxxiv, 1851. 
 Pathological researches into the diseases of the ear. Fifth series. 
 
 Medico-Chirurgical Transactions, vol. xxxviii, 1855. 
 Pathological researches into the diseases of the car. Sixth series. 
 
 Medico-Chirurgical Transactions, vol. xxxviii, 1855. 
 On the diagnosis of the condition of the Eustachian tube, by means 
 
 of the otoscope, without the use of the catheter. Proceedings of 
 
 the Royal 3Iedical and Chirurgical Society. Medical Timcx 
 
 and Gazette, April 9, 1853. 
 
438 THE DISEASES OF THE EAR. 
 
 The results of some inquiries respecting the deaf and dumb. Pro- 
 ceedings of the lioyal 3Iedical and Cldrurgical Society. 3IedicaI 
 Times and Gazette, 1856. 
 
 On anchylosis of the stapes to the fenestra ovalis (stapedio-vestihular 
 articulation) associated Avith rheumatism and gout ; illustrated 
 by more than one hundred dissections. Proceedings of the Royal 
 Medical and Chirurgical Society, 1858. 
 
 A case of deaf-dumbness, of more than twenty years' duration, in 
 Avhich the hearing and the articulation Avere greatly benefited. 
 Proceedings of the Hoy al Medical and Chirurgical Society, 1858. 
 
 On the nature and treatment of those diseases of the ear which 
 have hitherto been designated otorrhoea and otitis. Trans- 
 actions of the Provincial 3Iedical and Surgical Association, 
 vol. xviii. 
 
 On osseous tumors growing from the walls of the meatus externus 
 of the ear, and on the enlargement of the walls themselves, 
 with cases. Wood-cuts. Proceedings of the Provincial Medical 
 and Surgical Association. The Journal of the Association. 
 1849. 
 
 On the use of an artificial membrana tympani, in cases of perfora- 
 tion or destruction of the organ. Proceedings of the Provincial 
 Medical and Surgical Association. The Journal, 1852. 
 
 Disease of the tympanic cavity, causing caries of the bone and 
 paralysis of the portio dura nerve. 
 
 Osseous tumors developed from the parietes of the external auditory 
 meatus. 
 
 Disease of the external auditory meatus, with suppuration of the 
 brain. 
 
 Series of preparations, illustrative of the diseases of the membrana 
 tympani. 
 
 Bony stricture of the Eustachian tube. Transactions of the Patholo- 
 gical Society of London, vol. i, 1849-1850. 
 
 A series of cases, illustrating diseases in the cerebral cavity, origi- 
 nating in affections of the auditory meatus. 
 Neuroma of the auditory nerve. 
 Molluscous tumors developed in the external auditory meatus. 
 
APPENDIX. 439 
 
 The effects of molluscous tumors on the petrous bone, Avlicn do- 
 veloped in the external auditory meatus. 
 
 Prcj^arations illustrative of hypertrophy in the epidermoid and der- 
 moid lamimxj of the membrana tympani. 
 
 Caries of the petrous bone and abscess of the cerebellum. Trans- 
 actions of the Pathological Society, vol. ii, 1850-1851. 
 
 Congenital malformation of the external ear and meatus on each side. 
 
 Calcareous matter in the cavity of the vestibule. 
 
 Examination of the ears of a deaf and dumb child, in ^\•hich a 
 portion of one of the membranous semicircular canals was dis- 
 tended with otoconie. 
 
 Disease of the base of the brain, extending from the tympanum 
 through the labyrinth. 
 
 Necrosis of the squamous portion of the temporal bone, originating 
 in catarrhal inflammation of the external meatus. 
 
 Cholesterine in the mastoid cells. Transactions of the Pathological 
 Society, vol. iii, 1851-1852. 
 
 Case of ulceration of the fibrous lamini^ of the membrana tympani. 
 Case of complete bony anchylosis of the stapes to the fenestra 
 
 oval is. 
 A case of perforate membrana tympani treated by the substitution 
 
 of an artificial membrane. 
 On the mode of dissecting the ear for pathological investigation. 
 Neuroma of the auditory nerve. Transactions of the Pathological 
 
 Society, vol. iv, 1852-1853. 
 
 Caries of the temporal bone, and disease of the brain produced by 
 retention of the discharge in the tympanum, after scarlet fever, 
 by the thickened membrana tympani. 
 
 Anchylosis of the stapes. 
 
 Disease of the ear affecting the lateral sinus and cerebellum. 
 Transactions of the Pathological Society, vol. v, 1853-1854. 
 
 Encephaloid disease of the tympanic cavity, extending to the brain. 
 Acute inflammation of the mastoid cells extending to the brain. 
 On the causes of accumulations of cerumen in the meatus audito- 
 
 rius externus, and their effects on different parts of the ear. 
 
 Transactions of the Pathological Society, vol. vi, 1855-1856. 
 
440 THE DISEASES OF THE EAR. 
 
 Dissection of a case of malfovmation in the ears of a child. Edin- 
 burgh Montldy Journal of Medical Science^ 1847. 
 
 On the pathology and treatment of the deafness attendant upon old 
 age. 3IonfJdf/ Journal and Hetrosjyect of the Medical Sciences. 
 Nos. 98 and 99, 1849. 
 
 Case of stricture of the Eustachian tube, -with an account of the 
 appearances presented on dissection. Monthly Journal of 
 Medical Science, 1850. 
 
 On the tuhular ear speculum. The Lancet, Oct. 1, 1850. 
 
 On tlie removal of foreign bodies from the ear. Provincial Medi- 
 cal and Surgical Journal, 1850. 
 
 On the nature and treatment of polypi of the ear. 3fedical Times 
 and Gazette, 1852. 
 
 On the excision of the tonsils and uvula in the treatment of deaf- 
 ness. Medical Times and Gazette, 1853. 
 
 On the removal of polypi from the ear by the lever-ring forceps and 
 the dressing-ring forceps. 3Iedical Times and Gazette. 
 
 On the functions of the muscles of the tympanum in the human ear. 
 British and Foreign 3Iedico-Chirurgieal Revieiv, 1853. 
 
 On the use of an artificial membrana tympani in cases of deafness 
 dependent upon perforation or destruction of the natural organ. 
 Octavo. 1853. 
 
 Do., do., Sixth Edition, 1858. 
 
 A course of clinical lectures on the pathology and treatment of the 
 affections of the ear causing disease in the brain or its mem- 
 branes, delivered at St. Mary's Hospital. With engravings. 
 3Iedical Times and Gazette, 1855. 
 
 A course of lectures on the nature and treatment of the diseases of 
 the ear, delivered at St. Mary's Hospital Medical School. 
 Medical Times and Gazette, 1856. 
 
 A descriptive catalogue of preparations illustrative of the diseases 
 of the ear in the museum of the author. 8vo. 1857. 
 
 THE END. 
 
BLANCHARD & LEA'S 
 MEDICAL AID iSURGICAL PUBLICATION'S 
 
 TO THE MEDICAL PROFESSION. 
 
 Tlie prices on the present catalogue are those at which our books can generally 
 be furnished by booksellers throughout the United States, who can readily procure 
 any which they may not have on hand. To physicians who have not convenient 
 access to bookstores, we will forward them by mail, at these prices, free of jwataye 
 (as long as the existing facilities are afforded by the post-office), for any distance 
 under 3,000 miles. As we open accounts only with booksellers, the amount must 
 in every case, without exception, accompany the order, and we assume no risks of 
 the mail, either on the money or on the books; and as we deal only in our own 
 publications, we can supply no others. Gentlemen desirous of purchasing will, 
 therefore, find it more advantageous to deal with the nearest booksellers whenever 
 practicable. 
 
 BLANCHARD & LEA. 
 
 Philadelphia, December, 1860. 
 
 *^* We have just issued a new edition of our Illustrated Catalogue of Medical 
 and Scientific Publications, forming an octavo pamphlet of 80 large pages, containing 
 specimens of illustrations, notices of the medical press, &c. &c. It has been pre- 
 pared without regard to expense, and will be found one of the handsomest specimens 
 of typographical execution as yet presented in this country. Copies will be sent to 
 any address, by mail, free of postage, on receipt of nine cents in stamps. 
 
 Catalogues of our numerous publications in miscellaneous and educational litera- 
 ture forwarded on application. 
 
 fcS^ The attention of physicians is especially solicited to the following important new works 
 and new editions, just issued or nearly ready : — 
 
 Ashton on the Rectum, See page 3 
 
 Coiuiie on Diseases ot Children, " 8 
 
 Churchill's Midwifery, " 9 
 
 Dickson's Elements of Medicine, "10 
 
 Druiit's Surgery, «' 10 
 
 Dalton's Human Physiology, " 11 
 
 Dunglison's Medical Dictionary, " 12 
 
 Erichsen's System of Surgery, '< 14 
 
 Flint on the Heart, « 14 
 
 Fownes' Manual of Chemistry, " 15 
 
 Gross's System of Surgery, " 16 
 
 Gray's Anatomy, Descriptive and Surgical, " 17 
 
 Habershon on Alimentary Canal, " 18 
 
 Hamilton on Fractures and Dislocations, " 18 
 
 Hodge on Diseases of Women " 19 
 
 Meigs on Diseases of Women, " ^1 
 
 Parrish's Practical Pharmacy, " 25 
 
 Stille's Therapeutics and Materia Medica, " 27 
 
 Simpson on Diseases of Women, " 27 
 
 Todd's Clinical Lectures, " 28 
 
 Toynbee on the Ear, " 29 
 
 Watson's Practice of Physic, " 30 
 
 Walshe on the Lungs, " 30 
 
 Wilson's Human Anatomy, " 31 
 
 Winslow on Brain and Mind, " 32 
 
 West on Diseases of Children " 32 
 
 TWO MEDICAL PeSiCAL|"fREE OF POSTAGE, 
 
 Containing over Fifteen Hundred large octavo pages, 
 
 FOR FiV£ DOLJLARI^ F£R AllflVOI. 
 
 THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, subject to 
 
 postage, when not paid for in advance, $5 00 
 
 THE MEDICAL NEWS AND LIBRARY, invariably in advance, - - 1 00 
 or, BOTH PERIODICALS mailed, free of postage, for Five Dollars remitted 
 in advance. 
 
 THE AMERICAN JOURNALOJFtHE MEDICAL SCIENCES, 
 Edited by ISAAC HAYS, M. D., 
 
 is published Qiiarterfy, on the first of January, April, July, and October. Each number contains 
 at least two hundred and eighty large octRVO pages, handsomely and appropriately illustrated, 
 wherever necessary. It has now been issued regularly for nearly forty years, and it has been 
 
BLANCHARD & LEA'S MEDICAL 
 
 under the control of the present editor for more than a quarter of a century. Throughout this 
 long period, it has maintained its position in the highest rank of medical periodicals both at home 
 and abroad, and has received the cordial support of the entire profession in this country. Its list of 
 Collaborators will be found to contain a large number of the most distinguished names of the pro- 
 fession in every section of the United States, rendering the department devoted to 
 
 ORIGINAL COMMUNICATIONS 
 
 full of varied and important mutter, of great interest to all practitioners. 
 
 As the aim of the Journal, however, is to combine the advantages presented by all the different 
 varieties of periodicals, in its 
 
 REVIEW DEPARTMENT 
 
 will be found extended and impartial reviews of all important new works, presenting subjects of 
 aovelty and interest, together with very numerous 
 
 BIBLIOGRAPHICAL NOTICES, 
 
 including nearly all the medical publications of the day, both in this country and Great Britain, with 
 a choice selection of the more important continental works. This is followed by the 
 
 QUARTERLY SUMMARY, 
 
 being a very full and complete abstract, methodically arranged, of the 
 
 IMPROVEMENTS AiND DISCOVERIES IN THE MEDICAL SCIENCES. 
 
 This department of the Journal, so important to the practising physician, is the object of especial 
 care on the part of the editor. It is classified and arranged under different heads, thus facilitating 
 the researches of the reader in pursuit of particular subjects, and will be found to present a very 
 full and accurate digest of all observations, discoveries, and inventions recorded in every branch of 
 medical science. The very extensive arrangements of the publishers are such as to aflord to the 
 editor complete materials for this purpose, as he not only regularly receives 
 
 ALL THE AMERICAN MEDICAL AND SCIENTIFIC PERIODICALS, 
 
 but alsu twenty or thirty of the more important Journals issued in Great Britain and on Uie Conti- 
 nent, thus enabling him to present in a convenient compass a thorough and complete abstract of 
 everything interesting or important to the physician occurring in any part of the civilized world. 
 
 To their old subscribers, many of' whom liave been on their list for twenty or thirty years, the 
 publishers feel that no promises lor the future are necessary; but those who may desire for the 
 first time to subscribe, can rest assured that no exertion will be spared to maintain the Journal in 
 the high position which it has occupied for so long a period. 
 
 By reference to the terms it will be seen that, in addition to this large amount of valuable and 
 practical intbrmation on every branch of medical science, the subscriber, by paying in advance, 
 becomes entitled, without further charge, to 
 
 THE MEDICAL NEWS AND LIBRARY, 
 
 a monthly periodical of thirty-two large octavo pages. Its "News Depart.ment" presents the 
 current informutiDn of the day, while the " Library Departme.^t" is devoted to presenting stanc- 
 ard works on various branches of medicine. Within a lew years, subscribers have thus receiver, 
 without expense, many works of the highest character and practical value, such as " Watson's 
 Practice," "Todd and Bowman's Physiology," " iMalgaigne's Surgery," "West on Children," 
 " West on Females, Part 1.," "Habershon on the Aliinciiiary Canal," &c. 
 
 While in the number for January, 18bO, is commenced a new and highly important work, 
 
 CLINICAL LECTURES ON THE DISEASES OF WOMEN. 
 
 By Professor J. Y. SIMPSON, of Edinburgh. 
 
 WITH NUMEROUS HANDSOME ILLUSTRATIONS. 
 
 These Lectures, published in England under the supervision of the Author, carry v^-ith them all 
 the weight of his wide experience and liisiing-uished reputation. Their eminently practical nature, 
 and the importance of the subject treated, cannot lail to render them in the highest degree satis- 
 factory to subscribers, who can thus secure iliem without cost. The present is therefore a par- 
 ticularly eligible time for gentlemen to commence their subscriptions. 
 
 It will thus be seen that lor the small sum of FIVE DOLLARS, paid in advance, the subscriber 
 will obtam a Quarterly and a Monthly periodical, 
 
 EMBRACING NEARLY SIXTEEN HUNDRED LARGE OCTAVO PAGES. 
 
 mailed to any part of the United States, free of postage. 
 
 Those subscribers who lio not pay in advance will uear in mind that their subscription of Five 
 Dollars will entitle them to the Journal only, without the News, and that they will be at the expense 
 ui tiitir own postage on the receipt of each number. The advantage of a remittance when order- 
 ing the Journal will thus be apparent. 
 
 As the Medical News and Library is in no case sent without advance payment, its subscribera 
 will always receive it free of postage. 
 
 Kemittances of subscriptions can be mailed at our risk, when a certificate is taken from the Post- 
 master that the money is duly inclosed and forwarded. 
 
 Address BLANCHARD & LEA, Philadiuhia. 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 ASHTON (T. J.), 
 
 Surgeon to the Blenlieim Dispensary, &c. 
 
 ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE 
 
 RECTUM AND ANUS; with remarks on Habitual Constipation. From the third and enlarged 
 London edition. With handsome illustrations. In one very beautifully printed octavo volume, 
 of about 300 pages. (Now Ready.) §2 00. 
 Introduction. Chapter I. Irritation and Itching of the Anus. II. Inflammation and Excoria- 
 tion of the Anus. III. E.Kcrescences of the Anal Region. IV. Contraciioti of the Amis. V. 
 Fissure of the Anus and lower part of the Rectum. Vi. Neuralgia of the Anus and exiremitv 
 of the Rectum. VII. Inllammalion of the Rectum. Vlll. Ulceration of the Rectum. IX. He- 
 morrhoidal Aflectioiis. X. Enlargement of Hemorrhoidal Veins. XI. Prolapsus of the Rectum. 
 XII. Abscess near the Rectum. XIII. Fistula in Ano. XIV. Pol vpi of the Rectum. XV. Stric- 
 ture of the Rectum. XVI. Malignant Diseases of the Rectum. XVII. Injuries of the Rectum 
 XVIII. Foreign Bodies in the Rectum. XIX. Malformations of the Rectum. XX. Habitual 
 Constipation. 
 
 reach of American practitioners. We are satisfied 
 after a carel'ul examination of the volume, ami a 
 comparison of its contents with those of its leading 
 
 The most complete one we possess on the subject. 
 Medico-Chirurgieal Review. 
 
 Its merits as a practical instructor, well arranged, 
 
 preilecessors and contemporaries, that llie best way 
 
 abundantly t'urnished with illustrative cases, and for the reader to avail himself of the excellent nd- 
 clearly and comprehensively, albeit too diffusely, vicegiven in theconcludingparagraph above, would 
 written, are incontestable. They have been sufR- ! be to provide himself with a c ipy of tiie book from 
 ciently endorsed by the verdict of his countrymen which it has been taken, and diligently to con its 
 in the rapid exhaustion of the first edition, and tliev ', instructive pages. They may secure to him many 
 would certainly meet with a similar reward in the 1 a triumph and I'ervent blessing.— jIot. Journal Med. 
 United Slates were the volume placed within the 1 Sciences, April, 155S. 
 
 ALLEN (J. M.), M. D., 
 
 Professor of Anatomy in the Pennsylvania Medical College, &c. 
 
 THE PRACTICAL ANATOMIST; or. The Student's Guide iu the Dissecting- 
 
 ROOM. With 266 illustrations. In one handsome royall2mo. volume, of over 600 pages, lea- 
 ther. $2 25. 
 
 However valuable may be the " Dissector's 
 Guides" which we, of late, have had occasion to 
 notice, we feel confident that the work of Dr. Allen 
 is superior to any of them. We believe with the 
 author, that none is so fully illustrated as this, and 
 the arrangement of the work is such as to facilitate 
 the labors of the student in acquiring a thorough 
 practical knowledge of Anatomy. We most cordi- 
 
 ally recommend it to their attention. — Western Lan- 
 ce . 
 
 We believe it to be one of the most useful works 
 upon the subject ever written. It is handsomely 
 Illustrated, well printed, and will be found of con- 
 venient size for use in the dissecting-room. — Med. 
 Examiner. 
 
 ANATOMICAL ATLAS. 
 By Professors H. H. Smith and W. E. Horner, of the University of Pennsyl- 
 vania. 1 vol. 8vo., extra cloth, with nearly 650 illustrations. |3^ See S.mith, p. 27. 
 
 ABEL (F. A.), F. C. S. AND C. L. BLOXAM. 
 HANDBOOK OF CHEMISTRY, Theoretical, Practical, and Technical; with a 
 
 Recommendatory Preface by Dr. Hofmann. In one large octavo voliune, extra cloth, of 662 
 pages, with illustrations. $3 25. 
 
 ASHWELL (SAMUEL), M.D., 
 
 Obstetric Physician and Lecturer to Guy's Hospital, London. 
 
 A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. 
 
 Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third 
 and revised London edition. In one octavo volume, extra cloth, of 528 pages. $3 00. 
 The most useful practical work on the subject in j The most able, and certainly the most standard 
 the English language. — jB 05ton Med. and ^'urg. and practical, work on female diseases that we have 
 Journal. \ yet seen. — Medico-CMrurgical Revieto. 
 
 ARNOTT (NEILL), M. D. 
 ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. 
 
 Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays, 
 M. D. Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra- 
 tions. $2 50. 
 
 BIRD (GOLDING), A. M., M. D., «tc. 
 URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND 
 
 THERAPEUTICAL INDICATIONS. Edited by Edmlnd Lloyd BiRKETr, M. D. A new 
 American, from the fifth and enlarged London edition. With eighty illustrations on wood. In one 
 handsome octavo volume, of a'joui 400 pages, extra cloth. $2 00. (Ju^t Issued.) 
 
 The death of Dr. Bird has rendered it necessary to entrust the revision of the present edition to 
 other hands, and in his performance of the duty thus devolving on him. Dr. Birketl has sedulously 
 endeavored to carry out the author's plan by introducing such new matter and modifications of 
 the text as the progress of science has called for. Notwithstanding the utmost care to keep the 
 work within a reasonable compass, these additions have resulted in a considerable enlargement. 
 It is, therefore, hoped that it will be found fully up to the present condition of the subject, and that 
 the reputation of the volume as a clear, complete, and compendious manual, will be fully maintained. 
 
BUDD (GEORGE), M. D., F. R. S., 
 
 Professor of Medicine in King's College, London. 
 
 ON DISEASES OF THE LIVER. Third American, from the third and 
 
 enlarged London edition. In one very handsome octavo volume, extra cloth, with four beauti- 
 fully colored plates, and numerous wood-cuts. pp. 500. $3 00. 
 
 Has fairly established for itself a place among the is not perceptibly changed, the history of liver dis- 
 classioal medical literature of England. — British eases is made more complete, and is kept upon a level 
 an>i Foreign Medico-Chir. Review, July, 1857. ' with the progress of modern science. It is Ihe best 
 
 Dr. Budil's Trealise on Diseases of the Liver is ^"^'^ "" Diseases of the Liver in any language.— 
 now a standard work in Medical literature, and dur- London Med. Times and Gazette, June 27, ie57. 
 ing the mtcrvals which have elapsed between the This work, now the standard book of reference on 
 successive editions, the author has incorporated into i the diceases of which it treats, has been carefully 
 the text the most striking novelties which have cha- I revised, and many new illustrations of the views of 
 racterized the recent progress of hepatic physiology [ the learned author iidded in the present edition. — 
 and pathology; so thataltliough the size of the book Dublin Quarlerlt/ Journal, Aug. 1&57. 
 
 BY THE SAME AUTHOR. 
 
 ON THE ORGANIC DISEASES AND FUNCTIONAL DISORDERS OF 
 
 THE STOMACH. In one neat octavo volume, extra cloth. $1 50. 
 
 BUCKNILL (J. C), M. D., 
 
 Medical Superintendent of the Devon County Lunatic Asylum; and 
 DANIEL H. TUKE, M. D., 
 
 Visiting Medical Officer to the York Retreat. 
 
 A MANUAL OP PSYCHOLOGICAL MEDICINE; containing the History, 
 
 Nosology, De>cription, Statistics, Diagnosis, Pathology, and Treatment of INSANITY. With 
 
 a Plate. In ore handsome octavo volume, of 536 pages. $3 00. 
 
 The increase of mental disease in its various forms, and the dillieult questions to which it is 
 constantly giving rise, render the subject one of daily enhanced interest, requiring on the part of 
 the physician a constantly greater familiarity with this, the most perplexing branch of his profes- 
 sion. At the same time there has been for some years no work accessible in this country, present- 
 ing the results of recent investigations in the Diagnosis and Prognosis of In.^anity, and the greatly 
 improved methods of treatment which have done so much in alleviating the condition or restoring 
 the health of the insane. To fill this vacancy the publishers present this volume, assured that 
 the distinguished reputation and experience of the authors will entitle it at once to the confidence 
 of both student and practitioner. Its scope may be gathered from the declaration of the authors 
 that "their aim has l)een to supply a te.xt book which may serve as a guide in the acquisition ol 
 such knowledge, sufficiently elementary to be adapted to the wants of the student, and sufficiently 
 modern in its views and explicit in its teaching to suffice for the demands of the practitioner." 
 
 BENNETT (J. HUGHES), M.D., F. R. S. E., 
 
 Professor of Clinical Medicine in the University of Edinburgh, &c. 
 
 THE PATHOLOGY AND TREATMENT OF PULMONARY TUBERCU- 
 
 LOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken 
 for or associated with, Phthisis. One vol. 8vo., extra cloth, with wood-cuts. pp. 130. $1 25. 
 
 BENNETT (HENRY), M. D. 
 A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, 
 
 ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. To which 
 is added, a Review of the present stale of Uterine Pathology. Fifth American, from the third 
 English edition. In one octavo volume, of about 500 pages, extra cloth. S'2 00. {Now Ready.) 
 The ill health of the author having prevented the promised revision of this work, the present 
 
 edition is a reprint of the last, without alteration. As the volume has been for some tune out of 
 
 fjrint, gentlemen desiring copies can now procure them. 
 
 BOWMAN (JOHN E.), M.D. 
 PRACTICAL HANDBOOK OF MKDICAL CHEMISTRY. Second Ame- 
 rican, from the third and revised English Edition. In one neat volume, royal 12mo., extra cloth, 
 with numerous illustrations, pp. 288. $1 2b. 
 
 BY THE SAME AUTHOR. 
 
 INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- 
 
 LYSIS. Second American, from the second and revised London edition. Withnumerousillus- 
 trations. In one neat vol., royal 12ino., extra cloth, pp.350. $125. 
 
 BKALR ON THE LAWS OF HRALTH IN RE- i BUCKLER ON THE KTIOLOGV, PATHOLOGY, 
 1-ATION TO MIND AND BODY. A Series of I AND TREATMENT OF FIBRO-BRONCHl- 
 Letters from an old Practitioner to a Patient. In I TISAND RIIEU.MATIC PNEU.MONIA. In 
 one volume, royal I'2mo., extra cloth, pp. 296. one 8vo. volume, extra cloth. pp.l5U. St 25. 
 &" cents. I BLOOD AND URLNE (MANUALS ON). BY 
 
 BUSHNAN'S PHYSIOLOGY OF ANIMAL AND 
 VEGETABLE LIFE; a Popular Treatise, on the 
 Functions and Phenomena of Organic Life. In 
 one handsome royal 12mo. volume, extra cloth, 
 with over 100 illustrations, pp.234. 80 cents. 
 
 JOHN ^VILLIAM GRIFFITH, G. OWEN 
 REESE, AND ALFRED MARKWICK. One 
 thick volume, royal 12mo., extra cloth, with 
 plates, pp. 460. SI 25. 
 BRODIE'S CLINICAL LECTURES ON SUR- 
 GERY. 1 vol. 8vo. cloth. 350 pp. 8125. 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 BARCLAY (A. W.), M. D., 
 
 Assistant Physician to St. George's Hospital, &.C. 
 
 A MANUAL OF MEDICAL DIAGNOSIS ; being an Analysis of the Signs 
 and Symptoms of Disease. Inoneneatoctavovolume, extra cloth, of 424 pages. $2 00. {Lately 
 
 issued.) 
 
