Chapter XLIX: Introduction: The object of the following essay is to give, as far as (5)

IDIOPATHIC EPILEPSY.--In idiopathic epilepsy--that is, in those cases where no gross changes in the brain can be demonstrated by autopsy--the eye symptoms are numerous and interesting. Wecker[287] tells us that at the commencement of the spasm there is contraction of the pupils. Usually, soon after the tonic spasm sets in or coincident with it, we have marked dilatation of the pupil and an abolition of the eye-reflexes, this {798} being shown by the want of contraction of the orbicularis or of the pupil when the conjunctiva is touched. Reynolds, Echeverria, Clouston, and Hammond have called attention to a development of hippus (an alternate contraction and dilatation of the pupil) at the end of the convulsive paroxysms; but this is exceptional. The last author considers a state of alternate contraction and dilatation of the pupils, or a contraction of one pupil with dilatation of its fellow, to be characteristic of the convulsive stage. When the convulsions are unilateral the head and eyes are often turned toward the convulsed side. Although ophthalmoscopic examination is favored by dilatation of the pupil, yet the convulsions make it so difficult that we have quite conflicting accounts of the state of the disc and retina during the paroxysm. Six cases have been accurately examined by Albutt during the convulsion, in three of which there was congestion of the disc, and pallor in the remainder. Jackson also reports cases of pallor during the convulsion. More lately, Schreiber[288] has examined three cases in which he found pallor in the convulsive stage, this being very marked in one case, where the convulsion was violent. Gowers, on the other hand, maintains that in convulsions which commence locally without initial pallor of the face he was unable to perceive any alteration of the calibre of an artery which he kept continuously in view during the convulsion. The same author tells us that during the stage of cyanosis the veins of the retina become distended and dark, and that once in the status epilepticus he has seen a congestion of the discs with oedema, which subsequently disappeared. He does not consider that there is any abnormal appearance of the discs in the intervals between the attacks, while both Albutt and Bouchut hold that they are congested. In several of the chronic cases which the writer has had an opportunity of examining there has been a low grade of atrophy of the discs with concentric limitation of the field of vision. That this, at least, is common in advanced cases is well shown by the observations of Michel,[289] who in 1867 published careful examination of the eye-ground, acuity, and field of vision of 58 epileptics. In 15 of these cases there were no visible changes; in 10, hyperæmia; in 1, hyperæmia with oedema; 1 of hyperæmia passing into atrophy; 10 of unilateral atrophy (9 of the right nerve and 1 of the left); 13 cases of atrophy of both optic nerves; the remaining cases showing changes in the eye-ground which were probably attributable to other causes. Auræ which affect the special senses have been recorded, and have been usually described as flashes of light or balls of fire. Maisonneuve (quoted by Robin) gives an instance where the auræ consisted in convulsions of the eyelids. Gowers gives 119 cases of auræ which affected the special senses, 84 of these being of the sense of sight. He divides the latter into five classes: I. Sensation in the eyeball; II. Diplopia; III. Apparent increase or diminution in the size of objects; IV. Loss of eyesight; V. Distinct visual sensations, consisting sometimes of flashes of light, colored spectra, and rarely some more specialized sensation, such as an apparition. The only one of these cases in which there was an autopsy appears to have been one of symptomatic rather than idiopathic character, as there was found a tumor of the occipital lobe which had extended as far forward as the angular gyrus.

[Footnote 287: _G. u. S._, Bd. iv. p. 565.]

[Footnote 288: _Ueber Voränderungen des Augenhintergrundes, etc._, 1878 (S. 42).]

[Footnote 289: _Inaug. Diss._, von Dr. Julius Michel, Würzburg, 1867.]

{799} HYSTERO-EPILEPSY.--The remarkable co-ordinated convulsions which are associated with hemianæsthesia, and which have been so minutely described by Charcot as characteristic of this disease, are constantly accompanied by subjective or objective disorders of the visual apparatus. Visions of animals, such as rats, vipers, crows, cats, etc., frequently precede the convulsive seizure, followed by a transient loss of sight; a return of the illusions (sometimes pleasant and gay, at others erotic in their nature, or again sad or terror-striking) coming on in a later stage. It is said that processions of animals are often seen, which usually come and go on the hemianæsthetic side as the attack passes off and the patient becomes quiet. The objective symptoms have been carefully studied by Landolt in Charcot's wards. They were found by him to consist in a diminution of the acuity of vision and a concentric limitation of the field for form and color. All these symptoms are bilateral, and much more marked on the anæsthetic side, they occurring before any ophthalmoscopic changes are visible. These are followed later by alterations in the eye-ground, which consist at first of slight congestion and oedema of the discs, followed by partial atrophy. The difference in the affection of the two eyes was so marked that Charcot at first described it as a crossed amblyopia, but he admits that the lesion is bilateral, as above described.[290]

[Footnote 290: _Leçons sur les Localisations dans les Mal. du Cerveau_, vol. i. p. 119 (foot-note), Paris, 1876.]