 Of works exclusively devoted to this important | The task of composing such a work is neither an 
 branch, our profession Ims at command, compara- ' easy nor a light one ; but Dr. Barclay has performed 
 lively, but few, and, therefore, in the publication of , it in a manner which meets our most unqualified 
 the present work, Messrs. Blanchard <k Lea have j approbation. He is no mere theorist; he knows his 
 conl'erred a great favor upon us. Dr. Barclay^from I work thoroughly, and in attempting to perform it, 
 having occupied, for a long period, the position of! has not exceeded his powers. — British Med. Journal, 
 Medical Registrar at St. George's Hospital, 
 
 pos- 
 sessed advantages for correct observation and reli- 
 able conclusions, as to the significance of symptoms, 
 which have fallen to the lot of but few, either in 
 his own or any other country. He has carefully 
 systematized the results of his observation of over 
 twelve thousand patients, and by his diligence and 
 judicious classification, the profession has been 
 presented with the most convenient and reliable 
 work on the subject of Diagnosis that it has been 
 our good fortune ever to examine; we can, there- 
 fore, say of Dr. Barclay's work, that, from his sys- 
 
 Dec. 5, 1857. 
 
 We venture to predict that the work will be de- 
 servedly popular, and soon become, like Watson's 
 Practice, an indispensable necessity to the practi- 
 tioner. — N. A. Med. Journal, April, 1S58. 
 
 An inestimable work of reference for the young 
 practitiimer and student. — Nashville Med. Journal, 
 May, 1858. 
 
 We hope the volume will have an extensive cir- 
 culation, not among students of medicine only, but 
 practitioners also. They will never regret a faith- 
 
 tematic manner of arrangement, his work is one of | l"ul study of its pages. — Cincinnati Lancet, Mar. '58. 
 
 the best works " for reference" in the daily emer- 
 gencies of the practitioner, with which we are ac- 
 quainted ; but, at the same time, we would recom- 
 niend our readers, especially the younger ones, to 
 read thoroughlyand study diligently theichole work, 
 and the ''emergencies" will not occur so often. — 
 Southern Med. and Surg. Journ., March, 1853. 
 
 To give this information, to supply this admitted 
 deficiency, is the object of Dr. Barclay's Manual. 
 
 An important acquisition to medical literature. 
 It IS a %vork of high merit, both from the vast im- 
 portance of the subject upon which it treats, and 
 also from the real ability displayed in its elabora- 
 tion. In conclusion, let us bespeak for this volume 
 that attention of every student of our art which it 
 so richly deserves— that place in every medical 
 library which it can so well adorn. — Peninsular 
 Medical Journal, Sept. 1858. 
 
 BARLOW (GEORGE H.), M. D. 
 
 Physician to Guy's Hospital, London, &c. 
 
 A MANUAL OF THE PRACTICE OF MEDICINE. With Additions by D. 
 
 F. CoNDiE, M.D., author of "A Practical Treatise on Diseases of Children," &c. In one hand- 
 some octavo volume, leather, of over 600 pages. $2 75. 
 
 We recommend Dr. Barlow'sManual in the warm- 1 will be found hardly less useful to the experienced 
 est manner as a most valuable vade-mecum. We : physician. The American editor has added to the 
 have had frequent occasion to consult it, and have | work three chapters — on Cholera Infantum, Yellow 
 found it clear, concise, practical, and sound. It is } Fever, and Cerebro-spinal Meningitis. These addi- 
 eminently a practical work, containing all that is tions, the two first of whicli are indispensable to a 
 essential, and avoiding useless theoretical discus- I work on practice destined for the profession in this 
 sion. The work supplies what has been for some country, are executed with great judgment and fi- 
 time wanting; a manual of practice based upon mo- delity, by Dr. Condie, who has also succeeded hap- 
 dern discoveries in pathology and rational views of pily in imitating the conciseness and clearness of 
 treatment of disease. It is especially intended for j style which are such agreeable characteristics of 
 the use of students and junior practitioners, but it | the original book. — Boston Med. and Surg. Journal. 
 
 BARTLETT (ELISHA), M. D. 
 THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS 
 
 OF THE UNITED STATES. A new and revised edition. By Alonzo Clark, M. D., Prof. 
 
 of Pathology and Practical Medicine in the N. Y. College of Physicians and Surgeons, ifee. In 
 
 one octavo volume, of six hundred pages, extra cloth. Price $.3 00. 
 
 It is the best work on fevers which has emanated i logy. His annotations add much to the interest of 
 from the American press, and the present editor has the work, and have brought it well up to the condi- 
 carefully availed himself of all information exist- tion of the science as it exists at the present day 
 ing upon the subject in the Old and New World, so I in regard to this class of diseases. — Southern Med. 
 that the doctrinesadvanced arebrought down to the I and Surg. Journal, Mar. 1857. 
 
 '«'esl date in the progress of this department of | ^-^^^ ^^^.^ ^f great practical value and interest, 
 Medical Science.-Lo«do» Med. Times and Gazette, containing much that is new relative to the several 
 May 2, lb57. diseases of which it treats, and, with the additions 
 
 Thisexcellent monograph on febrile disease, has of the editor, is fully up to the times. Thedistinct- 
 gtood deservedly high since its first publication. It ! ivefeaturesof the different forms of fever are plainly 
 will be seen that it has now reached its fourth edi- j and forcibly portrayed, and the lines of demarcation 
 tion under the supervision of Prof. A. Clark, a gen- ! carefully and accurately drawn, and to the Ameri- 
 tleman who, from the nature of his studies and pur- i can practitioner is a more valuable and safe guide 
 suits, is well calculated to appreciate and discuss : than any work on fever extant. — Ohio Med. and 
 the many intricate and difficult questions in patho- | Surg, Journal, May, 1857. 
 
 BROWN (ISAAC BAKER), 
 
 Surgeon- Accoucheur to St. Mary's Hospital, tec. 
 
 ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT- 
 MENT. With handsome illustrations. One vol. 8vo., extra cloth, pp. 27i5. $1 60. 
 
 Mr. Brown has earned for himself a high reputa- ; and merit the careful attention of every aurgeoa- 
 tion in the operative treatment of sundry diseases ^ accoucheur. — Association Journal. 
 and injuries to which females are peculiarly subject, i 
 We can truly say of his work that it is an important I 
 
 We have no hesitation'in recommending this book 
 
 addition to obstetrical literature. The operative '"^'f <="'■'='"' attention of all surgeons who mak^ 
 suggestions and contrivances which Mr. Brown de- , female cornp.aints a partof their study and prHCti<«. 
 scribes, exhibit much practical sagacity and gki\\\— Dublin (quarterly Journal. 
 
BLANUHAK.D & LiKA'S Mt-UiUAL. 
 
 CARPENTER (WILLIAM B.), M. D., F. R. S., &.C., 
 
 Examiner in Physiology and Comparative Anatomy in the University of London. 
 
 PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to 
 
 Psychology, Pathology, Therapeutics-, Hygiene, and Forensic Medicine. A new American, from 
 the last and revised London edition. With nearly three hundred illustrations. Edited, with addi- 
 tions, I)V Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsyl- 
 vania Medical College, &c. In one very large and beautiful octavo volume, of about nine hundred 
 large pages, handsomely printed and strongly bound in leather, with raised bands. $4 25. 
 
 In the preparation of this new edition, the author has spared no labor to render it, as heretofore, 
 a complete and lucid exposition ol' the most advanced condition of its important subject. The 
 amount of the additions required to eflect this object thoroughly, joined to the former large size of 
 the volume, presenting objections arising frpm the unwieldy bulk of the work, he has omitted all 
 those portions not bearing directly upon HUiMAN Physiology, designing to incorporate them in 
 his forthcoming Treatise on General Physiology. As a full and accurate text-book on the Phy- 
 siology of Man, the work in its present condition therefore presents even greater claims upon 
 the student and physician than those which have heretofore won for it the very wide and distin- 
 guished favor which it has so long enjoyed. The additions of Prof. Smith will be found to supply 
 whatever may have been wanting to the American student, while the introduction of many new 
 illustrations, and the most careful mechanical execution, render the volume one of the most at- 
 tractive as yet issued. 
 
 For upwards of thirteen years Dr. Carpenter's i To eulogize this great work would be snperfluoue. 
 work has been considered by the profession gene- We should observe, however, that in this edition 
 rally, both in this country and England, as the most the author has remodelled a large portion of the 
 valuable compendium on the EUl>jeet of physiology former, and the editor has added much matter of in- 
 in our language. This distinction it owes to the high terest, especially in the form of illustrations. We 
 attainments and unwearied industry of its accom- may confidently recommend it as the most complete 
 plished author. Thepresent edition (which, like the work on Human Physiology in our language. — 
 last American one, was prepared by the author him- i Southern Med. and Surg. Journal. 
 self), is the result of such extensive revision, that it Thg n,„st complete work on the science in oar 
 may almost be considered a new work. We need language.— 4ot. Med. Journal. 
 hardly say, in concluding this briel notice, that while , ^. , , . ■ , 
 
 the work is indispensable to every student of medi- The most complete work now extant in our lan- 
 ■ ■■■ ■ • guage. — N. O. Med. Register. 
 
 «ine in this country, it will amply repay the practi- 
 tioner for its perusal by the interest and value of its 
 contents. — Boston Med. and Surg. Journal. 
 
 The best text-book in the language on this ex- 
 tensive subject. — London Med. Times. 
 
 A complete cyclopaedia of this branch of science. 
 — iV. Y. Med. Times. 
 
 This is a standard work — the text-book used by all ! 
 medical students who read the Knglish language. 
 It has passed through several editions in order to The profession of this country, and perhaps also 
 keep pace with the rapidly growing science of Phy- of E urope, have anxiously and for some time a waited 
 siology. Nothing need be said in its praise, for its the announcement of this new edition of Carpenter's 
 merits are universally known; we have nothing to Human Physiology. His former editions have for 
 say of its defects, for they only appear where the many years been almost the only text-book on Phy- 
 BCience of which it treats is incomplete. — Western, siology in all our medical schools, and itscircula- 
 Lancet. j tion among the professiim has been unsurpassed by 
 
 Themostcompleteexpositionof physiology which ' any work in any department of medical science, 
 any language can at present eivo.— Brit, and For. ^' »» quite unnecessary for us to speak of this 
 Med.-clirurg. Review. I work as its merits would justily. The mere an- 
 
 nouncement of its appearance will afford the highest 
 
 The greatest, the most reliable, and the best book pleasure to every student of Physiology, while its 
 on the subject which we know of in the English perusal will be of infinite service in advancing 
 language. — Stethoscopt. | physiological science. — Ohio Med. and Surg. Joum. 
 
 BY THE SAMK AUTHOR. 
 
 PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from 
 
 the Fourth and Revised London edition. In one large and liandsome octavo volume, with over 
 three hundred beautiful illustrations, pp. 752. Extra cloth, $4 80 ; leather, raised bands, S5 25. 
 
 The delay which has existed in the appearance of this work has been caused by the very thorough 
 revision and remodelling which it has undergone at the hands of the author, and the laree number 
 of new illustrations which liave been prepared for it. It will, therefore, be found almost a new 
 work, and fully up to the day in every department of the subject, rendering it a reliable text-book 
 for all students engaged in this branch of science. Every effort has been made to render its typo- 
 graphical finish and mechanical execution worthy of its exalted reputation, and creditable to the 
 mechanical arts of this country. 
 
 This book should not only be read but thoroughly 
 studied by every member of the profession. N«me 
 are too wise or old, to be benefited thereby. But 
 especially to the younger class would we cordially 
 Commend it as best fitted of any work in the English 
 language to qualify them for the reception and coin- 
 pretiension of those truths which are daily being de- 
 veloped in physiology. — Medical Counsellor. 
 
 Without pretending to it, it is an encyclopfdia of 
 the subject, accurate and complete in all respects — 
 a truthl'ul retlecticm of the advanced state at which 
 the science has now arrived. — Dublin Quarterly 
 Journal o/ Medical Science. 
 
 A truly magnificent work — in itself a perfect phy- 
 siological study. — Ranking'! Abstract. 
 
 This work stands without its fellow. It is one 
 few men in Europe could have undertaken; it is one 
 
 1 no man, we believe, could have brought to so suc- 
 cessful an issue as Dr. Carpenter. It required for 
 its production a physiologist at once deeply read in 
 the labors of others, capable of taking a general, 
 critical, and unprejudiced view of those labors, and 
 of combining the varied, heterogeneous m^lerials at 
 
 I his disposal, so as to form an harmonious whole. 
 We feel that this abstract can give the reader a very 
 imperfect idea of the fulness of this work, and no 
 idea of its unity, of the admirable manner in which 
 
 , material has ueeu brought, from the most various 
 sources, to ccmduce to its completeness, of the lucid- 
 ity of the reasoning it contains, or of the clearness 
 of^language in which the whole is clothed. Not the 
 profession only, but the scientific world at large, 
 must feel deeply indebted to Dr. Carpenter for this 
 great work. It must, indeed, add largely even to 
 his high reputation. — Medical Tirrus. 
 
AND SCIENTIFIC PUBLICATIONS 
 
 CARPENTER (WILLIAM B.), M. D., F. R. S., 
 
 Examiner in Physiology and Comparative Anatomy in the University of London. 
 
 THE MICROSCOPE AND ITS REVELATIONS. With an Appendix con- 
 
 taming the Applications of the Microscope to Clinical Medicine, iSrc. By F. G. Smith, M. D. 
 Illustrated by lour hundred and thirty-four beautiful engravings on wood. In one large and very 
 handsome octavo volume, of 724 pages, extra cloth, $4 00 ; leather, $4 50. 
 
 Dr. Carpenter's position as a microscopist and physiologist, and his great experience as a teacher, 
 eminently qualify him to produce w^hat has long been wanted — a good text-book on the practical 
 use of the microscope. In the present volume his object has been, as stated in his Preface, " to 
 combine, within a moderate compass, that information with regard to the use of his 'tools,' which 
 is most essential to the working microsco|>ist, wilh such an account of the objects best fitted for 
 his study, as might quality him to comprehend what he observes, and might thus prepare him to 
 benefit science, whilst expanding and refreshing his own mind " That he has succeeded in accom- 
 plishing this, no one acquainted with his previous labors can doubt. 
 
 The great importance of the microscope as a means of diagnosis, and the number of microsco- 
 pists who are also physicians, have induced the American publishers, with the author's approval, to 
 add an Appendix, carefully prepared by Professor Smith, on the applications of the instrument to 
 clinical medicine, together with an account of American Micro>eopes, their modifications and 
 accessories. This portion of the work is illustrated with nearly one hundred wood-cuts, and, it is 
 hoped, will adapt the volume more particularly to the use of the American student. 
 
 Every care has been taken in the mechanical execution of the work, which is confidently pre- 
 sented as in no respect inferior to the choicest productions of the London press. 
 
 The mode in which the author has executed his intentions may be gathered from the following 
 condensed s-ynopsis of the 
 
 CONTENTS. 
 
 [ntroduction — History of the Microscope. Chap. I. Optical Principles of the Microscope. 
 Chap. II. Construction of the Microscope. Chap. III. Accessory Apparatus. Chap. IV. 
 Management of the Microscope Chap. V. Preparation, Mounting, and Collection of Objects. 
 Chap. VI. Microscopic Forms of Vegetable Life — Protophyles. Chap. VII. Higher Cryptoga- 
 mia. Chap. VIII. Phanerogamic Plants. Chap. IX. Microscopic Forms of Animal Life — Pro- 
 tozoa — Animalcules. Chap. X. Foraminifera, Polycystina, and Sponges. Chap. XI. Zoophytes. 
 Chap. XII. Echinodermata. Chap. XIII. Polyzoa and Compound Tunicata. Chap. XFV. 
 Molluscous Animals Generally. Chap. XV. Annulosa. Chap. XVI. Crustacea. Chap. XVII. 
 Insects and Arachnida. Chap. XVIII. Vertebrafed Animals. Chap. XIX. Applications of the 
 Microscope to Geology. Chap. XX. Inorganic or Mineral Kingdom — Polarization. Appendix. 
 Microscope as a means of Diagnosis — Injections — Microscopes of American Manufacture. 
 
 Those who are acquainted with Dr. Carpenter's 
 previous writings on Animal and Vegetable Physio- 
 logy, will fully understand how vast a store of know- 
 ledge he is able to bring to bear upon so comprehen- 
 sive a subject as the revelations of the microscope ; 
 and even those ■who have no previous acquaintance 
 with the eonstruetion or uses of this instrument 
 
 medical work, the additions by Prof. Smith give it 
 a positive claim upon the profession, for which we 
 doubt not he will receive their sincere thanks. In- 
 deed, we know not where the student of medicine 
 will find such a complete and satisfactory collection 
 of microscopic facts bearing upon physiology and 
 practical medicine as is cimtained in Prof. Smith's 
 
 will find abundance of information conveyed in clear { appendix; and this of itself, it seems to us, is fully 
 and simple language. — Med. Times and GazeUe. [ wortJi the cost of the volume. — Louisville Medical 
 Although originally not intended as a strictly! Review , N ov . 1856 . 
 
 BY THE SAME AUTHOR. 
 
 ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- 
 
 LOGICAL ANATOMy. Second American, from a new and revised London edition. With 
 
 one hundred and ninety illustrations. In one very handsome octavo volume, leather, pp. 566. 
 
 S3 GO. 
 
 In publishing the first edition of this work, its title was altered from that of the London volume, 
 by the substitution of the word " Elements" for that of " Manual," and with the author's sanction 
 the title of " Elements" is still retained as being more expressive of the scope of the treatise. 
 
 To say that it is the best manual of Physiology | Those who have occasion for an elementary trea- 
 now before the public, would notdo sufficient justice i tise on Physiology, cannot do better than to possess 
 to the author. — Buffalo Medical Journal. themselvesofthemanual of Dr. Carpenter. — Medical 
 
 In his former works it would seem that he had Examiner. 
 exhausted the subject of Physiology. In the present. The best and most complete expose of modern 
 hegives the essence, as it were, of the whole. — N. Y.\ Physiology, in one volume, extant in the English 
 Journal of Medicine. \ language. — St. Louis Medical Journal. 
 
 BY THE SAME AUTHOR. (Preparing.) 
 
 PRINCIPLES OF GENERAL PHYSIOLOGY, INCLUDING ORGANIC 
 
 CHEMISTRY AND HISTOLOGY. With a General Sketch of the Vegetable and Animal 
 Kingdom. In one large and very handsome octavo volume, wilh several hundred illustrations. 
 The subject of general physiology having been omitted in the last editions of the author's " Com- 
 parative Physiology" and "Human Physiology," he has undertaken to prepare a volume which 
 shall present it more thoroughly and fully than has yet been attempted, and which may be regarded 
 as an introduction to his other works. 
 
 BY THE SAME ATTTHOR. 
 
 A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH 
 
 AND DISEASE. New edition, with a Preface by D. F. Condie, M. D., and explanations of 
 scientific words. In one neat 12mo. volume, extra cloth, pp. 178. 50 cents. 
 
ISIjAJNUHAlti; « JjJiA'S MiiUlUALi 
 
 CONDIE (D. F.), M. D., Ac. 
 A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fifth 
 
 edition, revised and augmented. In one large volume, 8vo., leather, of over 750 pages. ^3 25. 
 (Just Issued, 1859.) 
 
 In presenting a new and revised edition of this favorite work, the publishers have only to state 
 that the atithor has endeavored to render it in every respect "a complete and faithful exposition of 
 the patholoiry and therapeutics of the maladies incident to the earlier stages of existence — a full 
 and exact account of the diseases of infancy and childhood." To acccmplish this he has subjected 
 the whole work to a careful and thorough revision, rewriting a considerable portion, and adding 
 several new chapters. In this manner it is hoped that any deficiencies which may have previously 
 existed have been supplied, that the recent labors of practitioners and observers have been tho- 
 roughly incorporated, and that in every point the work will Ije found to maintain the high reputation 
 it has enjoyed as a complete and thoroughly practical book of reierence in infantile affections. 
 
 A few notices of previous editions are subjoined. 
 
 Dr. Condie's scholarship, acumen, industry, and 
 practical sense are manifested in this, as in nil his 
 numerous contributions to science. — t)T. Holmes^s 
 
 Hfport to the American Medical Association. 
 
 Taken as a whole, in our judgment. Dr. Condie's 
 Treatise is the one from the perusal of which the 
 practitioner in this country will rise with the great- 
 est satisfaction. — Western Journal of Medicine and 
 Surgery. 
 
 One of the best works upon the Diseases of Chil- 
 dren in the English language. — Western Lancet. 
 
 We feel assured from actual experience that no 
 physicinn's library can be complete without a copy 
 of this work.— iV. y. Journal of Medicine. 
 
 We pronounced the first edition to be the best 
 work on the diseases of children in the English 
 language, and, notwithstanding all that has heen 
 published, we still regard it in that light. — Medical 
 Examiner. 
 
 The value of works by native authors on the dis- 
 eases which the physician is called upon to combat, 
 will be appreciated by all ; anl the work of Dr. Con- 
 die has gained for itself the character of a safe guide 
 for students, and a useful work for consultation by 
 those engaged in practice. — N. Y. Med. Times. 
 
 This is the fourth edition of this deservedly popu- 
 lar treatise. During the interval since the last edi- 
 
 tion, it has been subjected to a thorough revision 
 .^ ,, ,• . ■ , .. , , by the author; and all new observations in the 
 
 ■^ItVil^ni^.rf/iitlVufJi^ZtL^P^nr-^ ^""^ therapeutics of children have been 
 
 mori>.nn ino, 1/.0 ■ oiro „r^ Olito Mcdicul and includcd in tlie present volume. As we said btfore, 
 
 to American medical literature 
 Surgical Journal 
 
 We feel persuaded that the American medical pro- 
 fession will soon regard it not only as a very good, 
 but as the very best "Practical Treatise on the 
 Diseases of Children." — American Medical Journal. 
 
 In the department of infantile therapeutics, the 
 work of Dr. Condie is considered one of the best 
 which has been published in the English language. 
 — The Stethoscope, 
 
 we do not know of a better book on diseases of chil- 
 dren, and to a large part of its recommendations we 
 yield an unhesitating concurrence. — Buffalo Med. 
 Journal. 
 
 Perhaps the most full and complete work now be- 
 fore the profession of the United States; indeed, we 
 may say in the English language. It is vastly supe- 
 rior to most of its predecessors. — Transi/lvaniaMtd. 
 Journal. 
 
 CHRISTISON (ROBERT), M. D., V. P. R. S. E., Ac. 
 A DISPENSATORY; or. Commentary on the Pharmacopoeias of Great Britain 
 
 and the United States; comprising the Natural History, Description, Chemistry, Pharmacv, Ac- 
 tions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- 
 proved, with a Supplement containing the most important New Remedies. With copious Addi- 
 tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M. D. 
 In one very large and handsome octavo volume, leather, raised bands, of over 1000 pages. $3 50. 
 
 COOPER (BRANSBY BJ, F. R. S. 
 LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. 
 
 In one very large octavo volume, extra cloth, of 750 pages. $3 00. 
 
 COOPER ON DISLOCATIONS AND FRAC- 
 TURES OF THE JOINTS.— Edited by Brassbt 
 B. Cooper, F. R. S., &c. With additional Ob- 
 servations by Prof. J. C. Warren. A new Ame- 
 rican edition. In one handsome octavo volume, 
 extra cloth, of about 500 pages, with numerous 
 illustrations on wood. $3 25. 
 
 COOPER ON THE ANATOMY AND DISEASES 
 OF THE BREAST, with twenty-five .Miscellane- 
 ous and Surgical Papers. One large volume, im- 
 perial 8vo.,' extra cloth, with 252 figures, on 38 
 plates. *2 50. 
 
 COOPER ON THE STRUCTURE AND DIS- 
 EASES OF THE TESTIS, AND ON THE 
 THYMUS GLAND. One vol. imperial i-vo., ex- 
 tra cloth, with 177 figures on 29 plates. £2 00. 
 
 COPLAND ON THE CAUSES, NATURE, AND 
 TREATMExNT OF PALSY AND APOPLEXY. 
 In one volume, royal 12mo., extra cloth, pp.326. 
 60 cents. 
 
 CLYMER ON FEVERS; THEIR DIAGNOSIS, 
 PATHOLOGY, A.ND TREAT.MENT In one 
 octavo volume, leather, of 600 pages. ?1 50. 
 
 COLO.MBAT DE L'ISERE ON THE DISEASES 
 OF FEMALES, and on the special Hygiene of 
 their Sex. Translated, with many "Votes and Ad- 
 ditions, by C. D. Meigs, M.D. Second edition, 
 revised and improved. In one large volume, oc- 
 tavo, leather, with numerous wood-cuts. pp. 720. 
 S3 50. 
 
 CARSON (JOSEPH), M. D., 
 
 Professor of Materia Medica and Pharmacy in the University of Pennsylvania. 
 
 SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA 
 
 AND PHARMACY, delivered in the University of Pennsylvania. Second and revised edi- 
 tion. In one very neat octavo volume, extra cloth, of 208 pages. $1 50. 
 
 CURLING (T. B.), F. R.S., 
 
 Surgeon to the London Hospital, President of the Hunterian Society, Ac. 
 
 A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPERMA- 
 
 TIC CORD, AND SCROTUM. Second American, from the second and enlarged English edi- 
 tion. In one handsome octavo volume, extra cloth, with numerous illustrations, pp. 4".>0. S2 00. 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 CHURCHILL (FLEETWOOD), M. D., M. R. I. A. 
 ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American 
 
 from the fourth revised and enlarged London editioti. With Notes and Additions, by D. Francis 
 
 UoNDiE, M. D., author of a "Practical Treatise on the Diseases of Children," &c. With 191 
 
 illustrations. In one very handsome octavo volume, leather, of nearly 700 large pages. $3 50. 
 
 (Now Ready, October, ISGO.) 
 
 This work has been so long an established favorite, both as a text-book for the learner and as a 
 reliable aid in consultation ibr the practitioner, that in presenting a new edition it is only necessary 
 to call atlention to the very extended improvements which it has received. Having had the benefit 
 of two revisions by the author since the last American reprint, it has been materially enlarged, and 
 Dr. Churchill's well-known conscientious industry is a guarantee that every portion has been tho- 
 roughly brought up with the latest results of European investigation in all departments of the sci- 
 ence and art of obstetrics. The recent dale of the last Dublin edition has not left much of novelty 
 for the American editor to introduce, but he has endeavored to insert whatever has since appeared, 
 together wilh such matters as his experience has ^hown him would be desirable lor the Amsrican 
 student, including a large number of illustrations. Wilh the sanction of the author he has added 
 in the lorm of an appendix, some chapters from a little -'Manual tor Midwives and Nurses," re- 
 cently issued by Dr. Churchill, believing that the details there presented can hardly fail to prove of 
 advantage to the junior practitioner. Tne result of all these additions is that the work now con- 
 tains fully one-half more matter than the last American edition, with nearly one-half more illus- 
 trations, so that nitwilhstanding the use of a smaller type, the volume contains almost two hundred 
 pages more than before. 
 
 No elfort has been spared to secure an improvement in the mechanical execution of the work 
 equal to ihat which the text has received, and the volume is confidently presented as one of the 
 handsomest that has tlnis far been laid before the American profession; while the very low price 
 at which it is olfered should secure for it a place in every lecture-room and on every office table. 
 
 A better book in which to learn these important The most popular work on midwifery ever issued 
 
 poinls we have not met than Dr. Churchill's. Every 
 page of it is full ot" instruction; the opinion of all 
 writers of authority is given on questions of diffi- 
 culty, as well !is tlie directions and advice ot the 
 learned autiior himself, to which he adds the result 
 of statibtical inquiry, putting statistics in tlieir pro 
 per place and giving them their due weight, and no 
 more. We have never read a book more free from 
 professional jealousy than Dr. Churchill's. It ap- 
 pears to be written with the true design of a hook on 
 medicine, viz : to give all that is known on the sub- 
 ject of which he treats, both theoretically and prac- 
 tically, and to advance such opinions of his own as 
 he believes will benefit medical science, and insure 
 the safety of the patient. We have said enough to 
 convey to the profession that this book of Dr. Chur- 
 chill's is admirably Fuited for a book of reference 
 for the practitioner, as well as a text-book for the 
 student, and we hope it may be extensively pur- 
 chased amongst our readers. To them we most 
 Btrongly recommend it. — Dublin Medical Press, 
 June 20, 1S60. 
 
 To bestow praise on a book that has received such 
 marked approbation would be superfluous. We need 
 only say, therefore, that if the first edition was 
 thought worthy of a favorable reception by the 
 medical public, we can confidently affirm that this 
 will be found much more so. The lecturer, the 
 practitioner, and the student, may all have recourse 
 to its pages, and derive from their perusal much in- 
 terest anri instruction in everything relating to theo- 
 retical and practical midwifery. — Dublin Quarterly 
 Journal of Medical Science. 
 
 A work of very great merit, and such as we can 
 confidently recommend to the study of every obste- 
 tric practitioner. — London Medical Gazette. 
 
 This is certainly the most perfect system extant. 
 It is the best adapted for the purposes of a text- 
 book, and that which he whose necessities confine 
 him to one book, should select in preference to all 
 others. — Soutkem Medical and Surgical Journal. 
 
 BY THE SAME AUTHOR. (Lately Puhlixlied.) 
 
 ON THE DISEASES OF INFANTS AND CHILDREN. Second Araerican 
 
 Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Kkati.ng, M. D. In 
 one large and handsome volume, extra cloth, of over 700 pages. $3 00, or in leather, S3 25. 
 In preparing this work a second time for the American profession, the author has spared no 
 labor in giving it a very thorough revision, introducing several new chapters, and rewriting others, 
 while every portion of the volume has been subjected to a severe scrutiny. The efforts of the 
 American editor have l)een directed to supplying such information relative to matters peculiar 
 to this country as might have escaped the attention of the author, and the whole may, there- 
 fore, be safely pronounced one of the most complete works on the subject accessible to the Ame- 
 rican Profession. By an alteration in the size of the page, these very extensive additions have 
 been accommodated without imduly increasing the size of the work. 
 
 BY THE SAME AUTHOR. 
 
 ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- 
 
 CULIAR TO WOMEN. Selected from the wrilingsof British Aiilhors previous to the close of 
 the Eighteenth Century. In one neat octavo volume, extra cloth, of about 450 pages. $2 50. 
 
 from the American press. — Charleston Med. Journal. 
 Were we reduced to the necessity of having but 
 tne work on midwifery, and jterinitted to choose, 
 we would unhesitatingly take Churchill. — Western 
 Med. and Surg. Journal. 
 
 It is impossible to conceive a more useful and 
 slegant manual than Dr. Churchill's Practice of 
 Midwifery. — Provincial Medical Journal. 
 
 Certainly, in our opinion, the very best work on 
 he subject which exists. — N. Y. Annalist. 
 
 No work holds a higher position, or is more de- 
 serving of being placed in the hands of th'.- tyro, 
 the advanced student, or the practitionei;. — Medical 
 Examiner. 
 
 Previous editions, under the editorial supervision 
 of Prof R. M. Huston, have been received with 
 marked favor, and they deserved it; but this, re- 
 printed from a very late Dublin edition, carefully 
 revised and brought up by the author to the present 
 time, does present an unusually accurate and able 
 exposition of every important particular embraced 
 in the department of midwifery. * * Theclearn^£j 
 directness, and precision of its teachings, together 
 with the great amount of statistical research which 
 its text exhibits, have served to place it already in 
 the foremost rank of works in this department of re- 
 medial science. — N. O. Med. and Surg. Journal. 
 
 In our opinion, it forms one of the best if not the 
 very best text-book and epitome of obstetric science 
 which we at present possess in the English lan- 
 guage. — Monthly Journal of Medical Science. 
 
 The clearness and precision of style in which it is 
 written, and the great amount of statistical research 
 which it contains, have served to place it in the first 
 rank of works in this departmentof medical science. 
 —N. Y. Journal of Medicine. 
 
 Few treatises will be found better adapted as a 
 text-book for the student, or as a manual for the 
 frequent consultation of the young practitioner. — 
 American Medical Journal. 
 
10 BLANCHARD & LEA'S MEDICAL 
 
 CHURCHILL (FLEETWOOD), M . D., M . R, L A., fee 
 
 ON THE DISEASES OF WOMEN; including those of Pregnancy and CiiUd- 
 
 bed. A new American edition, revised by Ihe Author. With Notes and Additions, bv D Fran- 
 cis CoNDiE, M. D., author ot "A Practical Treatise on the Diseases of Children." With nume- 
 rous illustrations. In one large and handsome octavo volume, leather, of 768 pages. S.3 00. 
 This edition of Dr. Churchill's very popular treatise mav almost be termed a new work, so 
 thoroughly has he revised it in every portion. It will be found greatly enlarged, and completely 
 brought up to the most recent condition of the subjeot, while the verv handsome series ol illustra- 
 tions introduced, representing such pathological conditions as can be accurately portrayed, present 
 a novel feature, and afford valuable assistance to the young practitioner. Such addiiions as ap- 
 peared desirable for the American student have been made by the editor, Dr. Condie, while a 
 marked improvement in the mechanical execution keeps pace with the advance in all other respects 
 which the volume has undergone, while the price has been kept at the former very moderate rate. 
 It comprises, unquestionably, one of the most ex- ' extent that Dr. Churchill does. His, indeed, is the 
 act and comprehensive expositions of the present only thorough treatise we know of on the subject: 
 state of medical knowledge in respect to the diseases and' it may he commended to practitioners and stu- 
 of women that has yet been published.— jlwi. Journ. dents as a masterpiece in its particular department. 
 Med. Sciences, July, 1657. —Thi Western Journal of Medicine and Surgery. 
 
 This work is the most reliable which we possess As a comprehensive manual for students, or a 
 on this subject; and is deservedly popular with the , work of reference for practitioners, it surpasses any 
 profession.— CAnrieiion Med. Journal, July, 1857. other tliat has ever issued on the same subject from 
 
 We know of no author who deserves that appro- the British press. — Dublin Quart. Journal. 
 batioo, on "the diseases of females," to the same i 
 
 DICKSON (S. H.), M. D., 
 
 Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia. 
 
 ELEMENTS OF MEDICINE; a Compendious View of Pathology and Thera- 
 
 peutics, or the History and Treatment of Diseases. Second edition, revised. In one large and 
 handsome octavo volume, ol 750 pages, leather. $3 75. {Just Issued.) 
 
 The steady demand which has so soon exhausted the first edition of this work, sufficiently shows 
 that the author was not mistaken in supposing that a volume of this character was needed — an 
 elementary manual of practice, which should present the leading principles of medicine with the 
 practical results, in a condensed and perspicuous manner. Disencumbered of unnecessary detail 
 and fruitless speculations, it embodies what is most requisite for the student to learn, and at the 
 saiiie lime what the active practitioner wants when obliged, in the daily calls of his profession, to 
 refresh his memory on special points. The clear and attractive style of the author renders the 
 whole ea>-y of comprehension, while his long experience gives to his teachings an authority every- 
 where acknowledged. Few physicians, indeed, have had wider opportunities for obser\-ation and 
 experience, and lew, perhaps, have used them to better purpose. As the result of a long life de- 
 voied to study and practice, the present edition, revised and brought up to the date of publication, 
 will doubtless maintain the reputation already acquired as a condensed and convenient American 
 text-book on the Practice of Medicine. 
 
 DRUITT (ROBERT), M.R. C.S., fitc. 
 THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new 
 
 and revised American from the eighth enlarged and improved London edition. Illustrated with 
 four hundred and thirty-two wood-engravings. In one very handsomely printed octavo volume, 
 leather, of nearly 700 large pages. $3 50. {Now Ready, October, 1560.) 
 
 A work which like Druitt's Surgery has for so many years maintained the position of a lead- 
 ing favorite with all classes of the profession, needs no special recommendation to attract attention 
 to a revised edition. It is only necessary to state that the auilior has spared no pains to keep the 
 work up to its well earned reputation of presenting in a small and convenient compass the latest 
 condition of every department of surgery, considered both as a science and as an art; and that the 
 services of a competent American editor have been employed to introduce whatever novelties may 
 have escaped the author's attention, or may prove of service to the American practitioner. As 
 several editions have appeared in London since the issue of the last American reprint, the volume 
 has had the benefit of repeated revisions by the author, resulting in a very tnorough alteration and 
 improvement. The extent of these addiiions may be estimated from the tact that it now contains 
 about one-third more matter than the previous American edition, and that notwithstanding the 
 adoption of a smaller type, the i)ages have been increa.sed by about one hundred, while nearly two 
 hundred and fifty wood-cuts have been added to the former list of illustrations. 
 
 A marked iiuprovement will also be perceived in the mechanical and artisiical execution of the 
 work, which, printed in the I^est style, on new t\pe, and fine pajM?r, leaves little to be desired as 
 regards external finish; while at the very low price allixed it will be found one of the cheapest 
 volumes accessit)le to the profession. 
 
 This popular volume, now a most comprehensive nothing of real practical importance has been omit- 
 work in surgery, has undergone many corrections, ted; it presents a faithful epitomeofeveryihing re- 
 improvements, and additions, and the principles and lating t > surgery up to the present hour. It is de- 
 the practice of the art have been brought down to servedly a popular manual, both with the student 
 the latest record and observation. Of the operations and practitioner.— Lcnt^on Lancet, Nov. 19, 11^59. 
 in surgery it is inipoKsitile to (peak too highly. The t i • u- v. • /. • i 
 
 defcripiionsare so char and concise, and the illus- '" closing this brief notice, we recommend as cor- 
 trations so ascurale and numerous, that the student '''""^' »« "^^^ *•"« "'"*' useful and comprehensive 
 can have no difficulty, with instrument in hand, and hand-book. It must prove a vast assibtance, not 
 bcok bv his side, over the dead body, in obtaining ""'>" to the student of surgery, but also to the busy 
 a proper knowledge and sufficient tact in this much Pmctitiooer whi may not have the leisure to devote 
 neplectrddepiirimentofmedicaleducation.— /Jria'iA '"mBelf to the study of more lengthy volumes.— 
 and Forrign Midico-ckirurg. Review, Jan. ISCO. London Med. Times and Gazette, Oct. 22, 1S59. 
 
 In the present edition the author has entirely re- In a word, this eighth edition of Dr. Sruitl's 
 
 wriiien many of the chapters, and has incorporated Manual of Surgery is all that the surgical student 
 
 the various iraprovemenis and addiiions in modern or practitioner could desire. — Dublin Quarterly 
 
 surgery. On carefully going over it, we find that Journal of Mtd. Sciences, Nov. 1659. 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 11 
 
 DALTON, JR. (J. C), M. D. 
 
 Professor of Pliysiology in tlie College of Physicians, New York. 
 
 A TREx\TISE ON HUMAN PHYSIOLOGY, designed for the use of Students 
 
 and Prart it loners of Medicine. With two hundred and fit'ty-foiir illustrations on wood. In one 
 very beautiful octavo volume, of over 600 pages, extra cloth, $4 00 ; leather, raised bands, $4 25. 
 (Just Issued.) 
 
 This system of Physiology, both from the ex- 
 cellence of the arrrtngement studiously observed 
 throughout every page, and the clear, Im-id, and in- 
 structive manner in which each subject is treated, 
 promises to form one of the most generally received 
 class-books in the Knglish languajie. It is, m fact, 
 a most admirable epitome of all the really jmporlant 
 discoveries thai have always been received as incon- 
 testable truths, as well us of those wliich have been 
 recently added to our stock of knowledge on this sub- 
 ject. We will, however, proceed to give a few ex- i 
 tracts from the book itself, as a specimen of its style 
 and composition, and this, weconceive, will bequite 
 sufficient to awaken a general interest in a work 
 which isimmeasiirabl) superior in its details to the 
 majority of those of the same class t'l which it be- 
 longs. In its purity of style and elegance of com- 
 position it m-iy safely take its place with the very 
 best of our Knglish classics; while in accuracy of 
 cte8cripti(m it is impossible that it could be surpass 
 ed. In every line is beautifully shadowed forth the 
 emanations of the poliBhcd scholar, whose rellec- 
 tions are clothed in a garb as interesting as they are 
 impressive; with the one predominant feeling ap- 
 pearing to pervade the whole — an anxious desire to 
 please and at the same time to instruct. — Dublin 
 Quarterly Journ. of Med. Sciences, Nov. 1859. 
 
 The work before us, however, in our humble judg- 
 ment, is precisely what it purports to be, and will 
 answer admirably the purpose for which it is in- 
 tended. It is par excellence, a. text-book; and the 
 best text-book in tl is department that we have ever 
 Been. We have carefully read tlie book, and speak 
 of its merits from a more than cursory perusal. 
 Looking back upon the work we have just finished, 
 we must say a word concerning the excellence of its 
 illustrations. No department is so dependent upon 
 good illustrations, and those which keep pace with 
 our knowledge of the subject, as that of physiology. 
 The wo<id-cuts in the work before us are the best 
 we have ever seen, and, being original, serve to 
 illustrate precisely what is desired — Buffalo Med. 
 Journal, March, 1859. 
 
 A book of genuine merit like this deserves hearty 
 praise before subjecting it t.) any minute criticism. 
 We are not prepared to find any fault with its design 
 until we have had more time to appreciate its merits 
 as a manual for daily consultation, and to weigh 
 its statements and conclusions more deliberatelv. 
 Its excellences we are sure of; its defects we have 
 yet to discover. It is a work highly honorable to 
 
 its author; to his talents, his industry, his training: 
 to the institution with which he is connected, ana 
 to American science. — Boston Med. and Surgical 
 Journal, Feb. 24, 1859. 
 
 A NEW book and a fi rst rate one ; an original book, 
 and one wliich cannot be too highly a|)preciated, 
 and which we are proud to see emanating from our 
 country's press. It is by an author who, though 
 young, is considerably fiimous for physiological re- 
 search, and who in this work has erected for him- 
 self an enduring monument, a token at once of his 
 labor and liis success. — Nashville Medical Journal^ 
 March, 1859. 
 
 Throughout the entire work, the definitions are 
 clear and precise, the arrangement admirable, the 
 argument !)rie(iy and well stated, and the style 
 nervous, simple, and concise. Section third, treat- 
 ing of Reproduction, is a monograph of unap- 
 proached excellence, upon this subject, in the Eng- 
 lish tongue. For precision, elegance and force of 
 style, exhaustive method and extent of treatment, 
 fulness of illustration and weight of personal re- 
 search, we know of no Ameri -an contribution to 
 medical science which surpasses it, and the day is 
 far distant when its claims to the respectful atten- 
 tion of even the best informed scholars will not be 
 cheerfully conceded by all acquainted with its range 
 ana depth. — Charleston Med. Journal, May, 1859. 
 
 A new elementary work on Human Physiology 
 lifting up its voice in tlie presence of hue and sturdy 
 editions of Kirke's, Carpenter's, Todd and Bow- 
 man's, to say nothing of Duiglison's and Draper's, 
 should have something superior in the matter or the 
 manner of its utterance in order to win for itself 
 deserved attention and a name. Tiiat maiter and 
 that manner, alter a candid perusal, we think dis- 
 tinguish this work, and we are proud to welcome it 
 not merely for its nativity's sake, but for iis own 
 intrinsic excellence. Its language we find to be 
 plain, direct, unambitious, and falling with a just 
 conciseness on hypothetical or unsetiltd questions, 
 and yet with sufficient fulness on those living topics 
 already understood, or the path to whose solution 
 is definitely marked out. It does not speak exhaust- 
 i /ely upon every subject that it notices, but it does 
 speak suggestively, experimentally, and to their 
 main utiliiies. Into the subject of Reproduction 
 our author plunges with a kind of loving spirit. 
 Thriughout ttiislnteresting and obscure department 
 he is a clear and admirable teacher, sometimes a 
 brilliant leader. — Am. Med. Monthly, May, ls59. 
 
 DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. 
 THE CYCLOPEDIA OF PRACTICAL MEDICINE: comprising Treatises on 
 
 the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women 
 
 and Children, Medical Jurisprudence, &c. &c. in four large super-royal octavo volumes, of 
 
 3254 double-columned pages, strong-ly and handsomely bound, with raised bands. $12 00. 
 
 *^* This work contains no less than four hundred and eighteen distinct Ireati.ses, contributed by 
 eixty-eight distinguished physicians, rendering it a complete library of reference for the country 
 practitioner. 
 
 The most complete work on Practical Medicine titioner. This estimate of it has not been formed 
 extant; or, at least, in our language.— £u^'a/o from a hasty examination, but after an intimate ac- 
 Medical and Surgical Journal. quaintance derived from frequent c<msultation of it 
 
 „ . .. ■ I 11 • » _ during the past nine or ten years. The editors are 
 
 For reference, it is above all price to every prac- pr^etftioners of established reputati.m, and the list 
 titioner.— Western l^ancet. of contributors embraces many of the most eminent 
 
 One of the most valuable medical publications of professorsand teachers of London, Kdinburgh, Dub- 
 theday — as a work of reference it is invaluable. — Un, and Glasgow. It is, indeed, the great merit of 
 Western Journal oj Medicine and Surgery. this work that the principal articles have been t'ur- 
 
 It has been to us, both as learner and teacher, a nisheU by practitioners who have not only ilevoted 
 work for ready and frequent reference, one In which cspecialattention to the diseases about which they 
 modern Knglish medicine is exhibited in the most have written, but have also enjoyed opportunities 
 advantageous light.— Medical Examiner. f"r "" extensive practical acquaintance with them, 
 
 and whose reputation carries the assurance of their 
 
 We rejoice that this work is to be placed within i competency justly to appreciate the opinions of 
 the reach of the profession in this country, it being I others, while it stamps their own doctrines with 
 unquestionably one of very great value to tlie prae- \ high and just authority. — American Medical .Tourn. 
 
 DEWKKS'S COMPREHENSIVK SYSTEM OF | 
 MIDWIFERV. Illustrated by occasional cases ' 
 and many engravings. Twelfth edition, with the ■ 
 author's last improvements and correctiims In 
 oneoctavo volume, extracloth, of 600 pages. SJ320. j 
 
 DEWEES'S TREATISE ON THE PHYSICAL I 
 
 AND MEDICAL TREATMENT OF CHILD- 
 RE.N. The last edition. In one volume, octavo, 
 extra cloth, 518 pages. 82 80 
 
 DEWEES'S TREATISE ON THE DISEASES 
 OF FEMALES. Tenth edition. In one volume, 
 octavo extra cloth, 532 pages, with plates. S:3 00 
 
12 
 
 BLANCHARli) & LEA'S MEDICAL 
 
 DUNGLISON (ROBLEY), M.D., 
 
 ProfcMor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. 
 
 NE"W AND ENLARGED EDITION. 
 
 MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise 
 
 Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, 
 Therapeutic-6, PharmacologAS Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, Dentistry, 
 &c. Notices of Climate and of Mineral Waters; Formulae for OlTicinal, Empirical, and Dietetic 
 Preparations, lVtc. With French and other Synonymes. Revised and very greatly enlarged. 
 In one very large and handsome octavo volume, of 992 double-columued pages, ia small type; 
 strongly bound in leather, with raised bands. Price $4 00. 
 
 Especial care has been devoted in the preparation of this edition to render it in every re.«pect 
 worthy a continuance of the very remarkable favor which it has hitherto enjoyed. The rapid 
 sale of Fifteen large editions, and the constantly increasing demand, show that'll is regarded by 
 the profession as the standard authority. Stimulated by this fact, the author has endeavored in the 
 present revision to introduce whatever might be necessary "to make it a satisfactory and desira- 
 ble — if not indis()ensal)le — lexicon, in which the student may search without disappointment for 
 every term that has been legitimated in the nomenclature of the science." To accomplish this, 
 large additions have been foiind requisite, and the extent of the author's labors may l)e estimated 
 from the fact that about Six Thousand subjects and terms have been introduced throughout, ren- 
 dering the whole number of definitions about Sixty Thousand, to accommodate which, the num- 
 ber of pages has been increased by nearly a hundred, notwithstanding an enlargement in the size 
 of the pase. The medical press, both in this country and in England, has pronounced the work in- 
 dispensable to all medical students and practitioners, and the present improved edition will not lose 
 that enviable reputation. 
 
 The publishers have endeavored to render the mechanical execution worthy of a volume of such 
 universal use in daily reference. The greatest care has been exercised to obtain the typographical 
 accuracy so necessary in a work of the kind. By the small but exceedingly clear type employed, 
 an immense amount o( matter is condensed in its thousand ample pages, while the binding will be 
 found strong and durable. With all these improvements and enlargements, the price has been kept 
 at the former very moderate rate, placing it within the reach of all. 
 
 This work, the appearance of the fifteenth edition 
 of which, it has beeome our duty and pleasure to 
 announce, is perhaps the most stupendous monument 
 of hibor and erudition in medical literature. One 
 would hardly suppose after constant use of the pre- 
 ceding editions, where we have never failed to find 
 a sufficitntly full explanation of ever) medical term, 
 that in this edition '^ about six thousand subjects 
 and terms have been added,'^ with a careful revision 
 and correcti(m of the entire work. It is only nece s- 
 sarj- to announce the advent of this eilition to make 
 it occupy the place of the preceding one on the table 
 of every medical man, ns it is without doubt the best 
 and most comprehensive work of the kind which has 
 ever appeared. — Buffalo Med.Journ., Jan. 1858. 
 
 The work is a monument of patient research, 
 skilful judgment, and vast physical labor, that will 
 perpetuate the name of the author more etfectually 
 than any possible device of stone or metal. Dr. 
 Dunglison deserves the thanks not only of the Ame- 
 rican profession, but of the whole meilical world. — 
 Aorlh Am. Medieo-Chir. Review, Jan. 1658. 
 
 A Medical Dictionary better a<lapted for the wants 
 of the profession than any other with which we are 
 acquainted, and of a character which places it far 
 above comparison and competition. — Am. Joum. 
 Med. Sciences, Jan. 1858. 
 
 We need only say, that the addition of 6,000 new 
 terms, with their accompanying definitions, may be 
 said to constitute a new work, by itself. We have 
 eiainined the Dictionary attentively, and are most 
 happy to pronounce it unrivalled of its kind. The 
 erudition displayed, and the extraordinary industry 
 which must have been demanded, in its preparation 
 and perfection, redound to tlie lasting credit of its 
 author, and have t'urnished us witli a volume indis- 
 pensable at the present day, to all who would find 
 themselves au ntveau with the highest standards of 
 medical information. — Boston Medical and Surgical 
 Journal, Dec. 31, 1857. 
 
 Good lexicons and encyclopedic works generally, 
 are the most labor-saving contrivances which lite- 
 rary men enjoy; and the labor which is required to 
 produce Ihcm in the perfect manner of this example 
 18 something appalling to contemplate. The author 
 
 tells us in his preface that he has added about six 
 thousand terms and subjects to this edition, which, 
 before, was considered universally as the best work 
 of the kind in any language. — Silliman^s Journal, 
 March, 1858. 
 
 He has razed his gigantic structure to the founda- 
 tions, and remodelled and reconstructed the entire 
 pile. No less than six thousand additional subjects 
 and terms are illustrated and analyzed in this new 
 edition, swelling the grand aggregate to beyond 
 sixty thousand ! Thus is placed before the profes- 
 sion a complete and thorough exponent of medical 
 terminology, without rival or possibility of rivalry. 
 — Nashville Joum. of Med. and Surg., Jan. 1858. 
 
 It is universally acknowledged, we believe, that 
 I this work is incomparably the best and most com- 
 plete Medical Lexicon in the English language. 
 The amount of labor which thedistinguished author 
 has bestowed upon it is truly wonderful, and the 
 learning and research displayed in its preparation 
 are equally remarkable. Comment and commenda- 
 tion are unnecess;iry, as no one at the present day 
 I thinks of purchasing any other Medical Dictionary 
 than this. — St. Louts Med. and Surg. Journ., J&a. 
 1658. 
 
 It is the foundation stone of a good medical libra- 
 ry', and should always be included in the first list of 
 books purchased by the medical student. — Am. Med. 
 Monthly, Jan. 1858. 
 
 A very perfect work of the kind, undoubtedly the 
 most perfect in the English language. — Med. and 
 Surg. Reporter, Jan. 1858. 
 
 It is now emphatically the Medical Dictionary of 
 the English language, and t'or it there is no substi- 
 tute. — iV. H. Med. Joum., Jan. 18.38. 
 
 It is scarcely necessary to remark that any medi- 
 cal library wanting a copy of Duneli8<in's Lexicon 
 must be imperfect. — Cin. Lancet, Jan. 1858. 
 
 We have ever considered it the best authority pub- 
 lished, and the presenteditiim we may safely say has 
 no equ.Tl in the world. — Peninsular Med. Journal, 
 Jan. 1858. 
 
 The most complete authority on the subject to b« 
 found in any language. — Va.Med. Journal, Feb. '58. 
 
 BY THE SAME AUTHOR. 
 
 THE PRACTICE OF MEDICINE. A Treatise on Special Pathology and The- 
 rapeutics. Third Edition. In two lai^e octavo volumes, leather, of 1,500 pages. $6 25. 
 
AND SCIENTIFIC PUBLICATIONS. 13 
 
 DUNGLISON (ROBLEY), M.D., 
 
 Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. 
 
 HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and exten- 
 sively modified and enlarged, with five hundred and thirty-two illustrations. In two large and 
 handsomely printed octavo volumes, leather, of about 1500 pages. $7 GO. 
 
 In revising this work for its eighth appearance, the author has spared no labor to render it worthy 
 a continuance of the very great favor which has been extended to it by the profession. The whole 
 contents have been rearranged, and to a great extent remodelled; the investigations which of late 
 years have been so numerous and so important, have been carefully examined and incorparated, 
 and the work in every respect has been brought up to a level with the present state of the subject. 
 The object of the author has been to render it a concise but comprehensive treatise, containing the 
 whole body of physiological science, to which the student and man of science can at all times refer 
 with the certainty of finding whatever they are in search of, fully presented in all its aspects; and 
 on no former edition has the author bestowed more labor to secure this result. 
 