EXOPHTHALMIC GOITRE.

GRAVE'S DISEASE; BASEDOW'S DISEASE.--The most prominent characteristics of this affection are an irritability of the heart with increased frequency of the pulse, and enlargement of the thyroid gland and a swelling of the tissues of the orbit, which cause the eyeballs to become prominent. The size of the goitre and the amount of protrusion of the eyeball vary very much in different cases. Frequently there is a symptom to which Graefe was the first to call attention--namely, a disturbance of the usual consensual movements of the eyeball and upper eyelid. When the patient looks downward below the horizontal line, the lid no longer accompanies the eyeball in its motion, but halts in its course. This derangement in the action of the lid is supposed to depend upon some defect in the innervation of the orbicularis, as it is not present in cases of equal prominence of the eyeball from other causes. The amount of secretion from the tear-glands and from the conjunctival surface is also at times much diminished. Owing to the prominence of the eyes and the relaxation of the orbicularis, the fissure of the lids is wider open than usual, and the eye has a peculiar stare. At times, when the prominence of the eyes is very great, the lids fail to cover the balls during sleep, and the cornea becomes inflamed and ulcerated from exposure to air and dust. The disease rarely develops till after puberty, and is more frequent in females than in males: in the former it often develops after childbirth. It is so frequently accompanied by disease of the reproductive organs that Foerster, in his paper on the "Relation of Eye Diseases to General Disease,"[291] places it in the section devoted to eye symptoms from diseases of the sexual organs. Ophthalmoscopic examination usually shows a slight thickening of the fibre-layer of the retina in and around the disc, with dilatation and tortuosity of the veins--a state of affairs which may often {800} be fairly attributed to venous stasis caused by the swelling tissues. In addition to these symptoms there is sometimes, as Becker has pointed out, a dilatation of the arteries, which may almost equal the veins in calibre. At times there is an arterial pulse. As found by autopsies, the anatomical changes are usually enlargement and dilatation of the heart, hypertrophy and various degenerative changes in the thyroid glands, and a state of hyperæmia at times associated with hypertrophy of the fat tissue of both orbits.

[Footnote 291: _Graefe und Saemisch_, vol. vii. p. 97.]

Affections of the General System.

CHOLERA.--In this disease the eyelids are said to show an early development of cyanosis, which becomes more marked as this symptom develops in other parts of the body. The contents of the orbits shrink and the eyes are drawn back in their sockets, there being an imperfect closure of the lids, which leads at times to necrosis of the exposed lower part of the cornea. There is a marked diminution in the secretion of tears, and often a dilatation of the veins of the exposed part of the conjunctiva bulbi, which are turgid with the black blood, this state being at times accompanied by subconjunctival hemorrhages. The pupils are usually contracted. The retinal arteries are much diminished in size, and the veins although not dilated, are filled with blackish blood. Owing to the great feebleness of the circulation, the slightest pressure with the finger on the eyeball produces arterial pulse; Graefe[292] in some cases describes a pulsating movement of interrupted blood-columns in the veins, such as is sometimes seen in incomplete embolism of the arteria centralis.

[Footnote 292: _A. f. O._, xii. 2, p. 210.]

RHEUMATISM AND GOUT.--In the older books on diseases of the eye we constantly meet references to rheumatic and arthritic forms of inflammation of that organ. In the later works on the subject the list has been greatly reduced, partly because an anatomical classification has been attempted, and partly because many such affections have been attributed to other causes, such as syphilis, etc. Catarrho-rheumatic ophthalmia, rheumatic iritis, rheumatic paralysis of the eye-muscles, etc. have been so classified, not on account of their occurrence in the course of attacks of acute rheumatism, but because the writers have been unable to attribute them to any other source than that designated as having taken cold. That recurrent attacks of iritis are frequent in some individuals who have recurrent attacks of chronic inflammation of the joints is a fact familiar to many practitioners, amply attested by the cases published by Hutchinson[293] and by Foerster.[294] As regards gout, the direct proofs of its relations to eye disease are still less manifest, and most cases supposed to be attributed to this cause by both the older and more modern writers are to be classed as primary or secondary glaucoma.

[Footnote 293: "A Report on the Forms of Eye Disease which occur in connection with Rheumatism and Gout," by Jonathan Hutchinson (_R. L. O. H. Reps._, vol. vii. pp. 287-332; also vol. viii. pp. 191-216).]