 We believe that it can truly be said, no more com- The best work of the kind in the English lao- 
 ptete repertory of facts upon the subject treated, guage. — Silliman^s Journal. 
 
 can any where 'be found The author has, moreover, T-|,e present edition the author has made a pcifcct 
 that enviable tact at description and that facility mirror of the science as it is at the present hour, 
 and ease of expression which render him peculiarly ^s a work upon phvsiolosry proper, the science of 
 acceptable to the casual, or the studious reader, the functions performed bv'^t.he body, the student will 
 This faculty, bo requisite in setting forth many gnj jt all he wishes.— jVasAri//e Journ. of Med. 
 praver and less attractive subjects, lends additional „■ ^i, i ■ j . ^> 
 
 charms to <me always fascinating— Boston Med.\ . That he has succeeded, most admirably succeeded 
 and Surg Journal. '" his purpose, is apparent from the appearance of 
 
 an eighth e<lition. It is now the erreat encyclopaedia 
 
 The most complete and satisfactory system of on the subject, and wortliy of a place in every phy- 
 Physiology in the English language. — Amer.Med.', sician's library. — Western Lancet. 
 Journal . I 
 
 BY THE SAME AUTHOR. {A new edition.) 
 
 GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a 
 
 Medical Text-book. With Indexes of Remedies and of Diseases and their Remedies. Sixth 
 Edition, revised and improved. With one hundred and ninety-three illustrations. In two large 
 and handsomely printed octavo vols., leather, of about 1100 pages. S6 00. 
 
 In announcing a new edition of Dr. Dunglison's | The work will, we have little doubt, be bought 
 General Therapeutics and Materia Medica, we have I and read by the majurity of medical students: its 
 no words of commendation to bestow upon a work \ size, arrangement, and reliability recommend it to 
 whose merits have been heretofore so often and so all ; no one, we venture to pretliet, will study it 
 justly extolled. It must not be supposed, however, j without profit, and there are few to whom it will 
 that the present is a mere reprint of the previous not be in some measure useful us a work of refcr- 
 edition: the character of the author for laborious ence. The young practitioner, more especially, will 
 research, judicious analysis, and clearness of ex- find the copious indexes appendtd to this ediiion of 
 pression, is fuUv sustained by the numerous addi- ' great assistance in the selection and preparation of 
 tions he nas made to the work, and the careful re- suitable formulae. — Charleston Med. Journ. and Re- 
 Vision to which he has subjected the whole. — A'. A. , vieio, Jan. 165s. 
 Medico-Chir. Review, Jan. IboS. > 
 
 BY THE SAME AUTHOR. (A lieiO Editt07l.) 
 
 NEW REMEDIES, WITH FORMULA FOR THEIR PREPARATION AND 
 
 ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo 
 volume, leather, of 770 pages. $3 75. 
 
 Another edition of the " New Remedies" having been called for, the author has endeavored to 
 add everything of moment that has appeared since the publication of the last edition. 
 
 The articles treated of in the former editions will be found to have undergone considerable ex- 
 pansion in this, in order that the author might be enabled to introduce, as lar as practicable, the 
 results of the subsequent experience of others, as well as of his own observation and reilection ; 
 and to make the work still more deserving of the extended circulation with which the preceding 
 editions ha%'e been favored by the profession. By an enlargement of the page, the numerous addi- 
 tions have been incorporated without greatly increasing the bulk of the volume. — Preface. 
 
 One of the most u8eful.of the author's works.— 
 Southern Medical and Surgical Journal. 
 
 Tills elaborate and useful volume should be 
 found in every medical library, for as a book of re- 
 ference, for physicians, it is unsurpassed by any 
 other work in existence, and the double index for 
 diseases and for remedies, will be found greatly to 
 
 The great learning of the author, and his remark- 
 able industry in pushing his researches into every 
 source wlience informatiim is derivable, have enabled 
 him to tlirow together an extensive mass of facts 
 and statements, accompanied by full reference to 
 authorities; which last feature renders the work 
 practically valuable to investigators who desire tf 
 
 enhance its value.— A'ew York Med. Gazette. examine the original papers.— r/ie American Journal 
 
 of Pharmacy. 
 
 ELLIS (BENJAMIN), M.D. 
 THE MEDICAL FORMULARY : being a Collection of Prescriptions, derived 
 
 from the writings and practice of many of the most eminent physicians of America and Europe. 
 Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added 
 an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The 
 whole accompanied with a few brief Pharmaceutic and Medical Observations. Tenth edition, 
 revised and much extended by Robert P. Tho.mas, M. D., Professor ol Materia Medica in the 
 Philadelphia College of Pharmacy. In one neat octavo volume, extra cloth, of 296 pages. $1 75. 
 
BLANCHARD & LEA'S MEDICAL 
 
 ERICHSEN (JOHN), 
 
 Professor of i^urstery in University College, London, 4c. 
 
 THE SCIENCE AND ART OF SURGERY; being a Treatise on Suhgical 
 
 Inji-riks, IJisEASES. AM> OPERATIONS. New and improved American, from the second enlarged 
 
 and carelullv revised London t-dilion. Illustrated with over four hundred engravings on wood. 
 
 In one large and handsome ootavo volume, of one thousand closely printed pages, leather, 
 
 raised bands. S4 50. (Just Issued.) 
 
 The very di-iingnished favor with which this work has been received on both sides of the Atlan- 
 tic has Biirnulated tlie author to render it even more worthy of the position which it has so rapidly 
 attained as a standard authority. Every portion has been carefully revised, numerous additions 
 have been made, and the most watchful care has been exercised to render it a complete exponent 
 of the most advanced condition of surgical science. In this manner the work has been enlarged by 
 about a hundred pages, while the series of engravings has been increased by more than a hundred, 
 rendering it one of the most thoroughly illustrated volumes before the profession. The additions of 
 tlie author liaviiig rendered unneces>ary most of the notes of the former American editor, but little 
 has been added in this coinitry ; some few notes and occasional illustrations have, however, been 
 introduced to elucidate American modes of practice. 
 
 It Is, in our liumble judgment, decidedly the best step of the operation, and not desertine him until the 
 book of the kind \n the Kn^lish language. Strange final issue of the case is decided. — Sethofcope. 
 that just such books are noiopener produced by pub- | Embracing, as will be perceived, the whole snrgi- 
 
 lic leacherf of surgery in lliis country and Great 
 Britain Indeed, it is a matter of great astonishment, 
 but no less true than a-^loMishing. that of the many 
 workson surgery republished in this country wiiliin 
 the last fifteen or twenty years as text-books for 
 medical students, ihi' is the only one that even ap- 
 proximates (o the fulfilment of the peculiar wants of 
 youngmen jusi ciUering upon the study of this branch 
 of the profession. — WaUrnJoxtr .of Med. an<l Surgery. 
 
 Its value is greatly enhanced by a very copious 
 
 cal domain, and each division of itself almost com- 
 plete and perfect, each chapter full and explicit, each 
 subject faithfully exhibited, we can only express out 
 esiimaie of it in the aggregate. We consider it an 
 excellent contribution to surgery, as probably the 
 bes! single volume now extant on the subject, and 
 with great pleasure we add it to our lexi-books. — 
 Nashville Journal of Medicine and Surgery. 
 
 Prof. Erichsen's work, for its size, has not been 
 surpassed; his nine hundred and eight page.s, pro- 
 well-arransied nidex. We regard tliis as one of the [ fu«ely illustrated, are rich in physiological, patholo* 
 most valuable contributions to modern surgery. To gical. and operative suggestions, doctrines, details, 
 one entering his novitiate of practice, we re-jard it '■ and processes; and will prove a reliable resource 
 the most serviceable guide which he can consult. He ' for information, both lo physician and surgeon, in the 
 will find a tulnessof detail leadinghiin through every ' hour of peril.— JV. 0. Med. and Surg. Journal. 
 
 FLINT (AUSTIN), M. D., 
 
 Professor of the Theory and Practice of .Medicine in the University of I^nisville, &c. 
 
 PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT- 
 ING THE RESPIK.\TORY OKGANS. In one large and handsome octavo volume, extra 
 cloth, 63*3 pages. $3 00. 
 
 We reeard it, in point both of arrangement and of | A work of original observation of the highest merit, 
 the marked abilitv of its treatment of the subjects. We recommend the treatise to every one who wishes 
 as destined to take the first rank in works of this to become a correct auscultator. Based to a very 
 class So far as our information extends, it has at | large extent Hp(m cases numerically examined, it 
 present no equal. To the practitioner, as well as carries the evidence of careful study and discrimina- 
 the student, it will be invaluable in clearing up the tion ui.on every pau'e. It does credit to the author, 
 diagnosis of doiibtl'ul eases, and in shedding light and, through him, to the profession in this country, 
 upon difficult phenomena. — Buffalo Med. Journal. I It is, what we cnnnot call every book up(m auscui- 
 
 I tation, a readable book. — Am. Jour. Med. Sciences. 
 
 BY THE SAME AUTHOR. (Now Keatiy.) 
 
 A PRACTICAL TREATISE ON THE DIAGNOsis, PATHOLOGY, AND 
 
 TREATMENT OF DISEASES OF THE HEART. Li one neal octavo volume, of about 
 
 000 pages, extra cloth. §2 75. 
 
 We do no* know that Dr. Flint has written any- | diseases of the chest. We have adopted his work 
 thing which is not first rate; but this, his latest con- .upon the heart as a text-book, believing it to be 
 tribiition to medical literature, in our opinion, sur- more valu.ible I'or that purpose than »ny work of the 
 
 passes all the others. The work is most comprehen' 
 81 ve in Its pcope,and mcst sound in the views it enun- 
 ciatts. The descriptions are clear and methodical; 
 the slatemcnts are substantiated by facfs, and are 
 made with such simplicity and sincerity, that with- 
 out them they would carry conviction. The style jhe "nrost'varui.bie'prac'ticai work of it's kind!— iv" 6! 
 18 admirably clear, direct, and tree from dryness Med. Aews Nov. 1S59. 
 
 kind that has yet appeared. — Nashville Med.Journ., 
 Dec. lSo9. 
 
 With more than pleasure do Are hail the advent of 
 this work, for it fills a wide gap on the list i f text- 
 books for our schools, ami is, tor the practitioner, 
 
 With Dr. Walslie's excellent treatise before us, we 
 have no hesitation in saying that Dr. Flint's book is 
 the best work on the heart in the English language. 
 — Boston Mfd. and Surg. Journal, Dec. 15, l,~o9. 
 
 We have thus endeavored to present our readers 
 with a fair analysis of tins remarkable work. Pre 
 
 In regard to the merits of the work, we have no 
 hesitation in pronouncing it full, accurate, and ju- 
 dicious. Considering the pres-nt state of science, 
 such a work was much needed. It shniiM lie in the 
 hunils of every practitioner. — Chicago Med . Journal , 
 
 ferring toeinploy the very wordsofthedistinguished i -April, KhO. 
 aull'.or, wherever It was possible, we have essayed ' But these are very trivial spots, and in no wise 
 to condense into the briefest spaeea genenil view of ' prevent us from declaring our most hearty approval 
 Ins obscrviitlons and suggestions, and to direct the , of the author's ability, industry, and conscientious- 
 attention of our brethren to the abounding stores of \ nesi.— Di(blin Quarterly Journal of Med. Sciences, 
 valuable mutter hcrecollccted and arraiiged for their ' Feb. l?li(). 
 uaeand in-truetion. No medical library will here i He has labored on wi'h the same indu.'^try and care, 
 
 after be considered complete without this vcduine; 
 and we tnis' It will promptly find its way into the 
 hands nf every Amciican student and physician. — 
 iV. Am. Med. Chir. Review, Jan ISOO. 
 This last work of Prof. Flint will add much to 
 
 and his place among the /!r,<t authors of our country 
 is becoming fully esi.-ibliLhed. To I his end, the work 
 whose title is given above, coniributes in no small 
 degree. Our spa e will not admit of tn extended 
 analysis, and we will clogt this iirief no'ice by 
 
 his previous well-enrned celebrity, as a writer of ! commending it without reserve to every class of 
 great forccand beauty, and, with his previous work, 1 readers in the profession. — Peninsular Med. Journ., 
 places him at the head of American writers upon Feb. l!?CO. 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 15 
 
 FOWNES (GEORGE), PH. D., «tc. 
 A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. 
 
 From the seventh revi>eil and correcteii London edition. With one himdred and ninety-seven 
 
 illustrations. Edited !)v Robert Bridges, M. D. In one large royal 12mo. volnme, of (300 
 
 pages. In leather, $1 65; extra cloth, $1 50. {Jiixt Isaned.) 
 
 The death of the author liavnig; placed the editorial care of" this work in the practised hands ol 
 Drs. Bence Jones and A. \V. Hudrnan, everything ha< l)een done in its revision which experience 
 could suggest to keep it on a level with the rapid advance of chemical science. The additions 
 requisite to thi* purpose have Heces>ilated an enlargement of the page, notwithstanding which the 
 work has been increased by about fifty pages. At the same time every care has been used to 
 maintain its distinctive character as a condensed manual for the student, divested of all unnecessary 
 detail or mere theoretical speculation. The additions have, of course, been mainly in the depart- 
 ment of Organic Chemistry, which has made such rapid progress within the last few years, but 
 yet equal attention has been bestowed on the other branches of the subject — Chemical Physics and 
 inorganic Chemistry — to present all investigations and discoveries of importance, and to keep up 
 the reputation of the volume as a complete manual of the whole science, admirably adapted for the 
 learner. By the use of a small but exceedingly clear type the matter of a large octavo is compressed 
 within the convenient and portable limits of a moderate sized duodecimo, and at the very low price 
 affixed. It is otVered as one of the cheapest volumes before the profession. 
 
 Dr. Fownrs' excellent work lias lieen universally 
 recopnized everywhere in Ills own and this country, 
 as the best elemenlHry treatise on chemistry in the 
 
 English tongue, and is very generiillv ailnptcd, we 
 believe, as the standard text book in all < urcolk'ses, 
 both literary nnd Ecientific. — Charleston Med Journ. 
 anc Itvieic, i*ept. 1859. 
 
 A standard m.inual, which has long enjoyed the 
 reputatimi of emtiodying much knowlediroin a small 
 space. The author hasachieved the diflicult task of 
 eondensation with masterly taot. His hook is con- 
 cise without being dry, and brief without being too 
 dogmatical or general. — Virginia Med. and Surgical 
 Journal. 
 
 The work of Ur. Fownes has long been before 
 the public, and its merits have been I'uUy appreci- 
 ated as the best text-book on chemistry now in 
 existence. We do not, of course, place it in a rank 
 superior to the ,,-orks of Brande, Graham, Turner, 
 Gregory, or Gmelin, but we say that, as a work 
 for stuclents, it is preferable to any of them. — Lon- 
 don Journal of Medicine. 
 
 A work well adapted to the wants of the student 
 It is an excellent exposition of the chief cloctrines 
 and factsof modernchemistry. The size of the work, 
 and still more the condensed yet perspicuous style 
 in which it is written, absolve it from the charges 
 very properly ur^ed against most manuals termed 
 popular. — Edinburgh Journal of Medical Science. 
 
 FISKE FUND PRIZE ESSAYS —THE EF- 
 FECTS OF CLI.MATE ON TaiJERCULOUS 
 DISEASE. I!v EnwiN Lee, M. R. C S , London, 
 and THK INFIATENCE OF PREGNANCY ON I 
 THE DEVELOl'MEIMT OF TUBERCLES By 
 
 Edward Wabken, M. D , of Edent.on, N. C. To- 
 srether in one neat 8vo vnlume, extra cloth. SI 00. 
 FRICK ON RENAL AFFECTIONS; their Diag- 
 nosis and Pathology. With illustrations. One 
 volume, royal ISmo., extra cloth. 75 cents 
 
 FERGUSSON (WILLIAM), F. R. S., 
 
 Professor of Surgery in Kind's Collea;e, London, &c. 
 
 A SYSTEM OP PRACTICAL StlRaERY. Fourth American, from the third 
 
 and enlarged London edition. In one large and beautifully printed octavo volume, of about 700 
 pages, with 393 handsome illustrations, leather. $3 00. 
 
 GRAHAM (THOMAS), F. R. S. 
 THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applica- 
 
 lions of the Science in the Arts. New and much enlarged edition, by He.nry Watts and Robert 
 Bridgks, M. D. Complete in one large and handsome octavo voliime, of over SOO very large 
 pages, with two hundred and thirty-two wood-cuts, extra cloth. $4 00. 
 ^t*i^ Part II., completing the work from p. 431 to end, with Index, Title Matter, &c., may be 
 
 had separate, cloth backs and paper sides. Price $2 50. 
 
 From Prof. E. N. Horsford, Harvard College. \ afford to be without this edition of Prof. Graham's 
 It has, in its earlier and less perfect editions, been Kleincnts.— Si/r/wian's /ottrnoZ, March, 1859. 
 
 familiar to me, and the excellence of its plan and p^„,„ p^„^ ^^^j g;^^ ^ y. Free Academy. 
 
 the clearness and completeness of its discussions, ™, " » 
 
 have long been my admiration. . The work is an admirable one in all respects, and 
 
 its republication here cannot fiil to exert a positive 
 No reader of English works on this science can influence upon theprogressof science in thiscountry. 
 
 GRIFFITH (ROBERT E.), M. D., &c. 
 A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- 
 ministering Ollicinal and other Medicines. The whole adapted to Physicians and Pharmaceu. 
 lists. Seco.nd Edition, thoroughly revised, with numerous additions', by Robert P. Tho.mas, 
 M. D., Profe>sor of Materia .Medica in the Philadelphia College of Pharmacy. In one large and 
 handsome octavo volume, extra cloth, of er^O pages, double columns. S3 00; or in sheep, $3 25. 
 It was a work requiring much per.severaiice, and This is a work of six hundred and fifty-one pages 
 
 when published wa.« looked upon as by far the best 
 work of its kind that had issued from the American 
 pres.s. Prof Tlioma= has certainly "improved." as 
 well as added lolliis Formulary, and has rendered ii 
 additionally deserving of the confidence of pharma- 
 ceutists and physicians. — Am. Journal of Pharmacy. 
 We are happy to announce a new and improved 
 edition of this, one of the most valuable and useful 
 works that have e-naiiated from an American pen. 
 
 embracing all on the su!>jeci of preparing and admi- 
 iilslerine medicines that can he desired by the physi- 
 cian ana pharmaceutist. — Wesiern Lancet. 
 
 The amouiilof useful, every-day mauer.for a prac- 
 ticiiie; physician, is really immense.— £ox/on Med. 
 and Surg. Journal. 
 
 This edition has been etreatU improved by the re- 
 vision and ample a<ldnioiis of Dr Thomas, and is 
 now, we believe, one of the mosi complete works 
 
 It would do credit to any country, and will he found "f"' wi.wi , Vn,: i„n„ YL ^\ .u. .,mc,c wur»» 
 „f H„ilv „.,,-„l,„... ,„ nr,.e.;Mnnnr« „,■ m..,ll,.;„e. ,. „ "' '." '"'"' '" ""> 'inguage. The additions amount 
 
 of daily u-efuliiess to practitioners of medicine; it is 
 
 to about seventy pairc«, and nc effort ha-; been spared 
 
 euer adapted lo iheir purposes hai, ihe dispensaio- . ,„ i,,^.,,,,,^ j,, ,^Vm all the recent improvemen 
 
 Ties. — Southern Mtd. and Surg. Journal. 
 
 work of this kind appears to u« indispensable to the 
 
 Itis one of the most useful books a country practl- 1 physician, and ihere is none we can more cordially 
 ioner can possibly have.— Jtferfi'cni CAro/iic.'*. ' recommend.— iV. Y. Journal of Medicine. ^ 
 
 recommend.— iV. Y. Journal of Medicine. 
 
Iti BLANCHARD & LEA'S MEDICAL 
 
 GROSS (SAMUEL D.), M. D., 
 Professor of Surgery lu the Jeircrson Medical College of Philadelphia, &c. 
 Just Issued. 
 A SYSTEM OF SURGERY : Pathological, Diagnostic, Therapeutic, and Opera- 
 tive. Illusiraled by Nine HuNnuED and Thirtv-six Engravings. In two larg-e and beautifully 
 • printed octavo volume-, of aearl J' twenty-four hundred pages; strongly bound in leather, with 
 rai»ed bands. I'rice $12. 
 
 From the Author's Preface. 
 
 " The object of this work is to furnish a syslematic and comprehensive treatise on the science and 
 practice of siirpery, considered in the broadest sense; one that shall serve the practitioner as a 
 faithful and availiibie guide in his daily routine of duty. It has been too much the custom of mod- 
 ern writers on this department o( the healing art to omit certain topics altogether, and to speak ol 
 others at undue length, evidently assuming that their readers could readily supply the deficiencies 
 Irom other sources, or that what has been thus slighted is of no particular practical value. My aim 
 has been to eml)race the whole domain of surgery, and to allot to every subject its legitimate claim 
 to notice in the great family of external diseases and accidents. How far this object has been accom- 
 plished, it is not for me to determine. It may safely be utiirmed, however, that there is no topic, 
 properly appertaining to surgery, that will not be found to be discussed, to a greater or less extent, 
 in these volmnes. If n larger space than is customary has been devoted to the consideration of 
 mllammalion and its results, or the great princijiles of surgery, it is because of the conviction, 
 grountled upon long and close observation, that there are no subjects so little understood by the 
 general practitioner. Special attention has also been bestowed upon the discrimination of diseases; 
 and an elaborate chapter has been introduced on general diagnosis." 
 
 That these intentions have been carried out in the fullest and most elaborate manner is sufficiently 
 shown by the great extent of the work, and the length of time during which the author has been 
 concentrating on the task his studies and his experience, guided by the knowledge which twenty 
 years of lecturing on surgical topics have given him of the wants of the profession. 
 
 Of Dr. GroBs's treatise on Surgery we can say 1 At present, however, our object is not to review 
 no more than that it is the most elaborate and com- the work (this we purpose doing hereafter), but 
 pletf work on this branch of the I.eiiliiig art which simply to announce its appearance, that m the 
 has ever been published in any country. A sys- j meantime our readers may procure aud examine it 
 tcmatic work, it admits of no analytical review; i for themselves. But even this much we cannot do 
 but, did our space pi-riiut, we should gladly give j without expressing the opinion tliat, in putting forth 
 gome extracts from it, to enable our readers to judge thpse two volumes. Dr. Gross has reared for hira- 
 of the c'assiciil style of the author, and the exhaust- I self a lasting monument to his skill as a surgeon, 
 ing way in which each subject is trented. — Dublin ' and to his industry and learning as an author. — St. 
 Quarterly Journal of Med. Science, Nov. 1859. I Louis Med. and Surg. Journal, Nov. 1S59. 
 
 The work is so superior to its predecessors in j "With pleasure we record the completion of this 
 matter and extent, as well as in illustrations and long-anticipated work. The reputation which the 
 style of publication, that we can honestly recom- autlior has for mauv vears sustained, both as a sur- 
 mend It as the best work of the kind to be taken | pe„n „nj „g ^ writerj had prepared us to expect a 
 home by the young practitioner.—^;/!. Med. Joum., | treatise of great excellence aud originality; but we 
 Jan. ISCO. confess we were by no means prepared tor the work 
 
 The treatise of Prof. Gross is not, therefore, a I which is before us — the most complete treatiseupon 
 mere te.xl-liook for undergraduates, but a systema- surgery ever published, either in this or any othtr 
 tic record of more than thirty years' experience, I country, and we might, perhaps, safely say, the 
 reading, and retlection by a man of observation, ! most original. There is no subject belonging pro- 
 sound judgment, and lare practical tact, and as such j perly to surgery which has not received from the 
 deserves to take rank with the renowned produc- I authoia due share of attention. Dr. Grots has sup- 
 lions of a similar character, by Vidal and Boycr, of [ plied a want in surgical literature which has long 
 France, or those of Ohelius, Blasius, and Langen- been felt by practitioners; he has furnished us with 
 been, of (jerinany. Hence, we do not hesitate to a complete practical treatise upon sargery in all its 
 
 departments. As .■Xmericins, we are proud of the 
 achievement; as surgeons, we are most sincerely 
 thankful to him for his extraord narv labors in our 
 behalf— iV. Y. Monthly Review and Buffalo Med. 
 Journal, Oct. 1S50. 
 
 express the opinion that it will speedily take the 
 same elev:ited position in regard to surgery that has 
 been given by common consent to the masterly work 
 of Pereira in Materia Medica, or to Todd and Bow- 
 man in Physiology. — y. O. Med.amd Swg. Journal, 
 Jan. IbGO. | 
 
 BY THE SAMS AUTHOR. 
 
 ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, thoroughly 
 
 revi>ed mid greatly improved. In one large and very handsome octavo volume, with about three 
 hundred and lif'ty U-autiful illustrations, of which a large numlier are from original drawings. 
 I'rice in extra cloth, $J 75; leather, rai-sed bands, S!i 25. (Lately Piihli.^lied.) 
 The very rapid advances in the Science of Pathological Anatomy during the last few years have 
 rendered essential a thorough modification of this work, with a view of making it a correct expo- 
 nent of the present state of the subject. The very careful manner in which this task has been 
 executed, and the aiuount of alteration which it has undergone, have enabled the author to say thai 
 " wilh the iiiniiy changes and iiTiprovements now introduced, the work may be regarded almost as 
 a new treatise," while the etiorts of the atithor have l)een seconded as regards the mechanical 
 execution of the volume, rendering it one of the handsomest productions o( the American press. 
 
 We most sincerely congratulate the author on the , We have been favorably impressed with the gene- 
 ■uccessfiil manner in w.'iich he has accomplished his ' ral manner in which Dr. Gross has executed his task 
 propnied object. His book is most admirably cal- , of affording a comprehensive digest of the present 
 Rulatrd to fill up a blank which has long been fi;lt to [ state of the literature of Pathological Anatomy , and 
 exist in IliiH drp.-irtment of medical literature, and have much pleasure in recommending his work to 
 as such must become very widely circulatetl amongst our readers, as we believe one well deserving of 
 all clnHsrR of the profession. — Dublin <^iiar«er/y , diligent perusal and careful study. — Montreal Med. 
 Joum. of Med. Science, Nov. 1857. j Ckron., Sept. 1657. 
 
 BY THK SAMK AUTHOR. 
 
 A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PAS- 
 
 SAGE^. Ill one handsome octavo volume, extra cloth, with illustrations, pp. 4t)8. $2 75. 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 17 
 
 GROSS (SAMUEL D.), M. D., 
 Professor of Surgery in the Jefferson Medical College of Philadelpliia, &c. 
 
 A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND 
 
 MALFORMATIONS OF THE UKINAKY BLADDER, THE PROSTATE GLAND, AND 
 THE URETHRA. Second Edition, revised and much enlarg-ed, with one hundred and eighty- 
 four illustrations. In one large and very handsome octavo volume, of over nine hundred pages. 
 In leather, raised bands, $5 25; extra cloth, $4 75. 
 
 Philos'ipliio.Tl in its design, metlKidiciil in its ar- i agree with us, that there is no work in the English 
 rangement, simple and sound in its practical details, language which can make any just pretensions to 
 it may in truth he said to leave scarcely anything to be its equal. — N. Y. Journal of Medicine . 
 be desired on so important a subject.— Uosron Med. . a volume replete with truths and principles of the 
 
 utmost value in the investigation of these diseases. - 
 
 and SuTg Journal. 
 
 Whoever will peruse the vast amount of valuable 
 practical intormation it contains, will, we think, 
 
 American MedicalJoumal . 
 
 GRAY (HENRY), F. R. S., 
 
 Lecturer on Anatomy at St. George's Hospital, London, &c. 
 
 ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. 
 
 Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital ; the Dissections jointly 
 by the Author and Dr. Carter. In one magnificent imperial octavo volume, of nearly 800 
 pages, with 363 large and elaborate engravings on wood. Price in extra cloth, $6 25; leather 
 raised bands, $7 00. (Just Issued.) 
 
 The author has endeavored m this work to cover a more extended range of subjects than is 
 customary in the ordinary text-books, by giving not only the details necessary for the student, but 
 also the application of those details in the practice of medicine and surgery, thus rendering it both 
 a guide for the learner, and an admirable work of reference (or the active practitioner. The 
 ejigravings form a special feature in the work, many of them being the size of nature, nearly all 
 original, and having the names of the various purls printed on the body of the cut, in place of figures 
 of reference with descriptions at the foot. They thus form a complete and splendid series, which 
 will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to refresh 
 the memory of those who may find in the exigencies of practice the necessity of recalling the details 
 of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, with a thorough 
 treatise on systematic, descriptive, and applied Anatomy, the work will be found of essential use 
 to all physicians who receive students in their offices, relieving both preceptor and pupil of much 
 labor in laying the groundwork of a thorough medical education. 
 
 The work before us is one entitled to the highest 1 to exist in this country. Mr. Gray writes through- 
 praise, and we accordingly \veleome it as a valu- : out with both branches of his subject in view. His 
 able addition to medical literature. Intermediate ^ description of each particular part is followed by a 
 in fulness of detail between the treatises of S lar : notice of its relations to tie parts with which it is 
 pey and of Wilson, its characteristic merit lies in i connected, and this, too, sufficiently ample for all 
 the number and excellence of the engravings it | the purposes of the 0|>erative surgeon. After de- 
 contains. Most of these are original, of much j scribing tlie bones and muscles, he gives a concise 
 larger than ordinary size, and admirably executed, statement of the fractures to which the bones of 
 The various parts are also lettered after the plan the extremities are most liable, together with the 
 adopted in Holden's Osteology. It would be uiffi- amount and direction of the displacement to which 
 cult to over-estimate the advantages offered by this the fragments are subjected by muscular action, 
 mode of piciorial illusiratiun. Bones, ligaments. The section on arteries is remarkably full and ac- 
 muscles, bloodvessels, and nerves are each in turn , curate. Not only is the surgical anatomy given to 
 figured, and marked with their appropriate names; evjry important vessel, with directions for its liga- 
 thus enabling the student to c( mpreliend,ata glance, tion, but at the end of the description of each arte- 
 what would otherwise often be ignored, or at any rial trunk we have a useful summary of the irregu- 
 rate, acquired only by prolonged and irksome ap- larities which may occur in its origin, course, and 
 plication. In conclusion, we heartily commend the termination. — N. A. Med. Chir. Review, Mar. 1559. 
 work of Mr. Gray to the attention of the medical 
 
 profession, iVeling certain tliat it should be regarded 
 as one of the most valuable contributions ever made 
 to educational literature. — A'. Y. Monthly Review. 
 Dec. 1859. 
 
 In this view, we regard the work of Mr. Gray as 
 far better adapted to the wants of the professiim, 
 and especially of the student, than any treatise on 
 anatomy yet published in this country. It is destined. 
 we believe, to supersede \\[ others, both as a manual 
 of dissections, and a standard of reference to the 
 student of general or relative anatomy. — N. Y. 
 Journal of Medicine, Nov. 1859. 
 
 This is by all comparison the most excellent work 
 on Anatomy extnnt. It is just the thin^ that has 
 bc«n long desired by the profession. With such a 
 euide as this, the student of anatomy, the practi- 
 tioner of medicine, and the surgical devotee have 
 all a newer, deirer, and more radiant light thrown 
 npon the intricacies and mysteries of this wonder- 
 ful tcience, and are thus enabled to accomplisli re- 
 sults which hitherto seemed poscible only to the 
 ■pecialist. The plates, which are copied Crom re- 
 
 Mr. Gray's book, in excellency of arrangement 
 and comnleteness of execution, e.xcteds any work 
 on anatomy hitherto published in the English lan- 
 guage, affording a complete view of the structure of 
 the tiuman body, with especial reference to practical 
 surgery. Thusthe volume constitutesa perfectbook 
 of reference for the practitioner, dem.inding a place 
 in even the most limited library of the physician or 
 surgeon, and a work of nee ssity for the student to 
 fix in his mind what he has learneil by the dissecting 
 knife from the book of nature. — The Dublin Quar- 
 terly Journal of Med. Sciences, Nov. 1858. 
 
 In our judgment, the mode of illustration adopted 
 in the present volume cannot but present many ad- 
 vantages to the studentof anatomy. To the zealous 
 disciple of Vesalius, eiirnestly desirous of real im- 
 provement, the book will certainly be of immense 
 value; but, at the same time, we must also confess 
 that to those simply desirous of "cramming" it 
 will be an undoubted eodsend. The peculiar value 
 of Mr. Gray's mode of illustration is nowhere more 
 markedly evident than in the chapter on osteology, 
 and especially in those portions which treat of the 
 
 cent dissections, are so well executed, that the most bones of the head and of th-ir development. The 
 superficial observer cannot fail to perceive the posi gt^jy „f j|,pgg p.^^jg jg t,,ug „„^,|g „„g „f comparative 
 
 ense, if notof positive pleasure : and those bugbears 
 
 tions, relations, and distinctive features of the vari- 
 ous parts, and to tnkf in more of anatomy at a glance, 
 than by many long hours of diligent study over the 
 most erudite treatise, or, perhaps, at the dissecting 
 table itself. — Med.Journ. of N. Carolina, Oct. 1^59. 
 For thi.s truly admirable work the profession is 
 indebted to the distinguished author of "Gray on 
 the Spleen." The vacancy it fills has been long felt 
 
 if the student, the leinjioral and sphenoid bones, are 
 shorn of half their terrors. It is, in our estimation, 
 an admirable and complete text-book for the student, 
 and a useful work of reference for the practitioner; 
 its pictorial character forming a novel element, to 
 which we have already sufficiently alluded. — Am. 
 Journ. Med. Sci., July, 1859. 
 
18 
 
 BLANUHAKD & LEA'S MEDICAL 
 
 GIBSO.V'S INSTITL'TKS AND PRACTICE OF i 
 8URGKUV. Eirhih rditifin, improveil niid hI- 
 tertd. With thirty-four platrs. In two handsome 
 (Hrtavo volumti, containtnir iibuut 1,000 pages, 
 leather, raised band 1. SO SO. 
 
 GARDNKR'S MKUICAL CHKMISTRY, for the 
 use of (Students and the Profi'Rsion. In one royal 
 I2ino. vol., clotli, pp. :J90, with woodcuts. 91. 
 
 UI.fUE'S ATL.\.S or PATHOi.OGICAL HIS- 
 TOLOGY. Trar.8lutid, wilh Notes and Addi- 
 
 tions, by Joseph Leidy, M. D. In one volume, 
 very lar^e imperial quarto, extra cloih, wi'i320 
 cupper- plate hgures, plain and eolorcd, S5 00. 
 
 HUGHES' INTRODUCTION TO THE PRAC- 
 TICE OP AUSCL'LTAI'ION A.M/ OTHER 
 .MODE!* OF PHYSICAL DIAGNOSIS IN DIS- 
 EASES OF THE LUNGS AND HEART. Se- 
 cond edition 1 vol. royal lamo., ex. cloth, pp. 
 304. 81 00. 
 
 HAMILTON (FRANK H.), M. D., 
 
 ProiVggor of Surpcry in the Uaivergity of BulTalo, &c. 
 
 A PRACTICAL TREATISE ON FRACTURES AND DISLOCATIONS. 
 
 In 
 
 one lurjre and hQiidsome ocluvo volume, of over 700 pages, with 289 illuslralioiisi. SI 25. (Nou> 
 
 litady, January, ISOO.) 
 
 This is n valuable contribution to the surgery of ' illustrated, which will be a desideratum for those 
 most important atTectitms.and is the more welcome, practitioners who cannot conveniently see the mo- 
 inasmuch as at tlie prcstnt time we do not pi>8gcs» dels applied. — A'em Yorlt Med. Press, Feb 4, 1860. 
 a siHRle complete treatue on Fraciurcs and Dislo- ^y^ rccard this work as an honor not <mly to its 
 cations in the Knijlish lanftua?e. It has remained for „uthor, but to the profession of our country. Were 
 our Amen.an brother to produce a complete treatise ^.g t„ review it thoroushlv, we could not convey to 
 upon the subject, and bring together in a convenient t,,^ „,ind „f ,,,e reader more forcibly our hontst 
 form those alterations and improvements that have opinion expressed in the few word..— we think it the 
 been made from time to time in the treatment of these ^^81 1 k ol its kind extant. Every man interested 
 
 affections. One great and valuable feature in the 
 work before us is the fact that it comprises all the 
 improvemen's introduced into the practice of both 
 ICo^lishand American surgery, and though far from 
 omitting mention of our continental neijjhborR, the 
 author by no means tncourages the notion — but too 
 prevalent in some quarters— that nothing is pood 
 unless imported from France or Germany. Tlie 
 latter half of the work is devoted to the considera- 
 tion of the various dislocations and their appropri- 
 
 in surgery will soon have this work on his desk. 
 He who does not, will be the loser. — Ntw Orleam 
 Medical l\'ews, March, 1660. 
 
 Now that it is before us, we feel bound tosay that 
 much as was expected from it. and onerous as was 
 tlie undertaking, it has surpassed expcctalbm, and 
 achieved more than was pledged in its behalf; for 
 its title does not express in full the rirhress of its 
 contents. On the whole, we are prouder of this 
 
 ate treatment, and its merit is fully equal to that of Y^"'"'' ,"'''" "'" ""y which has for years emanated 
 
 the preceding portion.— TAe London Lanett, May 5, ''^""? ".'^ American medical press; its sale will cer- 
 
 IgflO. ) .- I tainly be very large in this country, and we antiei- 
 
 ,.'. ,.•!.,,, . ,. , pate Its eliciting much attention in Europe. — Nash- 
 
 It IS emphatically the book upon the subjects of ^m^ Medical Record, Mar. l&OO. 
 
 which It treats, and we cannot doubt that it will „ ,,,,,, 
 
 cmtinue s>i to be for an indefinite period of time Every surgeon, young and old, should possess 
 
 When we say. however, that we believe it will at bimtelf of it, and give it a careful perusal, in d<iing 
 
 oncetakeilsplaceas the best book f<ir consultation ^v''""" ''«= W' ^•^ richly repaid.— S«. Louis Med. 
 
 by the practitioner; and that it will form the most "'"' ^"^S- Journal, March, ISGO. 
 
 complete, available, and reliable guide in emergen- Dr. Hamilton is fortunate in having succeeded in 
 
 ciesof every nature connected witli its subjects; and filling the void, so long felt, with wiiat cannot fail 
 
 also that thestu<lentof surgery may imike it his text- to be at once accepted as a model monograph in some 
 
 book wi:h entire confidence, and with pleasure also, respects, and a work of classicil authority. We 
 
 from Its agreeible and easy style — we think our own sincerely congratulate the profession of the United 
 
 opinion innv be gathered as to its value. — Boston Stales on the appearance of such a publication from 
 
 Medical and Surgical Journal, March 1, 1860. one of their number. We have reason to be proud 
 
 The work is concise, judicious, and accurate, and "f 'f "" «" original work, both in a literary and sei- 
 
 adapted to the wants of the student, practitimer, entific point of view, and to esteem it as a valuable 
 
 and investigator, lumoruble to the author and to the Pi'ide in a most ditlicult and important branch of 
 
 profession.— CAicn^o i»f«rf.Journai, March, 1800. study and practice. On every account, therefore, 
 
 we hope that it may soon be widely known abroad 
 
 We venture to say that this is not alone the cmly as an evidence of genuine prcgress on this side of 
 
 complete treatise on the subject in the language, the Atlantic, and further, that it may be still more 
 
 but the best and mout practical we have ever read! widely known at home as an authoritative teacher 
 
 The arrniigenient is simple and syslematic, the die- from which every one may profitably learn, and as 
 
 tion clear anil graphic, and the illustrations nume- airi>rding an example of honest, well-directed, and 
 
 rous and remarkable fur accuracy of delineutitm. uttiring industry in authorship which every surgeon 
 
 The various mechanical appliances are faithfully may en.ulate.- Am. Med. Journal, April, 1860. 
 
 HOBLYN (RICHARD D.), M. D. 
 A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE 
 
 COLL.ATliKAL SCIENCES. A new American edition. Revised, with numerous Additions, 
 
 by Isaac Hays, M. D., editor of the " Aniencnii Jotinial olthe Medical Sciences." In one large 
 
 royul r.im<). volume, leather, of over OOO double columned pages. $1 SO. 
 
 To both practitioner and stu<lentj we recommend use ; embracing every department of medical science 
 
 this dictionary as being convenient in size, accurate ' down to the very latest date.— ITt.Wf rn Lancet. 
 
 !,"rdinnr"v'.c';n:.'.'l'I!!,'""'"''r*"^''"" ""l' j-""'P''-'« ^''^ Hoblyn's Dictionarv has long been a favorite With 
 ordinar) c,m,u\taUon.-Charleston Med. Joum. „, n>,g „,p ,,^^, ,,„„k „( jeffnitions we have, and 
 
 We know of no dictionary belter arranged and ought always to be upon the student's table. — 
 •itapted. Itisnotincumbered with the obsoleteterms i Southtm Med. and Surg. Journal. 
 of a bygone age, but it contains all that are now in ■ 
 
 HOLLAND'S MEDICAL NOTES AND RE- 
 FLECTIONS. From the Ihitd L.mdon edition. 
 Id o6c handsome ocluvo volume, extra clo'.h. S:5. 
 
 HORNER'S SPECIAL ANATOMY AND HIS- 
 
 TOLOGY. Eighth edition. Extensivly revised 
 and moditied. In two large octavo volc.mes, ex- 
 tra cloth, of more than 1000 pages, with over 300 
 illustratiuna. S6 00. 
 
 HABERSHON (S. O.), M. D., 
 
 Assistant Physician to and Lecturer on .Materia .Mediea and Tlier;i|ieutics at Guy 's Hospital, 4c. 
 
 PATHOLOGICAL AND PRACTICAL (HiSEUVATlONS ON DISEASES 
 OF THE ALLMENTAHY CANAL, CESOPIIAGUS, STOMACH, C^CIJM. AND INTES- 
 TINES. With illuslrniions on Wood. In one handsome octavo volume of 312 pages, extra 
 cloth $\ 75. (A'otr Heady.) 
 
AND SCIENTIFIC PUBLICATIONS. 19 
 
 HODGE (HUGH L.), M.D., 
 Professor of Mid%vifery and the Diseases of Women and Children in the University of Pennsylvania, &c. 
 
 ON I)IS1':ASES peculiar to women, includintr Displacements of the 
 
 Uterus. AVith orig'inal illustrations. In one beautifully printed octavo volume, of nearly 500 
 pages. {Now ReaUy.) 
 
 The profession will look with much interest on a volume embodying the long and extensive ex- 
 perience of Professor Hodge on an important branch of practice in which his opporinnilies for 
 investigation have been so extensive. A short summary of the contents will show liie scope of 
 the Work, and the manner in which the subject is presented. It will be seen that, with the excej)- 
 tion of Displacements of the Uterus, he divides the Diseases peculiar to Women into iwo great 
 conslilutionai classes — those arising from irritation, and those arising from sedation. 
 
 CONTENTS. 
 
 PART I. Diseases of Ikritation. — Chapter I. Nervous Irritation, and its Consequences — H. 
 Irritable Uterus. — III. Local Symptoms of Irritable Uterus: Menorrhagia and Hsemorrhi-^ia; 
 Leucorrho?a ; Dysnienorrhira — IV. Local Symptoms of Irritable Uterus; Complications. — V. 
 General Symptoms of Irritable Uterus : Ccrebro-spniil Irritations. — VI. General Symptoms (if 
 Irritable Uierus. — VII. Progress and Kesulis of Irritable Uterus. — VIII. Cau.>^es and Pathology 
 of Irriiable Diseases — IX. Treatment of Irritable Uterus; Removal or Palliation of the Cause. 
 — X. Treatment of Irritable Uterus: To Diminish or Destroy the Morbid Irritability — XI. 
 Treatment of the Complications of Irritable Uterus. — XII. Treatment of the Complications of 
 Irritable Uterus. 
 
 PART II. Dispr.ACEMENTS OF THE Uteri:s. — Chapter I. Natural Position and Supports of the 
 Uterus. — II. Varieties of Displacements of the Uterus, and their Causes. — III. Symptoms of 
 Displacements of the Uterus. — IV. Treatment of Displacements of the Uterus. — V. Treatment 
 of Displacements; Internal Supports. — VI. Treatment of Ditplacements ; Lever Pessaries — 
 VII. Treatment of the Varieties of Displacements. — VIII. Treatment of Complications of Dis- 
 placements of the Uterus. — IX. Treatment of Enlargements and Displacements of the Ovaries, &c. 
 
 PART III. Diseases of Sedation. — Chapter I. Sedation and its Consequences: Organic and 
 Nervous Sedation; Passive Congestion; Reaction; Treatment — II. Sedation of the Uterus; 
 Amenorrhipa: Sedation of the Uterus from Moral Causes; Sedation of the Uterus from Physical 
 Causes. — II [. Diagnosis and Treatment of Sedation of the Uterus. 
 The illustrations, which are all original, are drawn to a uniform scale of one-half the natural size. 
 
 JONES (T. WHARTON), F. R. S,, 
 
 Professor of Ophthalmic Medicine and Surgery in University College, London, &c. 
 
 THE PRINCIPLES iVND PRACTICE OF OPHTHALMIC MEDICINE 
 
 AND SURGERV. With one hundred and ten illustrations. Second American from the second 
 and revised London edition, with additions b/ Edward Hartshor.n'e, M. D., Surgeon to Wills' 
 Hospital, &:c. In one large, handsome royal 12mo. volume, extra cloth, of SOU pages. $1 50. 
 
 JONES (C. HAND FIELD), F. R. S., & EDWARD H. SIEVEKING, M.D., 
 
 Assistant Physicians and Lecturers in St. .Mary's Hospital, London. 
 
 A MANUAL OF PATHOLOGICAL ANATOMY. First American Edition, 
 
 Revised. With three hundred and ninety-seven handsome wood engravings. In one large and 
 beautiful octavo volume of nearly 750 pages, leather. S3 75. 
 
 Aa a concise text-book, containing, in a condensed obliged to glean from a great number of monographs, 
 form, a complete outline of what is Itnown in the and the field was so extensive that but few cultivated 
 domain of Pathological Anatomy, it is perhaps the it with any dejrree of success. As a simple work 
 best work in the Knglish language. Its great merit of reference, therefore, it is of great value to the 
 consists in its completeness and brevity, and in this student of patholo|;ical anatomy, and should be in 
 respect it supplies a great desideratum in our lite- , every physician's library. — Western Lancet. 
 rature. Heretofore the student of pathology was 1 
 
 KIRKES (WILLIAM SENHOUSE), M. D., 
 
 Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, A-c. 
 
 A MANUAL OF PHYSIOLOGY. A new American, from the third and 
 
 improved London edition. With two hundred illustrations. In one large and handsome royal 
 r2mo. volume, leather, pp. 586. $2 GO. {Lately Published.) 
 
 This is a new and very much improved edition of ' One of the very best handbooks of Phy8i<dogy we 
 Dr. Kirkes' well-knnwn Handbook of Physiology, possess — presenting just such an outline of the sci- 
 It combines conciseness witli completeness, and is, ence as the student require? during his attendance 
 therefore, admirably adapted for consultation by the upon a course of lectures, or for reference whilst 
 busy prartiiioner. — Dublin Quarterty Journal. preparing for examination— yl/7i. Medical Journal. 
 
 Its excfllence is in its compactness, its clearness, For the student beginning this study, and the 
 and its caretully cited authorities. It is the most practitioner w^ho has but leisure to refresh his 
 convenient of text-books. These gentlemen, Messrs. memory, this book is invaluable, as it ctrntains all 
 Kirkes and Paget, have really an immense talent for that it is important to kn'>w, without special details, 
 silence, wliieli isnot so common or so clieapas prat- ! which are read with interest only by those who 
 ^in^ people fancy. They have the gift of telling us \ would make a specialty, or desire to possess a criti- 
 what we want to know, without thinking it neces- cal knowledge of the subject. — Ckarleston Med. 
 sary to tell us all they know. — Boston Med. and j Journal. 
 Surg. Journal. I 
 
20 
 
 BLANCHARD & LEA'S MEDICAL 
 
 LAVCOOK'S LKCTCRKS ON THE PRINCI- 
 PLES AND METHODS OF MEDICAL OB- 
 SERVATION AND RESEARCH. For the Use 
 of Advanced Students and Junior Pniotitionerg. 
 In one royal Vimo. volume, extra cloth. Price $1. 
 
 KNAPP'S TECHNOI-OGY ; or, Chemistry applied 
 to the Arts and to Manufactures. Edited hy Dr. 
 Ro.NAi.Dn, Dr. RiciiAKbsoN, and Prof. \\ . R. 
 JoHNso.N. In two hundsomr tivo. vols., with about 
 SOU wood' engravings. gO 00. 
 
 LALLEMAND AND WILSON. 
 A PRACTICAL TREATISE ON THE CAUSES, SYMPTOMS, AND 
 
 TREATMRNT OF SPEKMATORRHCEA. By M. Lalle.mand. Tran.Maled and edited by 
 
 11eni!Y.I M(l)orf;Ar.L. Third American fdition. To which is added ON DISEASES 
 
 OF THE VESiCTL/E SEMINALES; and their associated organs. With special refer- 
 ence to the Morbid Secretions of the Prostatic and Urethral Mucous Membrane. By Harris 
 Wilson, M.D. In one neat octavo volume, of about 400 pp., extra cloth. $2 00. (Just Issued.) 
 
 LA ROCHE (R.), M. D., &c. 
 YELLOW FEVER, considered in its Historical, Pathological, Etiological, and 
 
 Theru|)eutical Relations. Including a Skeldi of tiie Disease as it iias occurred in Philadelphia 
 from I'iWto IS/j-l, with an examination of the connections between it and the fevers known under 
 the same name in other parts of temperate as well as in tropical regions. la two large and 
 handsome octavo volumes of nearly l-OOO pages, extra cloth. $7 00. 
 
 nunt and unmana'jeable disease of modern times, 
 has for several years been prevailing in our country 
 to a greater extent than ever before; that it is no 
 longer confined to either large or small cities, but 
 penetrates country villages, plantations, and farm- 
 houses; that it is treated with scarcely better suc- 
 cess now than thirty or forty years ago; that there 
 is vast mischief done by ignorant pretenders to know- 
 ledge in regard to the disease, and in vie w of the pro- 
 bability tliat a majority of southern physicians will 
 be called upon to treat the disease, we trust that this 
 able and comprehensive treatise will he very gene- 
 rally read in the south. — Memphis Med. Recorder. 
 
 From Professor S. II. Dickson, f'harleston, S. C, 
 
 Sfplember 18, 1K55. 
 A monument of intelligent and well applied re- 
 ■eareli, almost without example. It is, indeed, in 
 itself, a large library, and is destined to constitute 
 the special' resort as a book of reference, in the 
 lubjcct of which it treats, to all future time. 
 
 We have not time at present, engaged as we are, 
 by dai- and by night, in the work of combating this 
 very disease, now prevailing in our city, to do more 
 than give this cursory notice of what we consider 
 as undoubtedly the most able and erudite medical 
 publication our country has yet produced. But in 
 view of the startlinu; fact, that this, the most malig- I 
 
 BY THE SAME ATJ-^HOR. 
 
 PNEUMONIA ; its Supposed Connection, Pathological and Etiological, with Au- 
 tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one 
 handsome octavo volume, extra doth, of 500 pages. $3 00. 
 
 LUDLOW (J. L.), M. D. 
 A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, 
 
 Practice of Medicine, Ob.'^tetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To 
 which is added a Medical Formulary. Third edition, thorousjhly revised and greatly extended 
 and enlarged. With 370 illustrations. In one handsome royal 12mo. volume, leather, of 816 
 large pages, $2 00. 
 
 The (Treat popularity of this volume, and the numerous demands for it during the two years in which 
 It has been out o( print, have induced the author in its revision to spare no pains to render it a 
 correct and accurate digest of the most recent condition of all the branches of medical science. In 
 many resp«Tis it may. therefore, be regarded rather as a new book than a new edition, an entire 
 section on Physiology having been added, as also one on Organic Chemistry, and many portions 
 having I)een rcwritlen. A very complete series of illustrations has l>een introduced, and every 
 care has t>cen taken in the mechanical execution to render it a convenient and satisfuciory book for 
 study or reference. The arrangement of the volume in the form of (piestion and answer renders it 
 especially suited for the olfice examination of students and for those preparing for graduation. 
 
 We know of no better companion for the student I crnmmtd into his head by the various professors to 
 during the hours spent in the lecture room, or to re- whom he is compelled to listen. — WesUm Lancet, 
 fresh, at a glance, his memory of the various topics | May, 1857. 
 
 LEHMANN (C. G.) 
 PHYSIOLOGICAL CHEMISTRY. Translated from the second edition by 
 
 Georoe E. Day, M. D., F. R. S., >.Vc., edited by R. E. Rogers, M. D., Professor of Chemistry 
 in the Medical Department of the University of Pennsylvania, with illustrations selected from 
 Fiinke's Atlas of Physiological Chemistry, and an Ap|)en(lix of plates. Complete in two large 
 and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus- 
 trations. $t) 00. 
 
 The work of I.rhmann stands unrivalled as the 
 most coniprehenKi ve book of reference and informa- 
 tion extant on every branch of the subject on which 
 it ttcat*.— Edinburgh J oumnl of Medical Science. 
 
 The most important contribution as yet made to 
 Physiological Chemistry Am. Journal Med. Sci- 
 ences, Jan. 1S56. 
 
 BY THE SAME AUTHOR. (Tjiltfly Puhlishfd.) 
 
 MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, 
 
 with Notes and Additions, by J. Cheston Morris, M. D., with an liilrodticlory Essay on Vital 
 Force, by Professor Samiel Jackson, M. D., of the University o( Pennsylvania. With illus- 
 trations on wood. In one very handsome octavo volume, extra cloth, of 336 pages. $2 25. 
 
 Frctr. Pre/. Jaci'sou's Introductory Ex.^ny, 
 In adopting the handbook of Dr Lehnmnn as a manual of Organic Chemistry for the use of the 
 etudenls of the University, and in recommending his original work of Physiological Chemistry 
 for their more mature studies, the high value of his researches, and the great weight of his autho- 
 rity in that important department of medical science are fully recognized. 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 21 
 
 LAWRENCE (W.), F. R. S., Slc. 
 A TREATISE ON DISEASES OF THE EYE. A new edition, edited, 
 
 with numerous additions, and 243 illustrations, by Isaac Hays, M. U., Surgeon to Will's Hospi- 
 tal, &c. In one very lar^e and handsome octavo volume, of 950 pages, strongly bound in leather 
 with raised bands. $5 00. 
 
 MEIGS (CHARLES D.), M.D., 
 
 Professor of Obstetrips, &c. in the .leflTerBon Medical College, Philadelphia. 
 
 OBSTETRICS : THE SCIENCE AND THE ART. Third edition, revised 
 
 and improved. With one hundred and twenty-nine illustrations. In one beautifully printed octavo 
 
 volume, leather, of seven hundred and fifty-two large pages. $3 75. 
 
 The rapid demand for another edition of this work is a sutTicient expression of the favorable 
 verdict of the profession. In thus preparing it a third time lor the press, tne author has endeavored 
 to render it in every respect worthy of the favor which it has received. To accomplish this he 
 has thoroughly revised it in every part. Some portions have been rewritten, others added, new 
 illustrations have been in many instances substituted for such as were not deemed satisfactory, 
 while, by an alteration in the typographical arrangement, the size of the work has not been increased, 
 and the price remains unaltered. In its present improved form, it is, therefore, hoped that the work 
 will continue to meet the wants of the American prolession as a sound, practical, and extended 
 System of Midwifery. 
 
 Though the work has received only five pages of 
 enlargement, its chapters throughout wear the im- 
 pressof careful revision. E.xpunging and rewriting, 
 remodelling its sentences, with occasional new ma- 
 terial, all evince a lively desire that it shall deserve 
 to be regarded as improved in maniier as well as 
 matur. In the matter, every stroke of the pen has 
 increased the value of the book, both in e.\pungings 
 and additions — Western Lancet, Jan. 1857. 
 
 The best American work on Midwifery that is 
 accessible to the student and practitioner — N. W. 
 Med. and Surg. Journal, Jan. lSo7. 
 
 This is a standard work by a great American Ob- 
 stetrician. It is the third and last edition, and, in 
 the larguage of the preface, the author has '-brought 
 the subject up to the latest dates of real improve- 
 ment in our art and Science." — Nashville Journ. of 
 Med. and Surg., May, 1857. 
 
 BY THE SAME AUTHOR. {J/iSt Is.ilted.) 
 
 WOMAN : HER DISEASES AND THEIR RE3IEDIES. A Series of Lee- 
 tures to his Class. Fourth and Improved edition. In one large and beautifully printed octav© 
 volume, leather, of over 700 pages. $3 60. 
 
 In other respects, in our estimation, too much can- 
 not be said in pr.iise of this work. It abounds with 
 beautiful passages, and for conciseness, for origin- 
 ality, and for all that is commendable in a work on 
 the diseases of females, it is not excelled, and pro- 
 bably not equalled in the English language. On the 
 whole, we know of no woru on the diseases of wo- 
 men which we can so cordially commend to the 
 student iind practitioneras the one before us. — Ohio 
 Med. and Surg. .Journal. 
 
 The body of the book is worthy of attentive con- 
 sideration, and is evidently the production of a 
 clever, thoughtt'ul, and sagacious physician. Dr. 
 Meigs's letters on the diseases of the external or- 
 gans, contain many interesting and rare cases, and 
 
 many instructive observations. We take our leave __ ^ _ 
 
 of Dr. Aleigs, with a high opinion of his talents and Charleston Med. "Journal 
 originality. — The British and Foreign Medico-Chi- 
 ruTgical Revieio. 
 
 Every chapter is replete with practical instruc- 
 tion, and bears the impress of being the composition 
 of an acute and experienced mind. There is a terse 
 ness, and at the same time an accuracy in his de 
 
 Full of important matter, conveyed in a ready and 
 agreeable manner.— St. Lonis Med. and Surg. Jour. 
 
 There is an off-hand fervor, a glow, and a warm- 
 heartedness infecting the efr)rt of Dr. Meigs, which 
 is entirely captivating, and which absolutely hur- 
 ries the reader through from beginning to end. Be- 
 sides, the book teems with solid instruction, and 
 it shows the very highest evidence of ability, viz., 
 the clearness with which the information is pre- 
 sented. We know of no better test of one's under- 
 standing a subject than the evidence of the power 
 of lucidly explaining it. The most elementary, as 
 well as the obscurest subjects, under the pencil of 
 Prof. Meigs, are isolated and made to stand out in 
 such bold relief, as to produce distinct impressions 
 upon the mind and memory of the reader. — Tht 
 
 Professor Meigs has enlarged and amended thi« 
 great work, for such it unquestionably is, having 
 passed the ordeal of criticism at home and abroao, 
 but been improved thereby ; for in this new edition 
 the author has introduced real improvements, and 
 increased the value and utility of the book im- 
 
 scription ot symptoms, and in the rules for diagnosis, Ljjeagurably. It presents so many novel, bright, 
 which cannot fail to recommend the volume to the „„j sparkling thoughts; such an exuberance of new 
 attention of the reader.— Ratik in g's Abstract. j jjg^g „„ almost every page, that we confess ouT- 
 
 It contains u vast amount of practical knowledge. , selves to have become enamored with the book 
 by one who has accurately observed and retained ! and its author; and cannot withhold tiur congratu- 
 the experience of many years. — Dublin Quarterly lations from our Philadelphia confreres, that such a 
 Journal. teacher is in their Bervice. — N. Y. Med. Gazett*. 
 
 BY THE SAME AUTHOR. 
 
 ON THE NATURE, SIGNS, AND TREATMENT OP CHILDBED 
 
 FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome 
 octavo volume, extra cloth, of 365 pages. $2 50. 
 
 The instructive and interesting author of this 
 work, whose previous labors have placed his coun- 
 trymen under deep and abiding obligations, again 
 challenges their admiration in the fresh and vigor- 
 ous, attractive and racy pages before us. it is a de- 
 
 lectable book. * * « This treatise upon child- 
 bed fevers will have an extensive sale, being des- 
 tined, as it deserves, to find a place in the library 
 of every practitioner who scorns tolag in the rear. — 
 Nashville Journal of Medicine and Surgery. 
 
 BY THE SAME AttTHOR ; WITH COLORED PLATES. 
 
 A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK 
 
 OF THE UTERUS. With numerous plates, drawn and colored from nature in the highest 
 style of art. In one handsome octavo volume, extra cloth. $4 50. 
 
 MAVNR'S DISPENSATORY AND THERA- 
 PEUTICAL REME.MBRaNCER. Witheverv 
 Practical Formula contiiined in the three British 
 Pharmacopoeias. Edited, with the addition of the 
 Formulae of the U. 3. Pharmacopoeia, by R. E. 
 GKirriTHjM.D. 1 12mo. vol. ex. cl.,. 300pp. 75 c. 
 
 MALGAIGNE'S OPERATIVE SURGERY.based 
 
 on Normal and Pathological Anatomy. Trans- 
 lated from the French by Frederick Brittan, 
 A. B.,M. D. With numerous illustrations on wood. 
 In one handsome octavo volume, extra cloth, of 
 nearly six hundred pages. B'i 25. 
 
22 
 
 BLANCHARD ic LEA'S MEDICAL. 
 
 MACLISE (JOSEPH), SURGEON. 
 SURGICAL ANATOMY. Forming one volume, very large imperial quarto. 
 
 With -ixiy-eighi large and i^plendid PUiie>, drawn in the best style and beautilully colored. Con- 
 taining one hundred and ninety Figure*, many of them the size of lile. Together with copious 
 and explanatory letter-press. Strongly and handsomely bound in extra cloth, being one of the 
 cheape-t and l)«,'st executed Surgical works as yet issued in this country. Sll 00. 
 •,• The size ofthi* work prevents its transmi>sion through the post-olRce as a whole, but those 
 
 who desire to have copies Ibrwarded by mail, can receive them in five parts, done up in stout 
 
 wrappers. Pnw S^ 00. 
 One of the (frratcit artistic triuiiiphi of the age A work which has no parallel in point of accu- 
 
 in Surgical Anatomy.— BririsA American Medical racy and cheapness in the English language.— iV. y. 
 
 Journal. Journal of Medicint. 
 
 No praclitlonrr whn«r menns will admit should 
 
 fail to piisums it. — Knnking's Abstract. 
 
 T<"> much ciinnot tie suid in its praise; indeed, 
 we havr not liineuiige to do it justice. — OMo Medi- 
 cal and Surgical Journal. 
 
 The most accurately engraved and beautifully 
 colored pliiles we hiive ever seen in an American 
 book — one of the hest and cheapest surgical works 
 ever publishe<l. — Bu_ffalo Medical Journal. 
 
 It ii very rare that so elegantly printed, so well 
 lustrate<l, and fo useful a work, is ofTered a 
 moderate a price. — Charleston Medical Journal. 
 
 We are extremely gratified to announce to the 
 profession the completion of this truly magnificeiit 
 work, which, as a whole, certiinly stands unri- 
 valled, both for accuracy of drawing, beauty of 
 coloring, and all the requisite explanations of the 
 subject in hand. — Tki I\'et» Orleans Medical and 
 Surgical Journal. 
 
 This is by far the ablest work on Surgical Ana- 
 tomy that has come under our observation. We 
 
 know of no other work that would justify a stu- 
 illustrateil.'and so useful a "work, 'is offered at so dent, in any degree, for neglect of actual dissec- 
 
 tion. In those sudden emergencies that so often 
 
 arise, and which require the instantaneous command 
 
 Its Dlatcs can bonst a superiority which places „f minute anatomical knowledge, a work of this kind 
 
 them almost lieyond the reach of competition —Afedt- ^^^pg the dcHiils of the disEccting-room perpetually 
 
 eal Examiner. ffj.gl, ;„ ti,g memory .-r^e Western Journal of Midi- 
 
 Country practitioners will find these plates of im- cine and Surgery. 
 mense value. — y. Y. Medical Gazette. ' 
 
 MILLER (HENRY), M. D., 
 
 Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. 
 
 PRINCIPLES AND PRACTICK OF OBSTETRICS, &c.; including the Treat- 
 
 menl of Chronic Intlummalion of the Cervix and Body of the Uterus considered as a frequent 
 
 caus«; of Abortion. With about one hundred illustrations on wood. In one very handsome oc- 
 
 lovo volume, of over 600 pages. (Lately Published.) $3 75. 
 
 The rcpulutioii of Dr. Miller as an obstetrician is too widely spread to require the attention oi 
 the prole>>i('n to be specially called to a volume containing ihe experience of his long and extensive 
 practice. The very I'avorable reception accorded to his " Treatise on Human Parturition," issued 
 some years since, is an earnest that the present work will fulfil the author's intention of providing 
 within a moderate compass a complete and trustworthy text-book for the student, and book of re- 
 lerence for the practitioner. 
 
 We congratulate the author that the task is done. ' tion to which its merits justly entitle it. The style 
 We congru'iiluie him that he hasgiven to the medi- is such that the descriptionsare clear, and each sub- 
 cal public a work which will secure for him a high ject is discussed and elucidated with due regard to 
 anil permau'-nt position among the standard autho- its practical bearincrs, which cannot fail to make it 
 rities on the principles and practice of obstetrics, acceptable and valuable to both students and prac- 
 Conpralulaliiins are not less due to the medical pro- titioncrs. We cannot, however, close this brief 
 fession of ihm C'luntry, on Ihe acquisili<m of a trea- notice without congratulating the author and the 
 tiscemboilyin? the results of the studies, reflections, profession on the production of such an excellent 
 and experience of Prof. Miller. Few men, if any, treatise. The author is a western man of whom we 
 in this Country, are more Competent than he to write feel proud, and we canni>t but think that his book 
 on thiidepartdieni of medicine. Kngaged for thirty- will find many readers and warm admirers wherever 
 five years in an extended practice of uhstetrics, for obstetrics is tonight and studied as a science and an 
 many years a teacher of this branch of instruction art. — TheCincinnati Lancttand Observer, Fe\).\65&. 
 in one of the lar-.st of our institutions, a diligent ^ most respectable and valuable additi.m to our 
 studentaswrlasacarefu observer, an originaland ^ome medical literature, and one reflecting credit 
 independent thinker, wedded to no hohbies, ever „|,ke on the author and the institution to wnich he 
 ready to consider witho.it prejudice new views, and jg attached. The student will find in this work a 
 toadopt innovntionMf they arc really impr..ve.iients, most useful guide to his studies: the country prae- 
 and withal a clear, agreeal.le writer, a practica. tiiioner, rusty in his reading, can obtain from its 
 treatise from his pen could not fail to possess great p„„eg „ (^^f resume of the modern literature of the 
 vn\ue. -Ruftalo Med Journal, Mrt. }bS8. scence; and we hope to see this American produc- 
 
 In fact, this volumeniust take its place among the tion generally consulted by the profession. — Ya. 
 ■tandard systematic treatises on obstetrics ; a posi- ' Med. Journal, Feb. 1868. 
 
 MACKENZIE (WJ, M.D., 
 
 Surgeon Oculist in Scotland in onlinary to Her Majesty, Ac. Ac. 
 
 A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE 
 
 EYE. To which is prefixed an Anatomical Introduction explanatory of a Horiziinlal Section ol 
 the Human Eyeball, by Thomas Wharton Jonks, F. R. S. From the Fourth Revised and En- 
 larged I.,oii(lon Edition. With Notes and Additions by Addinf.ll Hewson, AL D., Surgeon to 
 Wills Hospital, Arc. i:c. In one very large and handsome octavo volume, leather, raised bands, with 
 plates and numeroU!« wood-cuts. $•'3 '^5. 
 
 The treatise of Dr. .Mackenzie indisputably holds ' able manner in which the author's stores of learning 
 the first place, and forms, in respect of learning and and experience were rendered available lor general 
 research, an Knryclop.Tdia unequalled in extent by use, at once procured l"or the first edition, as well on 
 
 the cimiinent as in this country, that hich position 
 as a standard work which each succesHive edition 
 has more firmly established. We consider it the 
 duty of evcrv one wlio has the love of hu profession 
 and the welfare of his patient at heart, to make him- 
 self familiar with this the most complete work in 
 the English language upon the diseases of the eye. 
 
 any other work of the kind, either English or foreign. 
 — biroH on Di-'ttsfs of the Eft. 
 
 Few mixirm books on any department of medicine 
 or surgery have met with such extended circulation, 
 or have procured for their authors a like amount of 
 European celcliritv. The immense . :search wh.ch 
 
 it displayed, the thorough acquaintance with the ">' tnglisii language upoi 
 •abject, practically as well as •^- — 'ioally.and the'— ^"'- Titntsand liazettt 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 26 
 
 MILLER (JAMES), F. R.S.E., 
 
 Professor of Surgery in the University of Edinburgh, fee. 
 
 PKINCIPLES OF SURGERY. Fourth American, from the third and revised 
 
 Edinburgh edition. In one large and very beautilul volume, leather, of 700 pages, with two 
 hundred and forty illustrations on wood. $3 75. 
 
 The work of Mr. Miller is too well and too favor- 
 ably known among us, as one of our best text-books, 
 to render any further notice of it necessary than the 
 announcement of a new edition, the fourth in our 
 country, n proof of its extensive circulation among 
 us. As a concise and reliable exposition of the sci- 
 ence of modern surgery, it stands deservedly high — 
 we know not its superior. — Boston Med. and Surg. 
 Journal. 
 
 The work takes rank with Watson's Practice of 
 Physic; it certainly does not, fall bcliiiut tluit great 
 work in soundness of principle or deplh of reason- 
 ing and research. No physician w\n> v.ilues his re- 
 putation, or seeks tlie interests of his clients, can 
 acquit himself before his God and the world without 
 m.iking himself familiar with the soand and philo- 
 sophical views developed in the foregoing book. — 
 I New Orleans Med. and Surg. Journal. 
 
 BY THE SAME AUTHOR. {Jllst Issued.) 
 
 THE PRACTICE OF SURGERY. Fourth American from the last Edin- 
 
 burgh edition. Revised hy the Anierican editor. Illustrated by three hundred and sixty-four 
 engravings on wood. In one large octavo volume, leather, of nearly 700 pages. $3 75. 
 No encomium of ours could add to the popularity : his works, both on tlie principles nn<l practice of 
 of Miller's Surgery. Its reputation in this country | surgery have been assigned tliehigliest rank. If we 
 
 is unsurpassed by that of any other work, and, when 
 taken in connection with the author's Principles of 
 Surgery., eonslitutes a whole, withcmt rel'ercnce to 
 to which no conscientious surgeon woald be willing 
 practice his art. — Sotttkern Med. and Surg. Journal. 
 It is seldom that two volumes have ever made so 
 profound an impression in so short a time as the 
 " Principles" and the " Practice" of Surgery by 
 Mr. Miller — or so richly merited the reputation they 
 have acquired. The author is an eminently sensi- 
 ble, practical, and well-informed man, who knows 
 exactly what lie is talking about and exactly how to 
 talk it. — Kentucky Medical Recorder. 
 
 By the almost unanimous voice of the profession, | Sciences. 
 
 were limited to but one work on sursfcry, that one 
 should be Miller's, as we regard it as superior to all 
 others. — St. Louis Med. and Surg. Journal. 
 
 The author has in this and his" Principles," pre- 
 sented to the profession one of the most complete and 
 relialile systems of Surgery extant. His style of 
 writing is original, impressive, and engaging, ener- 
 getic, c<mcise, and lucid. Few have flic faculty of 
 condensing so much in small space, and at the same 
 time so persistently holding tlieattention. Whether 
 as a text-book tor students or a book of reference 
 for practitioners, it cannot be too strongly recom- 
 mended. — Southern Journal of Med. and Physical 
 
 MORLAND (W. W.), M. D., 
 
 Fellow of the Massachusetts Medical Society, &C.. 
 
 DISEASES OF THE URINARY ORGANS ; a Compendium of their Diagnosis, 
 
 Pathology, and Treatment. With illustrations. In one large and handsome octavo volume, ol 
 about 6()0 pages, extra cloth. (Just Issued.) $3 50. 
 Taken as a whole, we can recommend T)r. Mor 
 
 land's compendium as a very desirable addition to 
 the library of every im-dical or surgical practi- 
 tioner. — Brit, and For. Med.-Chir. Rev., April, 1859. 
 Every medical practitioner \vhose attention has 
 been to any extent attracted towards the class of 
 diseases to which this treatise relates, must have 
 often anil sorely experienced the want of some full, 
 yet concise r*cent compendium to which he cimld 
 refer. This desideratum has been sunplied by Dr 
 
 yet in a succinct, narrational style, such as to render 
 the work one of great interest', and one which will 
 prove in ttie highest degree useful to the general 
 practitioner. To" the members of ilie profession in the 
 country it will be peculiarly valuable, on account 
 of the characteristics which we have mentioned, 
 and the one broad aim of practical utility which is 
 kept in view, and which shines out upon every page, 
 toeether with the skill which is evinced in the com- 
 bination of this grand requisite with the utmost 
 
 Morland. and it has been ab'ly done. He has placed | l^^evity whicha just treatment of the subjects would 
 before us a full, judicious, and reliable ^\\.re^t.\^<^»iil—N.Y.Journ.ofMedtctnt,-\ov.ViS». 
 Each subject is treated with sutficient minuteness, I 
 
 MONTGOMERY (W. F.), M. D., M. R. I. A., Slc, 
 
 Professor of Midwifery in the King and Queen's College of Physicians in Ireland, &c. 
 
 AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 Wilh some other Papers on Subjects connected with Midwifery. From the seeoiul and enlarged 
 English edition. Wilh two exquisite colored plates, and luiiiierous wood-cuts. In one very 
 handsome octavo volume, extra cloth, of nearly 600 pages. {Lately PiMislifd.) $3 75. 
 A book unusually rich in practical suggestions. — I has been weighed and reweiglied thr<mgh years of 
 Am. Journal Med. Sciences, Jan. 1857. preparation; that this is of all others the book of 
 
 These several subjects so interesting in them- ! "''^'efie Law, on each of its several topics ; on all 
 
 selves, and so important, every one of them, to the 
 most delicate and precious of social relations, con- 
 trolling olten the honor and domestic peace of a 
 family, the legitimacy of offspring, or the life of its 
 parent, are all treated with an elegance of diction, 
 fulness of illustrations, acutenessand justice of rea- 
 soning, unparalleled in obstetrics, and unsurpassed in 
 medicine. The reader's inti-rest can never flag, so 
 fresh, and vigorous, and classical is our author's 
 style ; and one forgets, in the renewed ch;irin of 
 every page, that it, and every line, and every word 
 
 points connected with pregnancy, to be everywhere 
 received as a manual of speci.al jurisprudence, at 
 (mce announcing fact, affording argument, establish- 
 ing precedent, and governing alike the juryman, ad- 
 vocate, and judije. It is not merely in its legal re- 
 lations that we find this work s<i interesting. Hardly 
 a page but that has its hints or facts important to 
 the general practitioner; and not a chapter without 
 especial matter for the anatomist, physiologist, or 
 pathologist. — iV. A. Med.-Chir. Revieto, March, 
 1857. 
 
 MOHR (FRANCIS), PH. D., AND REDWOOD (TH EOPH I LUS). 
 PRACTICAL PHARxMACY. Comprising the Arrangements, Apj.aratus, and 
 
 Manipulations of the Pharmaceutical Shop and Laboratory. Edited, with exlen>ive Additions, 
 by Prof WiLLiA.M Procter, of the Philadelphia College of Pharmacy. In one handsomely 
 printed octavo volume, extra cloth, oi 570 pages, wilh over 500 engravings on wood. $2 75. 
 
24 BLANCHARD & LEA'S MEDICAL 
 
 NEILL (JOHN), M. D., 
 
 Surgeon to the Pennsylvania Hospital, 4c.; and 
 
 FRANCIS GURNEY SMITH, M.D., 
 
 Professor of Iiislitutcs of Medicine in the Pennsylvania Medical College. 
 
 AN ANALYTKWL COMPENDIUM OF THE VARIOUS BRANCHES 
 
 OK MEDICAL !?C1ENCE; for the Use ami Examination of Students. A new edition, revised 
 
 and improved. In one very large and handsomely printed royal 12mo. volume, ol about one 
 
 thousand pages, with 374 wood-cuts. Strongly bound in leather, with raised bands. $3 00. 
 
 The very tiattering reception which ha« been accorded to this work, and the high estimate placed 
 upon it by the profession, as evinced by the constant and increasing demand which has rapidly ex- 
 hausted two large editions, have stimulated the authors to render the volume in its present revision 
 more worthy o( the success which ha.s attended it. It has accordingly been thoroughly examined, 
 and such errors as had on former occasions escaped observation have been corrected, and whatever 
 additions were necessarv to maintain it on a level with the advance ofscience have been introduced. 
 The extended .series of illu>trations has been still further increased and much improved, while, by 
 a slight enlargement of the pjige, these various additions have been incorporated without increasing 
 the bulk of the volume. 
 
 The work is, therefore, again presentedaseminently worthy of the favor with which it has hitherto 
 been received. As a book for daily reference by the student requiring a guide to his more elaborate 
 text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate 
 examination, or as a source /rom which the practitioners of older date may easily and cheaply acquire 
 a knowledge of the changes and improvement in professional science, its reputation is permanently 
 established. 
 
 The best work of the kind with which we are ] the students is heavy, and review necessary for an 
 acquninlrd. — Med. Examiner. examination, a compend is not only valuable, but 
 
 Having made free use of this volume in our ex- I' '» alm.-st a sine qua non The one before us is, 
 aminati.fns of pupils, we can speak from experi- "I ™?l°^"'^^'V^"'"«' '^* |""^' unexceptionable 
 ence in r^com.iu-mling it as an admirable compend "f »" book* of the kind that we know of. The 
 for students, and as especially useful to preceptors "e^est and soundest doctrines and the atest ira- 
 who examine their pupils. It will save the teacher provements and discoveries are explicitly, though 
 much labor by enal'liiig him readily to recall all of . concisely, laid before the student. There is a class 
 the points upon whicTi his pupils should be ex- to whom we very sincerely commend this cheap book 
 amined. A w..rk of this sort should be in the hands asworth its weight in silver-that class is thegradu- 
 of every one who takes pupils into his office with a a'^« '» medicine of more than ten years' standing. 
 vtewofVxaminln?them: and this isunquestionably who have not studied medicine since. They will 
 the best of Its cUiiB.-Transylvania Med. Journal . \ perhaps find out from it that the science is not exactly 
 
 now what it was when they left it off. — Tnt SutM- 
 
 In the rapid course of lectures, where work for i scope. 
 
 NELIGAN (J. MOpRE), M. D., M. R. I. A., &.C. 
 {A spleitAid work. Just Issued.) 
 
 ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, extra 
 cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of 
 disea.se. $4 50. 
 
 This beautiful volume is intended as a complete and accurate representation of all the varieties 
 of Diseases of the Skin. While it can be consulted in conjunction with any work on Practice, it has 
 especial reference to the author's " Treatise on Diseases of the Skin," so favorably received by the 
 profession some years since. The publishers feel justified in saying that few more beautifully exe- 
 cuted plates have ever been presented to the profession of this country. 
 
 Nelignn's Atlas of Cutanenns Diseases supplies a ' give, at a toup d^cril, the remarkable peculiaritiea 
 long existent desideratum much felt by the largest of each individual variety. And while thus the dii- 
 class of our profession. It presents, in quarto size, ease is rendered more definable, there is yet no loss 
 16 plates, each containing from 3 to figures, and , of proporti<m incurred by the necessary conccntra- 
 forming in all a total of 90 distinct representations tion. Each figure is highly cobired. and so truthful 
 of the dilferent species of skin afTections, grouped has the artist been that the most fast id ous observer 
 together in genera or families. The illustrations could not justly take exception to the correctness of 
 have been faki-n from nature, and have leen copied the execution of the pictures under his scrutiny. — 
 with such fidelity that they present a striking picture Montreal Med. ChronicU. 
 of life; in which the reduced scale aptly serves to I 
 
 BY THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Third 
 
 American edition. In one neat royal 12mo. volume, extra cloth, of 334 pages. $1 00. 
 
 t&^ The two volumes will be sent by mail on receipt of Five DoUan. 
 