[Footnote 294: "Beziehungen der Allgemein-Leiden, etc., zu Veränderungen des Sehorgans," _Graefe u. Saemisch_, vol. vii. pp. 155-160.]

SYPHILIS.--All the tissues of the eyeball and eyelids may at times manifest the signs of this dread and searching dyscrasia, although it is {801} rarely so marked in its character as to be distinguished with certainty from other forms of eye disease by its appearance alone. Primary syphilis of the lid is rare, but when it occurs it is liable to be mistaken for epithelioma, where there is absence of a distinct history of infection. In the eyeball itself the uveal tract (iris, ciliary body, and choroid) is the favorite seat of disease. Iritis is said by Fournier[295] to be developed in from 3 to 4 per cent. of all cases of syphilis, and, according to Coccius, 11-6/10 per cent. out of 7898 cases of eye disease in Leipzig were due to this cause. Syphilitic iritis certainly constitutes a large proportion of the cases of inflammation of the iris seen in hospital practice: Coccius places the percentage at 46-6/10 per cent., while Wecker puts it at 50 to 60 per cent. It usually develops during the subsidence of the secondary skin affections, and is often to be distinguished by its insidious course and the amount of plastic exudation which accompanies it. There is ciliary injection and sluggishness of the pupil, with the formation of synechiæ, before there is any very decided pain or photophobia, this latter being usually strongly developed at a later period. The formation of gummata in the iris, which are generally seen in the smaller circle, is much rarer, generally developing in the tertiary stage of the disease; occasionally they are developed in the ciliary body. In the former situation they usually disappear under active treatment, leaving fair vision in the eye, but when situated in the latter place they usually lead to shrinking and atrophy of the eyeball, even under the most vigorous treatment. When iritis occurs in infants it is generally specific in origin. When they are born with posterior synechiæ and complicate cataract, similar occurrences during intra-uterine life may be suspected. Syphilitic choroiditis is frequent, but its frequency is probably overrated on account of a disposition to assume syphilis as a cause of cases of choroiditis in which the pathology is not evident. Foerster has very properly pointed out that a majority of the cases of disseminate choroiditis are not due to this cause, and that the changes are developed slowly, and remain stable for a long time even when not treated; while the usual form of specific choroiditis shows rapid progress, with failure of the sight, photopsies, vitreous opacities, hemeralopia, and zonular defects in the field of vision. Opinion, however, is divided on this point: Wecker thinks that two-thirds of the cases of disseminate choroiditis are due to syphilis. In many of the chronic cases of syphilitic choroiditis there is a wandering of the pigment out of the cells of the choroidal epithelium, and a distribution of it into the lymph-sheaths of the retinal vessels and capillaries, these changes producing ophthalmoscopic appearances which closely resemble those of typical pigmentary degeneration of the retina. Affections of the head of the optic nerve and superficial layers of the retina, such as are represented by Liebreich,[296] are much more rare, but the writer has repeatedly seen them both at Liebreich's Paris clinic and in our own hospitals. They are characteristic, and usually accompany the tertiary symptoms. There is a dense haze which seems to lie partly in front of the retina, and to extend around the disc for a space of one and a half to two disc-diameters, generally including the macula lutea, and rapidly diminishing as it approaches the equator. Vision is usually much reduced, and even under persistent {802} antisyphilitic treatment it is slow to clear up. Hereditary syphilis frequently manifests itself in an interstitial keratitis, which begins with small irregularly-rounded dots near the centre of the cornea. They gradually become more numerous, and coalesce, until the membrane appears as if a thin layer of ground glass had been imbedded in its tissue, leaving the epithelium clear and bright. Although there is no ulceration, yet there is a great tendency to the formation of new blood-vessels, which often goes on until the entire cornea is permeated by them and becomes of a dull venous blood-like red color. These vessels are continuous with superficial and deeper shoots which pass in from the two layers, normally forming loops in the corneal periphery. This form of keratitis is usually accompanied by marked photophobia, pain, ciliary injection, and low grades of iritis. The pathological processes which take place in the cornea during the disease generally leave it more or less clouded, and often much misshapen by softening and alteration of its curvature.

[Footnote 295: Quoted by Foerster, _Graefe und Saemisch_, vol. vii. p. 189.]

[Footnote 296: Plate 10, Fig. 2, ed. 1863.]