 OWKN ON THB DIFFKRENT FORMS OF I One vol. royal 12mo., extra cloth with numerouB 
 THE SKELETON, AND OF THE TEETH. | Ulusirations. 8125. 
 
 PIRRIE(WILLIAM), F. R. S. E., 
 
 Professor of Surgery in the University of .Aberdeen. 
 
 THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John 
 
 Nkill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon tothe Pennsylvania 
 Hospital, J^-c. In one very handsome octavo volume, leather, of 780 pages, with 316 illustrations. 
 $3 75. . 
 
 We know of no other tnrgical work of a reason- ' rately diicossed the principles of surgery, and a 
 able size, wherein there ii somuch Iheoryand prac- safe and effectual practice predicated upon them, 
 tice, or where subjects are more soundly or clearly Perhaps no work upon this subject heretofore issued 
 taught. — The Suthoicopt. is so lull upon the science of the art of surgery. — 
 
 Prof. Pirric, in the work before us, has elabo- ^'<^i>ivilU Journal of Medicine and Surgery . 
 
AND SCIENTIFIC PUBLICATIONS. 
 
 25 
 
 PARRISH (EDWARD), 
 
 Lecturer on Practical Pharmacy and Materia Medica in tlie Pennsylvania Academy of Medicine, 4c. 
 
 AN INTRODUCTION TO PRACTICAL PHARMACY. Designed as a Text- 
 
 Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many For- 
 mulae and Prescriptions. Second edition, greatly enlarged and improved. In one handsome 
 octavo volume of 720 pages, with several hundred Illustrations, extra cloth. $3 GO. (iVuM> 
 Rearlij.) 
 
 During the short time in which this work has been before the profession, it has been received 
 with very great favor, and in assuming the position of a standard authority, it has filled a vacancy 
 which had been severely felt. Stimulated by this encouragement, the author, in availing himself 
 of the opportunity of revision, has spared no pains to render it more worthy of the confidence be- 
 stowed upon it, and his assiduous labors have made it raiher a new book than a new edition, many 
 portions having l/een rewritten, and much new and important matter added. These alterations and 
 improvements have been rendered necessary by the rapid progress made by pharmacenticral science 
 during the last few years, and by the additional experience obtained in the practical use of the 
 volume as a text-book and work of reference. To accommodate these improvements, the size of 
 the page has been materially enlarged, and the number of pages c<insiderably increased, presenting 
 in all nearly on(-half more matter than the last edition. The work is therefore now presented as a 
 complete exponent c)f the subject in its most advanced condition. From the most ordinary matters 
 in the dispensing otlice, to the most complicated details of the vegetable alkaloids, it is hoped that 
 everything requisite to the practising physician, and to the apothecary, will be found fully and 
 clearly set forth, and that the new matter alone will be worth more than the very moderate cost of 
 the work to those who have been consulting the previous edition. 
 
 there is no production of the kind in the Eng:lish 
 
 That Edward Parrish, in writing a book upon 
 Xirattical Pharmacy some few years ago — one emi- 
 nently original and unique — did the medical and 
 pharmaceutical professions a great and valuable ser- 
 vice, no one, we lluulc, who has had access to its 
 pages will deny ; doubly welcome, then, is this new 
 edition, containing the added results of his recent 
 and rich experience as an observer, teacher, and 
 practic il operator in the pharmaceutical laboratory. 
 The excellent plan of the first is more thoroughly, 
 and in detail, carried out in this edition. — Peninsular 
 Mid. Journal, Jan. ISCO. 
 
 We know of no work on the subject which would 
 be more indispensable to the physician or student 
 desiring informaticmcm the subject of which it treats. 
 With Griffith's " Medical Formulary" and this, the 
 practising physician would be supplied with nearly 
 or quite all the most useful infonnation on the sub- 
 ject. — Ckarleslon Med. Journal and Review, Jan. 
 1&60. 
 
 This edition, now much enlarged, is one of the 
 most useful works of the past year. — N. O. Med. 
 and Surg. Journal, Jan. 1800. 
 
 The whole treatise is eminently practical; and 
 
 lansjuage so well adupted to the wants of the phar- 
 maceutist and druga: ist. To physicians, also, it can- 
 not fail to be highly valuable, especially to those 
 who are oliliged to prepare and compound many of 
 their own medicines. — iV. Am. Med. Ckir. Review, 
 Jan. ISGO. 
 
 Of course, all apothecaries who have not already 
 a copy of the first edition will procure one of this; 
 it is, therefore, to physicians residing in the country 
 and in small towns, who cannot avail themselves of 
 the skill of an educated pharmaceutist, that we 
 would especially commend this work. In it they 
 will find all that they desire to know, and should 
 know, but very little of which they do really Know 
 in reference to this important collateral branch of 
 their profession; for it is a well established fact, 
 that, in the education of physicians, while the sci- 
 ence of medicine is generally well taught, very 
 little attention is paid to the art of preparing them 
 for use, and we know not how this defect can be so 
 well remedied as by procuring and consulting Dr. 
 Pairish's excellent work. — St. Louis Med. Journal. 
 Jan. ISGO. 
 
 PEASLEE (E. R.), M. D., 
 
 Professor of Physiology and General Pathology in the New York Medical College. 
 
 HUMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology; 
 
 for the use of Medical Students. With four hundred and thirty- four illustrations. In one hand- 
 some octavo volume, of over 600 pages. (Lately Published.) $3 75. 
 
 We would recommend it to the medical student 
 
 It embraces a library upon the topics discussed 
 within itself, andis just what the teacher and learner 
 need. Another advantage, by no means to be over- 
 looked, everything of real value in the wide range 
 which it embraces, is with great skill compressed 
 into an octavo volume of but little more than si.x 
 hundred pages. We have not only the whole sub- 
 ject of Histology, interesting in itself, ably and fully 
 
 and practitionerj as containing a summary of all that 
 is known of tlie important subjects which it treats ; 
 of all that is contained in the great works of Simon 
 and Ijchinann, and the organic chemists in general. 
 Master this (me volume, we would say to the medical 
 student and practitioner — master tl.is book and you 
 know all that is known of the great fundamental 
 
 discussed, but what is of infinitely greater interest j principles of medicine, and we have no hesitation 
 
 to the student, because of greater practical value, 
 are its relations to Anatomy, Physiology, and Pa- 
 thology, which are here fully and satisfactorily set 
 Unth..— Naskville Journ. of Med. and Surgery, Dec. 
 1357. 
 
 n saying that it is an honor to the American medi- 
 cal profession that one of its members should have 
 produced it. — St. Louis Mid. and Surg. Journal, 
 March, 1853. 
 
 PEREIRA (JONATHAN), M. D., F. R. S., AND L. S. 
 THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. 
 
 Third American edition, enlarged and improved by the author; including Notices of most of the 
 Medicinal Substances in use in the civilized world, and forming an Encyclop«?dia of Materia 
 Medica. Edited, with Additions, by Joseph Carson, M. D., Professor of Materia Medica and 
 Pharmacy in the University of Pennsylvania. In two very large octavo volumes of 2100 pages, 
 on small type, with about 500 illustrations on stone and wood, strongly bound in leather, with 
 raised bands. Sir* 00. 
 1).*^ Vol. II. will Qo longer be sold separate. 
 
 PARKER (LANGSTON), 
 
 Surgeon to the C^ueen's Hospital, Birmingham. 
 
 THE MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRI- 
 MARY AND SECONDARY; comnrisinglhe Treatment of Constitutional andConfirmed Syphi- 
 lis, by a safe and successful methoti. With numerous Cases, Formulae, and Clinical Observa- 
 tions. From the Third and entirelv rewritten London edition. In one neat octavo volume, 
 extra cloth, of 316 pages. $175. 
 
26 
 
 BLANCHARD & LEA'S MEDICAL 
 
 RAMSBOTHAM (FRANCIS H.), M.D. 
 THE PRINCIPLES AND I'RACTICE OF OHSTETRIC MEDICINE AND 
 
 SLFRlJKKY, in relereiice to tlie Process* o( Parturition. A new and enlarged edition, thoroughly 
 revi.'^'d l»y the Author. With Additions by W. V. Keating, M. D. In one large and handsome 
 iniijerial of luvo volume, ol>).')0 pagec, ^trongly bound in leather, with raised bands; with sixty- 
 four beauiilul Plates, and numerous Wood-cuts in the text, containing in all nearly two himdred 
 large and beautiful figures. $.0 00. 
 
 From Prof. Hod^$, of ike University of Pa. 
 To the American public, it la moBt valiiiitile, from its intrinsic umlDuhted excellence, and as being 
 the belt authorized exponent of Britisli Midwifery. Its circulation will, 1 trust, be extensive throughout 
 oar country. 
 
 It is unneeesBnrv to siiy anything in regard to the i truly elegnnt style in which they have brought it 
 ntility <»f this work. It i's already u|iprfcmted in our i out, excelling themselves in its production, espe- 
 couDtry for the value of the matter, the clearness of eiallv in its plates. It is dedicated to Prof. Meigs, 
 Its style, and the fulness of its illustrations. To the and has the emphatic endorsement of I'rof. Hodge, 
 physician's library it Is indispenKable, while to the as the best exponent of British Midwifery. We 
 student as a ti-xt-book. from which to extract the knt.w of no text-book which deserves in all respects 
 material for laying the foundation of an education on ' to he more highly recommended to students, and we 
 obstetrical »ci.-nce, it has no superior.— OAio JVfed I could wish to see it in the handsof every practitioner, 
 anti Surg. Journal. I for they will find it invaluable for reference.— 3fed. 
 
 The publishers have secured its success by the I i****"*' 
 
 RICORD (P.), M. D. 
 
 A TREATISE ON THE VENEREAL DISEASE. By John Hunter, F. R. S. 
 
 With oojiious Additions, by Ph. Kicord, M. D. Translated and Edited, with Notes, by Fref.mam 
 J. BiwsTF.AD. M. D , Lecliirer on Venereal at the College of Physicians and Surgeons, New York. 
 Second editiin, revised, coiilaining a re.-nime of Ricord's Recent Lectures o.n Chancre. In 
 one handsome octavo volume, extra cloth, or.'J50 pages, with eight plates. $3 25. {Just Issued.) 
 In revising this work, the editor has endeavored to introduce whatever matter of interest the re- 
 cent inve>tigaiions of syphilographers have added to our knowledge of the subject. The principal 
 Kource from which this has been derived is the volume of "Lectures on Chancre," publi>lied a few 
 months since by M. Ricord, which ntl'oids a large amount of new and instructive material on many 
 controverted pi>iiits. In the previous edition, M. Ricord's additions amounted to nearly one-third 
 of the whole, and with the mailer now introduced, the work may be considered topreseul his views 
 nnd experience more thoroughly and completely than any other. 
 
 oecretaries, sometimes accredited and sometimes not. 
 In the notes 10 Hunter, the master subaiituies him- 
 
 Kvcry one will recognize llie auracliveiicss and 
 Talue which this work derives from thus pre.«eniiDg 
 the opinion" of these two masters side by side. Bui, 
 It must I'O admitted, what has made the forlune oi 
 the book, is ihe fuel lliai it coiiluius ilie "most coni- 
 
 flele embodim^'iu of the veriublc doctrines of the 
 lApital du Alidi," which has ever been made public. 
 The doctrinal id<'as of M. Ricord. ideas which, if not 
 universally adopted, aie incorilesiably dominant, have 
 heretofore only been interpreted by more or lessskilful 
 
 selfforhis interpreters, and gives hisoriginal ihoufrhts 
 to ilie world in a lucid and perfectly iiilrlliijiblc man- 
 ner. Ill conclusion we can say thai this is incon- 
 lesiably the best treaiise on syphilis with which we 
 are acquainted, and. as we do nol ofieii employ the 
 phrase, wc may be excused lor expressing ilie hope 
 thai it may find a place in the library of every phy- 
 sician. — Virginia Mid. and Surg. Journal. 
 
 BY THE SAME AUTHOR. 
 
 RICORD'S LETTERS ON SYPHILIS. Translated by W. P. Lattimore, M. D. 
 
 In one neat octavo volume, of 270 pages, extra cloth. $2 00. 
 
 ROYLE'S MATERIA MEDICA AND THERAPEUTICS; including the 
 
 Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United btates. 
 With many new medicines. Edited by Joseph Carson, M. D. With ninety-eight illustrations. 
 In one large octavo volume, extra cloth, of about 700 pages. S.'^ 00. 
 
 ROKITANSKY 
 
 Curator of the Imperial Pathological Museum, 
 
 A MANUAL OF PATHOLOGICAL 
 
 bound in two. extra cloth, of nboiit 1200 pasres. 
 KING, C. H. Moore, and G. E. Day. S-O .10 
 The profession is too well acquainted with the re- 
 putation of Rokitansky's work to need our assur- 
 ance that this is one of the most profound, thorough, 
 and valualile books ever issued from the medical 
 press. It IS .<Mi g'ft<rt.«, and has no standard of com- 
 parison. It is only necessary to announce that it is 
 issued inn form ns cheap as is coiiipatilile with its 
 size nnd preservation, and its sale follows as a 
 matter of course. No library can be called com- 
 plete without it. — Buffalo Med. Journal. 
 
 Au attempt to give our readers any adequate idea 
 of the vast amount of instruction accumulated in 
 these volumes, would be feeble and hopeless. The 
 cITort of the distinguished author to concentrate 
 in a small space his great fund of knowledge, has 
 
 (CARL), M.D., 
 
 and Proiessor at the University of Vienna, &C. 
 
 ANATOMY. Four volumes, octavo, 
 Translated by W. E. Swaine, Edward Sikvb- 
 
 80 charged his text with valuable truths, that any 
 attempt of a reviewer to epitomize is at once para- 
 lyzed, and must end in a failure. — Western Lancet. 
 
 As this is the highest source of knowledge upon 
 the important subject of which it treats, no real 
 student can afford to be without it. The American 
 publishers have entitled themselves to the thanks of 
 the profession of their country, for this tiiiieousand 
 beautiful edition. — I\'a.'ihville Journal of Medicim. 
 
 Asa book of reference, therefore, this work must 
 prove of inestimable value, and we cannot loo highly 
 recommend it to the profession. — Charleston Med. 
 Journal and Heview. 
 
 This book is a necessity to every practitioner. — 
 Am. Med. Monthly. 
 
 RIGBY (EDWARD), M. D., 
 
 Senior PhvHician to tlie IJeneral Lving-in Hospital, ice. 
 
 A SYSTEM OF .MiinVlFERY. With Notes and Additional Illustrations. 
 
 Second American Edition. One volume octavo, extra cloth, 422 pages. $2 50. 
 BY the same author. [Lately Publishfii.) 
 
 ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES. 
 
 In one neat royal 12mo. volume, extra cloth, of alx)ut 250 pages. $1 00, 
 
AND SCIENTIFIC PUBLICATIONS. 27 
 
 STILLE (ALFRED), M.D. 
 THERAPEUTICS AND MATERIA MEDICA ; a Systematic Treatise on the 
 
 Action, and Uses of Medicinal Agents, including their Description and History. In two large and 
 
 handsome octavo volumes, of 17S9 pages. (Now Ready, ISdO.) $S 00. 
 
 This work is designed especially for the student and practitioner of medicine, and treats the various 
 articles of the Materia Medica from the point of view of the bedside, and not ol the shop or of the 
 lecture-room. While thus endeavoring to give all practical informaiion likely to be useful with 
 respect lo the employment of special remedies in special affections, and the results to be anticipated 
 from their administration, a copious Index of Diseases and their Kemedies renders the work emi- 
 nently titled lor reference by showing at a glance ihe ditVerent means which have been employed, 
 and enabling the practitioner to e.xiend his resources in ditlicull ca-es with ail that the experience 
 of the prole-^sion has suggested. At the same time panicular care has been given to the subject 
 of General Therapeutics, and at the commencement of each class of medicines there is a chapter 
 devoted lo the consideration of their common indtience upon morbid conditions. The action of 
 remedial aiients upon the healthy economy and on animals has likewise received particular notice, 
 from the ci iiviction that their physiological ellects will afford frequent explanations of iheir patho- 
 logical inlluence. and in many ca>es lead lo new and important suggestions a,- to their practical use 
 in disease. Within the scope thus designed by the auihor, no labor has been spared lo accumulate 
 all the facts which have accrued from the experience of the profession in all airt^s and all countries ; 
 and the vast amoimt of recent re^earches recorded in the periodical literature of both hemispheres 
 has been zealously laid under contribution, resulting in a mass of practical iafonnatioii scarcely 
 attempted hulierto in any similar work in the language. 
 
 Our expectations of the value of this work were the practical utility of his book by passin;; briefly 
 based on the well-known reputalion and cliaracter over the physical, botani 'al, aiid ennnnercial history 
 of the author as a man of scholarly attainments, an nf medicines, and direciiiig attention ehitfly to their 
 elegant writer, a candid inquirer after truth, and a physiological action, and their application for the 
 philosophical thinker ; we knew that the task would amelioration or cure of disease. He igrnores hypothe- 
 be conseieiitinusly performed, and that few, if any, sie and theory which are so alluring to many medical 
 ainoD^ the distinguished medical teachers in this writers, and so liable to lead them astray, and con- 
 counlry are Ijettcr qualified than he to prepare a fines himself to such facts as have been tried in the 
 systeaatic treatise on therapeutics in aecnrdance crucible of experience. — Chicago Medical Journal, 
 with the present requirements of medical science, i March, ISOO. 
 
 Our priliminary examination of the work has satis- , The plan pursued by the author in these veryela- 
 fied us that we were not mistaken in our anticipi- borate volumes is not strictly one of scientific unity 
 li.ms. In cmjratulating the au-hor on the comple- (j^j precision ; he has rather subordinated these to 
 tion of the great labor which such a work involves, | practical utility. Ur. Stille has produced a work 
 we are happy in expressing the conviction that its , which will be valuable equally to the student of 
 merits will receive that rew.ard which is above all medicine and the busy practitioner. -i-o/iioTi Lan- 
 price— the grateful apprtciation of his medical bre- jjj Alarch 10 1S60. 
 
 thren.— Ntw Orleans Medical News, M&TCh, ISOO. ,',r-.u ti •' n' i- i\t-. in Aitr ju 
 
 ' ' I Wilh Pereira, Dunglison, Mitchell, and Wood be- 
 
 We think this work will do much to obviate the j fore us, we may well ask if there was a necessity 
 reluctance to a thorough investigation of this branch , for a new book on the subject. After examining this 
 of scientific study, for in the wide range of medical ' work with some care, we can answer affirmatively, 
 literature treasured in the English t(mgue, we shall [ Dr. Wood's book is well adapted for students, while 
 hardly find a work written in a style more cle.ir and j J)r. StiUe's will be more sitisfacfory to the practi- 
 simple, cuDVpying forcibly the facts taught, and yet \ tioner, who desires to study the action of medicines, 
 t'ree from tursridiiy and redundancy. There isa fas- i The author needs no encomiums from us, ("or he is 
 cination in its pages that will insure to it a wide | well known as a ripe scholar and a man of the most 
 popularity and attentive perusal, and a degree of ^ extensive reading in his profession. This work bears 
 usefulnets not often attained through the influence' evidence of this fact on every page. — Cincinnati 
 of a single work. The author has much enhanced i Lancet, April, IsOO. 
 
 SMITH (HENRY H.), M.D. 
 MINOR SURGERY; or, Hints on the E very-day Duties of the Surgeon. With 
 
 247 illustrations. Third edition. 1 vol. royal 12ino., pp. 456. In leather, $2 2-5; cloth, $2 00. 
 
 BY THE SAME AUTHOR, AND 
 
 HORNER (WILLIAM E.), M.D., 
 Late Professor of Anatomy in the University of Pennsylvania. 
 
 AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. 
 In one volume, large imperial octavo, extra cloth, wilh about six hundred and fifty beautiful 
 figures. $3 00. 
 
 These figures are well selected, and present a 
 complete and accurate representation of that won- 
 derful fabric, the human body. The plan of this 
 Atlas, which renders it so peculiarly convenient 
 for the student, and its superb artistical execution, 
 have been already pointed out. We must congratu- 
 
 late the student upon the completion of thisAtlaS] 
 as it is the most convenient work of the kind that 
 has yet appeared ; and we must aiUI, the very beau- 
 tif^ul manner in which it is " got up" is so creditable 
 to the country as to be flattering to our national 
 pride. — ArTurican Medical Journal. 
 
 SHARPEY (WILLIAM), M. D., JONES QUAIN, M. D., AND 
 
 RICHARD QUAIN, F. R. S., &.c. 
 
 HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Letdt, 
 
 M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo 
 volumes, leather, of about thirteen hundred pages. Beautifully illustrated with over five hundred 
 engravings on wood. $6 00. 
 
 SIMPSON (J. Y. , M. D., 
 
 Professor of Midwifery, &e., in the University of Edinburgh, Sec. 
 
 CLINICAL LECTURES ON THE DISEASES OF FEMALES. With numo- 
 
 rous illustrations. 
 
 This valuable series of practical Lectures is now appearing in the "Medical News and 
 Library" for 1560, and can thus be had without cost by subscribers to the "American Journal 
 OF THE Medical Sciences." See p. 2. 
 
28 BLANCHARD & L.EA'S3 MBUIUALi 
 
 SARGENT (F. W.), M. D. 
 ON BAXDAGING AND OTHER OPERATIONS OF MINOR SURGERY. 
 
 Second edition, enlarged. One handsome royal 12mo. vol., of nearly 400 pages, willi 182 wood- 
 cuts. Extra cloth, SI 40; leather, SI 50. 
 
 Sareent's Minor s^urgpry hue always been popular, I A work that has been so long and favorably' known 
 and deservedly »o. It furnislies that knowledge of the | to tlie profession ^as Dr^ Sargcnt^s Minor tjurgery, 
 
 must f " , _ -. .,_, ~ ,..™ ..„ «,.,.,.. , ,„.».,. 
 
 art wli 
 
 loe cliDieal lectures. Tlie art of bandaging, which I dom gets that attention in our schools tliat its im- 
 is regularly UuRlit in Europe, is very frequently I portance deserves. Our larger works are also very 
 overlooked by teachers in this country ; the student defective in tlieir teaching on these siiuill practical 
 and junior pruclilioner, therefore, may often require points. This little book will supply the void which 
 that knowledge which this little volume so tersely all must feel who have not studied its pages.— TTeil- 
 and happily supplies —CAor/es«o« Med. Journ. and em Lanctt, xMarch, lb56. 
 
 'requently requisite performances of surgical needs no commendation from us. We would remark, 
 lieh cannot be entirely understood by attend- j however, in this connection, that minor surgery sel- 
 ioical lectu 
 ularly taug 
 Miked by ten 
 inior pructil 
 nowledge v 
 happily suppi 
 iiavMio, March, lb36. 
 
 SMITH (W. TYLER), M. D., 
 
 PhysiciJUi Accoucheur to St. Mary's Hospital, See. 
 
 ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OP 
 
 OBSTETKICS. In one royal 12mo. volume, extra cloth, of 400 pages. $125. 
 
 BY THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE ON THE PATHOLOGY AND TREATMENT 
 
 OF LEUCOKKliCEA. With numerous illu!«traiions. In one very handsome octavo volume, 
 extra cloth, of about 250 pages. SI 50. 
 
 SOI.LV ON THK HU.MAN BRAIN; its Structure, | handsome octavo volume, extra cloth, of overC50 
 Physiology, and Diseases. From the Sec<md and ! pages, with about one hundred wood-cuts. ?3 35. 
 much enluiged London edition. In one octavo ! giMoNS GENKKAi. PATHOLOGY, as conduc- 
 volume, extra cloth, of 500 pages, with 120 wood- I j^e ,„ the Estabhsniiitnt of Rati.mal Principles 
 cuts. 9'i 00. f(>r the prevention ano Cure of Disease. In one 
 
 SKEY'S OPERATIVE SURGERY. In one very ' octavo volume, extra cloth, of 212 pages. 81 25. 
 
 TODD (R. B.), M.D., F. R. S., &.c. 
 CLINICAL LECTURES ON CERTAIN DISEASES OF THE URINARY 
 
 ORGANS AND ON DROPSIES. In one octavo volume, 2S4 pages. $1 50. 
 BY THE SAME AUTHOR. {Now Ready.) 
 
 CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one neat 
 
 octavo volume, of 320 pages, extra cloth. SI 75. 
 
 The subjects treated in this volume are — Rheu.matic Fever, Continued Fever, Erysipelas, 
 Acute Internal Inflammation, Py>e.mia, Pneumonia, and the Therapeutical Action of Alco- 
 hol. The importance of these matters in the daily practice of every physician, and the sound 
 practical nature of Dr. Todd's writings, can hardly fail lo attract to this work the general attention 
 that it merits. 
 
 TANNER (T. HJ, M. D., 
 
 Physician to the Hospital for \Vomen, &c, 
 
 A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS. 
 
 To which is added The Code of Ethics of the American Medical Association. Second 
 American Edition. In oae neat volume, small 12mo., extra cloth, S7j cents. 
 
 TAYLOR (ALFRED S.), M. D., F. R. S., 
 
 Lecturer on .Medical Jurisprudence and Chemistry in Guy's Hospital. 
 
 MEDICAL JURISPRUDENCE. Fourth American Edition. With Notes and 
 
 References to A merican Decisions, by Edward Hartshorne, M. D. In one large octavo volume, 
 leather, of over seven hundred pages. S3 00. 
 
 No work upon the subject can be put into the | It is not excess of praise to say that the volume 
 hands of students either of law or medicine which before us is the very best treatise extant on Medical 
 
 will engage them more closely or profitably; and 
 none couM be oflcred to the busy practitioner ol 
 either calling, for the purpose of casual or hasty 
 reference, that would be more likely toalTord the aid 
 desired. We tlicrcl'ore recommend it as the best and 
 ■afest manual for daily \xw.— American Journal oj 
 Medical Sciences. 
 
 Jurisprudence. In saying this, we do not wish to 
 be understood as detracting from the merits of the 
 excellent works of Beck, 'Ryan, Traill, Guy, and 
 others; but in interest and value we think it must 
 be conceded that Taylor is superior to anything that 
 has preceded it. — iV. IV. Medical and Surg. Journal. 
 
 BY THK SAME AtJTHOR. (New Edition, ju^t issued.) 
 
 ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND 
 
 MEDICINE. Second American, from a second and revised London edition. In one large 
 
 octavo volume, ol 755 pages, leather. $3 50. 
 
 Since the first appearance of this work, the rapid advance of Chemistry has introduced into 
 use many new substances which may become fatal through accident or design — while at the 
 same time il has likewise designated new and more exact modes olcouiUeractinir or detecting those 
 previou>ly treated of. Mr. Taylor's po>ition as the leading medical juri>t of England, has during 
 this periud conferred on him extraordinary advantages in acquiring experience on these subjects, 
 nearly all cases of moment being referred to him lor examination, as an exj^ert whose testimony 
 iti generally accepted as (inal. The results of his labors, therefore, as gathered together in this 
 volume, cureliilly weighed and sil'ted. and presented in the clear and intelligible style for which 
 he IS noted, may be received as an acknowledged authority, and as a guide to be Ibllowed with 
 implicit cuufideuce. 
 
AND SCIENTIFIC PUBLICATIONS. 29 
 
 TODD (ROBERT BENTLEY), M. D., F. R. S., 
 
 Professor of Physiology in King's College, London ; and 
 
 WILLIAM BOWMAN, F. R. S., 
 
 Demonstrator of Anatomy in King's College, London. 
 
 THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With 
 
 about three hundred large and beautiful illustrations on wood. Complete in one large octavo 
 
 volume, of 950 pages, leather. Price $4 50. 
 
 ^^ Gentlemen who have received portions of this work, as published in the " Medical News 
 AND Library," can now complete their copies, if immediate application be made. It will be fur- 
 nished as follows, free by mail, in pa|ier covers, with cloth backs. 
 
 Parts I., II., III. (pp. 25 to 502), $2 50. 
 
 Part IV. (pp. 553 to end, with Title, Preface, Contents, &c.), $2 00. 
 
 Or, Part IV., Section II. (pp. 725 to end, with Title, Preface, Contents, &c.), $1 25. 
 
 A magnificent contribution to British medicine, 
 and the American pliysician who shall fail to peruse 
 it, will have failed to read one of the most instruc- 
 tive books of the nineteenth century. — iV. O. Med 
 and Surg. Journal, Sept. 1857. 
 
 It is more concise than Carpenter's Principles, and 
 more modern than tlie accessible edition of .MQller's 
 Elements; its details are brief, but sufhciert; its 
 descriptions vivid ; its illustrations exact and copi- 
 ous ; and its language terse and perspicuous. — 
 Charleston Med. Journal, July, 1857. 
 
 We know of no work on the subject of physiology 
 
 so well adapted to the wants of the medical student. 
 Its completion has been thus loni^ delayed, that the 
 authors might secure accuracy by personal observa- 
 tion. — St. Louis Med. and Surg. Journal, Sept. '57. 
 
 Our notice, though it conveys but a very feeble 
 and imperfect idea of the magnitude and importance 
 of the work now under consideration, already tran- 
 scends our limits ; and, with the indulgence of our 
 readers, and the hope that they will peruse the book 
 for themselves, as we feel we can with confidence 
 recommend it, we leave it in tlieir hands. — The 
 Northteestern Med. and Surg. Journal. 
 
 TOYNBEE (JOSEPH), F. R. S., 
 
 Aural Surgeon to, and Lecturer on Surgery at, St. Mary's Hospital. 
 
 A PRACTICAL TREATISE ON DISEASES OF THE EAR; their Diag- 
 
 nosis. Pathology, and Treatment. Illustrated with one hundred engravings on wood. In one 
 very handsome octavo volume, extra cloth, $3 00. {Now Ready.) 
 
 Mr. Toyiil'ce's name is too widely known as the highest authority on all matters connected wilk 
 Aural Surgery and Medicine, to require special attention to be called to anything which he may 
 communicate to the profession on the subject. Twenty years' labor devoted to the present work 
 has embodied in it the results of an amount of experience and observation which perhaps no otlier 
 living practitioner has enjoyed. It therefore cannot fail to prove a complete and trui^tworthy guide 
 on all matters connected with this obscure and little known class of diseases, which so frequently 
 embarrass the general practitioner. 
 
 The volume will be found thoroughly illustrated with a large number of original wood-engrav- 
 ings, elucidating the pathology of the organs of hearing, instruments, operations, &c., and in every 
 respect it is one of the handsomest specimens of mechanical execution issued from the American 
 press. 
 
 The following condensed synopsis of the contents will show the plan adopted by the author, and 
 the completeness with which all departinents of the subject are brought under consideration. 
 CHAPTER I. Introduction — Mode of Investigation — Dissection. I[. The External Ear — Ana- 
 tomy — Pathology — .Malformations — Diseases. III. The External Meatus — Its Exploration. 
 IV. The External Meatus — Foreign Bodies and Accumulations of Cerumen. V. The External 
 Meatus — The Dermis and Its Diseases. VI. The External Meatus — Polypi. VII. The External 
 Meatus — Tumors. VIH. The Membrana Tynipani — Structure and Functions. IX. The Mem- 
 brana Tympani — Diseases. X. The Membrana Tympani — Diseases. XL The En>tachiaa 
 Tube — Obstructions. XII. The Cavity of the Tympanum — Anatomy — Pathology — Diseases. 
 XIII. The Cavity of the Tympanum— Di.>eases. XIV. The Mastoid Cells— Diseases. XV. 
 The Diseases of the Nervous Apparatus of the Ear, producing what is commonly called " Nerv- 
 ous Deafness." XVI. The Diseases of the Nervous Apparatus, continued. XVII. Malignant 
 Disease of the Ear. XVIII. On the Deaf and Dumb. XIX. Ear-Trumpets and their uses. 
 Appe.ndix. 
 
 WILLIAMS (C. J. B.), M.D., F. R. S., 
 
 Professor of Clinical Medicine in University College, London, tea. 
 
 PRINCIPLES OF MEDICINE. An Eleineataiy View of the Causes, Nature, 
 
 Treatment, Diagnoses, and Prognosis of Disease; with briet remarks on Hygienics, or the pre- 
 servation of health. A new American, from the third and revised London edition. In one octavo 
 volume, leather, of about 500 pages. S2 50. (Just Issued.) 
 We find that the deeply-interesting matter and i expressed. It is a judgment of almost unqualified 
 
 style of this book have so far fascinated us, that we 
 have unconsciously hung upon its pages, not too 
 long, indeed, for our own profit, but longer than re- 
 viewers can be permitted to indulge. We leave the 
 furtheranalysis to the student and practitioner. Our 
 Judgment ot the work has already been sufficiently 
 
 praise. — London Lancet. 
 
 A text-book to which no other in our language is 
 comparable. — Charleston Medical Journal. 
 
 No w^ork has ever achieved or maintained a more 
 deserved reputation. — Va. M(d. and Surg. Journal. 
 
 WHAT TO OBSERVE 
 AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. 
 
 Publishediindertheauthority of the London Society for Medical Observation. A new American, 
 
 from the second and revised Londoi. edition. In one very handsome volume, royal 12mo., extra 
 
 doth. $1 00. 
 
 To the observer who prefers accuracy to blunders I One of the finest aids to a yonng practitioner we 
 and precision to carelessness, this little book is in- have ever seen. — Peninsular Journal of Mtdieint. 
 valuable. — iV. II. Journal of Medic m*. I 
 
30 BLANCHARD b LEA'S MEDICAL 
 
 New and much enlarged edition— (Just Issued.) 
 
 WATSON (THOMAS), M. D., Sec, 
 Lute I'liysician tn the Middlesex Hospital, iic. 
 
 LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. 
 
 Delivered at King's Colleee, London. A new American, from the las-t revised and enlarged 
 
 Enffli^'h edition, with Additions, by D. Francis Co.ndie, M. D., author of "A Praciical Treatise 
 
 on the Di>eu*es olC'hildren," ice. With one hundred and eighty. five illustrations on wood. In 
 
 one very large and handsome volume, imperial octavo, of over 1200 closely printed pages in 
 
 email type; the whole strongly bound in leather, with raised bands. Price $4 Qf). 
 
 That the high reputation of this work might be fully maintained, the author has subjected it to a 
 
 ihorouKh revision; every portion has been examined wiih the aid of the most recent researches 
 
 in pathology, and the results of modern investigations in both Iheore'.ical and practical subjects 
 
 have f»een carefully weighed and embodied throughout its pages. The watchful scrutiny of the 
 
 editor has likewise introduced whatever possesses immediate importance to the American physician 
 
 in relation to diseases incident to our climate which are little known in England, as well as those 
 
 points in which experience here has led lodilferent modesof practice ; and he has also added largely 
 
 to the series of illu>trations, believing that in this manner valuable assistance may be conveyed to 
 
 the student in elucidating the text. The work will, therefore, l)e found thoroughly on a level with 
 
 the most advanced state of medical science on both sides of the Atlantic. 
 
 The additions which the work has received are shown by the (act that notwithstanding an en- 
 largement in the size of the pagp, more than two hundred additional pages have l>een necessary 
 to accommodate the two large volumes of the London edition (which sells at ten dollars), within 
 the compass of a single volume, and in its present form it contains the matter of at lea<t three 
 ordinary octavos, l^elievina it to be a work which should lie on the table of every physician, and 
 be in the hands of every student, the publishers have put it at aprice within the reach of all, making 
 it one of the cheapest books as yet presented to the American profession, while at the same time 
 the beauty ot its mechanical execution renders it an exceedingly attractive volume. 
 
 The fourth edition now appears, so carefully re- The lecturer's skill, his wisdom, his learning, are 
 vised, as to add eonsideniljiy to the value of a book equalled by the ease of his graceful diction, his elo- 
 already acknowledged, wherever the English Ian- quenee, and the far higher qualities of candor, of 
 guage is read, to be beyond all comparison the best courtesy, o( modesty, and of generous appreciation 
 8>Btematic work on tlie Principles and Practice of of merit in others. Mny le lo'ug remain to instruct 
 Physic in the whole range of medical literature, us, and to enjoy, in the glorious sunset of his de- 
 Every lecture contains proof of the e.xlreme anxiety dining years, the honors, the confidence and love 
 of the author to keep pace with 'he advancing know- gained during his useful life.— iV. A. Med-Chir. 
 ledge of the day, and to bring the results of the Reviete, July, ISSti. 
 
 labors, not only of physicians, but of chemists and ,,. , • ., j ,_ t u, 
 
 histologists, before his readers, wherever they can Watson's unrivalled, perhaps unapproachable 
 be turned to useful account. And this is done with work on Practice-the copious adduions made to 
 such a cordial appreciation of the merit due to the which (the fourth edition) have given it all the no- 
 industrious .)b8erver, such a generous desire to en- v^lty and much of the interest o| a new book.— 
 courage younger and rising men, and such a candid Charleston Med. Journal, July, 165... 
 acknowledgment of his own obligations to them. Lecturers, practitioners, and students of medicine 
 that one scarcely knows whether to admire most the ^yjn equally hail the reappearance of the work of 
 pure, simple, forcible English— the vast amount of Dr. Watson in the form of a new— a fourth— edition, 
 useful practical intormati<m condensed into the \Ve merely do justice to our own feelings, and, we 
 Lectures— or the manly, kind-htarted, unassuming are sure, of the whole profession, if we thank him 
 character of the lecturer shining thr.mgh his work. (,„ having, in the trouble and turmoil of a large 
 —London Med. Times and Gazette, Oct. 31, 1857. 1 practice, made leisure to supply the hiatus caused 
 Thus these admirable volumes come before the ! by the exhaustion of the puiilislier's stock of the 
 professit>n in their fourth eiliiion,abfmnding in those third edition, which has been severely felt for the 
 distinguished attributes of moderation, judgment, last three years. For Dr. Watson has not merely 
 erudite cultivation, clearness, and eloquence, with caused the lectures to be reprinted, but scattered 
 which they were from the first invested, but yet [ through the whole work we find additions or altera- 
 richer than before in the results of more prolonged tions which prove that the author has in every way 
 observation, and in the alile appreciation of the ] sought to bring up his teaching to the level of th« 
 latest advances in pathology and medicine by one j most recent acquisitions in science. — Brit, and For. 
 of the most profound medical thinkers of the day. — Medieo-Chir. Hevieui, Jan. 165S. 
 London Lancet, Nov. 14, 1857. | 
 
 WALSHE (W. H.), M. D., 
 
 Professor of the Principles and Practice of Medicine in University College, London, ie. 
 
 A PRACTICAL TUKATISE ON DI-JEASES OF THE LUNGS; including 
 
 the Principles of Physical Diagnosis. A new American, from the third revised and much en- 
 larged London edition. In one vol. octavo, of 4b8 pages. {Just Issued, June, 1860.) §2 25. 
 The present edition hns been carefully revised and much enlarged, and may be said in the main 
 to be rewritten. Descriptions of several diseases, previously omitted, are now iiitrixluced ; the 
 causes and mode of produc-tion of the more important allcclions, so far as they possess direct prac- 
 tical significance, are succinctly inquired into; an effort has been made to bring the description ol 
 anatomical characters lo the level of the wants of the practical physician ; and the diagnosis and 
 prognosis of each complaint are more completely considered. The sections on Treat.mext and 
 the Appendix (conceriiiiig ilic intluence of climate on pulmonary disorders), have, especially, been 
 largely extended. — Aiit/ior's Preface. 
 
 0,*^ To be followed by a similar volume on Diseases of the Heart and Aorta. 
 
 WILSON (ERASMUS), F. R. S., 
 
 Lecturer on Anatomy, London. 
 
 THE DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy. Third 
 
 American, from the last revised and enlarged Engli^h edition. Modified and rearranged, by 
 William Hunt, M. D., Demonstrator of Anatomy in the University ol Pennsylvania. In one 
 large and handsome royal 12mo. volume, leather, of 582 pages, with 154 illustrations. $2 00. 
 
AND SCIENTIFIC PUBLICATIONS 31 
 
 Ne'w and much enlarged edition — (Just Issued.) 
 
 WILSON (ERASMUS), F. R. S. 
 
 A SYSTEM OF HUiMAN ANATOMY, General and Special. A new and re- 
 
 vined American. frt)m the last and enlarged Eiigli>h Edition. Edited by W. II. Gobkkcht, M. D. 
 
 Professor of" Anatomy in the Pennsylvania Medical College, &:c. lllnstrated witli liiree hundred 
 
 and ninety-seven engravings on wood. In one large and exquisitely printed octavo volume, ol 
 
 over 600 large pages; leather. $3 25. 
 
 The publishers trust that the well earned reputation so long enjoyed by this work will l)e more 
 than maintained by the present edition. Besides a very thorough revision by the author, it has been 
 most carefully examined by the editor, and the elTorts of both have been directed to introducing 
 everything which increased experience in its ii>e has suggested as desirable to render it a complete 
 text-book tor those seeking to obtain or to renew an acquaintance with Human Anatomy. The 
 amount of additions wliich it has thus received may be estimated from the (iict that the present 
 edition contains over one-fourth more matter than the last, rendering a smaller type and anenlar^'ed 
 page requisite to keep the volume within a convenient size. The author has not only thus added 
 largely to the work, but he has also made alterations throughout, wherever there appeared the 
 opportunity of improving the arrangement or style, so as to present every fact in its most appro- 
 priate manner, and to render the whole as clear and intelligible as possible. The editor has 
 exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the 
 number of illustrations, of which there are about one hundred and fifty more in this edition than 
 in the last, thus bringing di>tinctly before theeye of the student everything of interest or imjiortance. 
 
 It may be recoininencled to the student as no less , beauty of its mecliiinical execution, and the clear- 
 distinguished by its accuracy and clearness of de- ness of tlie descriptions whidi it contains is equally 
 scriptnm tli;in by its typograpliical elegance. The evident, l^et, students, by all means examuie the 
 wood-cuts are exquisite. — Brit, and For. Medical claims of this work on their notice, bel'ure theypur- 
 ""■""'""" chase a text-book of the vitally important science 
 
 which this volume so fully and easily unfolds. 
 
 Lancet. 
 
 Review. 
 
 An elegant edition of one of the most useful and 
 accurate systems of anatomical science which has 
 been issued from the press The illustrations are 
 really beautil'ul. In its style the work is extremely 
 concise and intelligible. No one can possibly take 
 
 We regard it as the best system now extant for 
 students. — Western Lancet. 
 
 It therefore receives our highest commendation. 
 
 up this Volume without being struck with the great ] Southern Med. and Surg. Journal. 
 BY THE SAME AUTHOR. (Just Issued.) 
 
 ON DISEASES OF TPIE SKIN. Fourth and enlarged American, from the last 
 
 and improved London edition. In one large octavo volume, of 650 pages, extra cloth, $2 75. 
 
 The writings of Wilson, upondiseases of the skin, l at some of the more salient points with which it 
 are by fir the most scientific and practical that abounds, and which makeilincomparaurysupcriorin 
 have ever been prcsent«'d to the medical world on excellence to all other treatises<ni the subjectofder- 
 this subject. The present edition isa great improve- matology. No mere speculative views are allowed 
 meut on all its predecessors. To dwell upon all the a place in this volume, which, without a doubt, will 
 great merits and high claims of the work before us, for a very long period, be acknowledged as the chief 
 jer/affOT, would indeed be an agreeable service ; it standard work on dermatology. The princii)les of 
 would be a mental homage which we could freely an enlightened and rational therapeia are introduced 
 ofTer, but we should thus occupy an undue amount on every appropriate occasion. — Am. Jour. Med. 
 of space in this Jo«r»a/. We will, however, look Science, Oct. 1857. 
 
 ALSO, NOW READY, 
 
 A SERIES OF PLATES ILLUSTRATING WILSON ON DISEASES OF 
 
 THE SKIN ; consisting of nineteen beautifully executed plates, of which twelve are exquisitely 
 colored, presenting the Normal AnaU)my and Pathology of the Skin, and containing accurate re- 
 presentations of about one hundred varieties of disease, most of them the size of nature. Price 
 in cloth S-l "-5. 
 In beauty of drawing and accuracy and finish of coloring these plates will be found equal to 
 
 anything ol' the kind as yet issued in this country. 
 
 The plates by which this edition is accompanied . We have already expressed our high appreciation 
 
 leave nothing to be desired, so far as excellence of of Mr. Wilson's ireatise <m Diseases of the Skin. 
 
 delineation and perfect accuracy of illustration are The plates are comprised in a sejiarate volume 
 
 concerned. — Medico-Ckirursiical Hei-icw. which we counsel all those who possess the text to 
 
 Of these plates it is impossible to speak loo highly purchase. It is a beautiful tpecimen of color prinl- 
 
 The representatiims of the various forms of cutane- "'n i »"J 'he representations ol the various forms of 
 
 skin disease an- iis laithful as is possible in jilates 
 of the Bize.—Hoston Med. and Surg. Journal. April 
 S, 185«. 
 
 I 
 
 ous disease are singularly accurate, and ilie color- 
 ing exceeds almost anything we have met with in 
 point of delicacy and finish.— .Brjtii/i anrf Foreign 
 Medical Review. 
 
 BY THE SAME AUTHOR. 
 
 ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON 
 
 SYPHILITIC ERUPTIONS. In one small octavo volume, extra cloth, beautifully printed, with 
 four exquisite colored plates, presenting more than thirty varieties of syphilitic eruptions. »2 25. 
 
 BY THE SAME AUTHOR. 
 
 HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- 
 tion and Management. Second American, from the fourth London edition. One neat volume, 
 royal 12uio., extra cloth, of about 300 pages, with numerous illustrations. £1 00; pajn^r cover, 
 75 cents. 
 
 VVHITKHK.XDON THE CAUSES AND TREAT- I Second American Edition. In one volume, octa- 
 MENT OF ABORTION AND STERILITY. I vo extra cloth, pp. 308. «1 75. 
 
32 BLANCH^RD & LEA'S MEDICAL PUBLICATIONS. 
 
 WINSLOW (FORBES), M.D., D. C. L., &.c. 
 ON OBSCURE J)ISKA.SES UF TIJE IJllAIN AND DISORDERS OF THE 
 
 MIND; their inci|)ifiit Symptoms, Pathology, Diagnosis, Treatment, and Prophylaxis. In one 
 hniid>oine octavo volume, oC nearly GOO pages. {Just Issued, June, IMJQ.) §3 GO. 
 The momentous questions discussed in this volume have perhaps not hitherto been so ably and 
 elaboralelv treated. Dr. Winslow's distinguished reputation and long experience in everything re- 
 lating to insanity invent his teachings with the highest authority, and in. this carel"ully considered 
 volume he has drawn upon the accumulated resources of a life ol" observation. His deductions 
 are lounded on a vast number of cases, the peculiarities of which are relaied in detail, rendering 
 tlie work not only one ol sound in^truction, but of lively interest; the author's main object l)eing 
 to point out the connection between organic disease and insanity, tracing the laiter through all its 
 blages Iroiu mere eccentricity to mania, and urging the necessity of early measures of prophylaxis 
 and u|>iiropriute treatment. A subject of greater importance to society at large could scarcely be 
 named ; while to the physician who may at any moment be culled upon for interference in the most 
 delicate relations of life, or for an opinion in a court of justice, a work like the present may be con- 
 sidered indisjieusable. 
 
 The treatment of the subject may be gathered from the following summary of the contents : — 
 Chapter I. Introduction. — II. Morbid Phenomena of Intelligence. III. Premonitory Symptoms 
 of Insanity- — IV. Confessions of Patients after Recovery. — V. Stale of the Mind during Re- 
 covery. — Vl. Anomalous and Masked Affections of tlie i\lind. — VII. The Stage o( Coii.-eiousness. 
 — Vlll. Stage of Exaltation. — IX. Stage of Mental Depression. — X. Siage of Aberration. — XI. 
 Impaifmcnt of Mind. — Xil. Morbid I'henomena of Attention. — XIII. Morbid Plienomena of 
 Memory — XIV. Acute Disorders of Memory. — W. Chronic Affections of Memory. — XVI. 
 I'erversion and lOxaltalion of Memory. — XVII. Psychology and Palholcgy of ileinory — XVIII. 
 Morbid I'henomena of Motion. — XIX. ISIorbid Phenomena ol Speech. — XX. Morbid Phenomena 
 of Sensation. — XXI. iMorbid Phenomena of the Special Senses. — XXII. Morbid Phenomena of 
 Vision. Hearing, Taste, Touch, and Smell. — XXIII. Morbid Phenomena of Sleep and Dreaming. 
 — XXIV. Morbid Phenomena of Organic and Nutritive Life. — XXV. General I'rinciples of Pa- 
 thology, Diagnosis, Treatment, and Prophylaxis. 
 
 WEST (CHARLES), M. D., 
 
 Accoucheur to and Lecturer on Midwifery at :»t. Biirtlmlomcw's Hospital, Physician to the Hospital for 
 
 Sick Chililreii,&c. 
 
 LECTURES ON THE DISEASES OF WOMEN. Now complete iu one hand- 
 some octavo volume, extra cloth, of about 500 pages; price $2 50. 
 
 Also, for sale separate, Part II, being pp. 809 to end, with Index, Title matter, 
 
 (See, Svo., cloth, price $1. 
 
 and children is not to be found in any country. — 
 Southern Merl. and Svrg. Journal, January ISSe*. 
 
 We gladly recommend his Lectures as in the high- 
 est degree instructive to all wtio are iuterestcd in 
 obstetric practice. — London Lancet. 
 
 We have to say of it, briefly and decidedly, that 
 it is the best work on the sutjject in any language; 
 and that it stamps Dr. West as the facile princeps 
 of British obstetric authors. — EUinb. Med. Journ. 
 
 We mustnnw conclude this hastily written sketch 
 with the confident assurance to our readeis that the 
 work will well repay perusal. The conscientious, 
 painstaking, practical physician isapparent on every 
 page. — A'. Y. Journal of Medicine, March, 1858. 
 
 We know of no treatise of the kind so complete 
 an'l yet so compact. — Chicago Med. Journal, Janu- 
 ary, 185a. 
 
 A fairer, more honest, more earnest, and more re- 
 liable investigator of the many diseases of women 
 
 BY THE SAME AUTHOR. {Nolo Ready.) 
 
 LECTURES ON THE DISEASES OF INFaNCI AND CHILDHOOD. 
 
 Third American, from the fourth enlarged and improved London edition. Iu one handsome 
 
 octavo volume, extra cloth, of about six hundred and fifty pages. $3 75. 
 
 The continued favor with which this work has been received has stimulated the author to ren- 
 der it in every respect more complete and more worthy the confidence of the prol'ession. Con- 
 taining nearly two hundred pages more than the last American edition, with several additional 
 Lectures and a careful revision and enlargement of those formerly comprised in it, it can hardly 
 fail to maintain its reputation as a cle»»r and judicious text-book for the student, and a safe and 
 reliableguide for the practitioner. The fact staled by the author that these Lectures '• now embody 
 the results of 'JOO observations and "288 post-mortem examinations made among nearly oO,000 
 children, who, during the past twenty-years, have come muier my care," is suliicient to show their 
 high practical value as the result of an amount of' exjierience which few physicians enjcy. 
 
 The three former editions of the work now before i diseases it omits to notice altogether. But those 
 us have placed the author in llie foremost rank of who know anything of the present condition of 
 lliosc physicians who have L'evotfd special attention pajdiatrics will readily admit that it would he next 
 to the iliseanes of early life We aiteinpt no ana- to impossible to effect more, or elfeot it belter, than 
 1} lit of til is edit ion, l>ul may refer the reader to some i the accoucheur of St. Bartholomew's has done m a 
 of the chapters to which the largest additiiins have I single volume. The lecture (XVl.) up(ui Disorcirs 
 
 been made — those on Uiplitheria, Disonlcrs of the 
 .Mind, niid lilincy, for instuiioe — as a prooi that the 
 work IB really u new edition; not a mere roprint. 
 In its prcienl shape it will be lound of the greatest 
 possible service in the cvery-day prnetiee of nine- 
 trnlliB of the professKm. — Med. times and Oazetle, 
 L.'nd<.n,Dcc. in, l?ol>. 
 All tilings considired, this book of Dr. West is 
 
 of ihe Mind in children is an admirable specimen of 
 the value ol the later inforinution eonvejed in the 
 Lectures of Dr. Charles W'esl. — London Lancet, 
 Oct. 2-2, 1S59. 
 
 Since the appearance of the first edition, about 
 eleven years ago, the experience of the author has 
 doubled ; so that, whereas the lectures at first were 
 founded on six hundred observations, and one hun- 
 
 hy fur the best treatise in our language upon such dred and eighty dissections made among nearly four- 
 niodihcations of morbid action and diseise as are teen thousand children, they now embody the results 
 witnessed when we have to deal with infancy and I of nine hundred observations, and two hundred and 
 childhood. It is true that it confines itself to such | eighty-eight post- mortem examinations made among 
 disorders as come within the province of the phy- nearly thirty thousand children, who, during the 
 iifian, and even with respect tn these it is unequal past twenty years, have been under his care. — 
 ns regards minuteness of consideration, and some j British Med. Journal, Oct. 1, 1859. 
 
 BY THE SAME AUTHOR. 
 
 AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCER- 
 ATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 00. 
 
GENERAL LIBRARY 
 UNIVERSITY OF CALIFORNIA— BERKELEY 
 
 RETURN TO DESK FROM WHICH BORROWED 
 
 This book is due on the last date stamped below, or on the 
 date to which renewed. 
 
 Renewed books are subject to immediate recall. 
 
 -£5- 
 
 m... r j 
 
 i OCT ? i^^4 
 
 OCT 1 o 1954 
 
 JUn 2 19G4 
 
 Lih^-^'i^j/ 
 
 21-lOOm-l. '54 (1887816)476 
 
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