TUBERCULOSIS.--Except in children, the eyeball is rarely the seat of a deposit of tubercles, and even then it is much more likely to give evidence of their seat in the membranes of the brain by its secondary affection than to be itself directly affected by them. When they form in the eye, they may affect the choroid, the intraocular end of the optic nerve, the retina, or the iris. Jaeger was the first to call attention to their ophthalmoscopic appearances. Their favorite seat, as is well shown in one of Jaeger's plates, is the macular region and its vicinity. They develop in the stroma of the choroid, and appear as whitish-yellow spots varying from one-eighth the diameter of the optic disc to the size of the disc itself, and by aggregation may form even larger masses. They are usually seen in cases of well-marked acute miliary tuberculosis, although doubtless they are often overlooked, on account of not giving rise to any symptoms; besides, thorough ophthalmoscopic examination of such sick and restless children is difficult, and the general diagnosis is usually well made out from other symptoms. They may, however, precede all other symptoms, as in the cases reported by Steffen[297] and Fraenkel.[298] Development of tubercular masses in the intraocular end of the opticus has been described by Chiari,[299] Michel,[300] and Gowers.[301] In the case cited by the last author the growth extended from the disc to the ora serrata, which during life gave rise to the peculiar reflection from the eye so often seen in intraocular tumor. According to Cohnheim,[302] tubercle is to be found in the choroid in all cases of acute miliary tuberculosis. Other observers, however, have not been able to support him in this assertion: Albutt,[303] who repeatedly searched for them both in living and dead subjects, failed to find them; Garlick[304] during two years' experience at a children's hospital found them but once; Heinzel[305] in ten cases of general tuberculosis in children was at the autopsies unable to find any tubercles of the choroid. According to Stricker, they may at times develop very rapidly, coming on in from twelve to twenty-four hours. Tubercles have been {803} found in the retina in the cases of papillary tuberculosis already referred to, and also with cases of tubercle in the iris (Perls, Manfredi). At times, tubercles in the iris occur in scrofulous and feeble children, appearing as growths in all respects closely resembling syphilitic gummata. As in the latter case, they are accompanied by severe iritis, and at times with hypopyon. Tuberculosis of the conjunctiva is a very rare affection. It is described as commencing with swelling of the lids, and when these are everted exuberant granulations of the conjunctiva are seen which are most frequently situated in the retrotarsal folds. These granulations are at first of a grayish-red color, but when they have existed for some time, superficial erosion of their surface occurs, and uneven yellowish-red ulcers are formed. The disease usually occurs in young people, and generally affects but one eye. Haab[306] has given a description of six cases of it, with reference to a few instances described by other authors.

[Footnote 297: _Jahresbericht f. Kinderheilkunde_, 1870 (Gowers).]

[Footnote 298: _Berliner klinisches Wochenschrift_, 1872, pp. 4-6 (Foerster).]

[Footnote 299: _Wien. Med. Jahrbucher_, 1877, p. 559.]

[Footnote 300: _Archiv der Heilkunde_, 1873.]

[Footnote 301: _Medical Ophthalmoscopy_, 1879, p. 250.]

[Footnote 302: _Virch. Arch._, 1867, Bd. xxxix. p. 49 (Foerster).]

[Footnote 303: Quoted by Gowers, p. 203.]

[Footnote 304: Quoted by Gowers, _Med. Ophth._, p. 200.]

[Footnote 305: Quoted by Foerster, p. 99, _Jahrbuch der Kinderheilkunde_, Neue Folge, viii., 3, p. 331.]

[Footnote 306: "Die Tuberculose des Auges," _A. f. O._, xxv., 4, p. 163.]

Toxic Amblyopiæ.

TOBACCO AND ALCOHOL.--These two lesions strongly resemble each other, and it is impossible to differentiate them when we find them in persons who are addicted to the abuse of both of these drugs; consequently, for a time, in Germany, there was a disposition to underrate the potent destructive agency of the latter drug, but every practitioner of experience in eye disease must have seen cases of tobacco amblyopia in which there has been no abuse of alcohol. The best proof of the deleterious influences of tobacco on the eyesight is the improvement which results by simple abstinence from its use where the vision has been seriously affected by its influence. In the earlier stages of both forms of amblyopia there is a contracted pupil and a slight dimness of vision, the patients claiming that they see better in feeble light and twilight. The ophthalmoscope shows a slight oedema of the disc with tortuosity of the veins, the rest of the eye-ground appearing normal. Later, the usual appearances of blue-gray atrophy set in. In the earlier stage there are often color scotomata, which are usually ovoid in form and lie between the disc and the macula lutea. Unless carefully looked for with color squares of one to two millimeters in diameter, they are apt to be overlooked. Later, there is a marked reduction of central vision. When the atrophy has progressed farther, there is decided contraction of the field.

LEAD-POISONING.--The deleterious effects of lead on the eyesight are undoubted, although rare in proportion to the cases of colic and wrist-drop produced by this metal. When amaurosis develops, it is usually either in acute lead-poisoning or after a gradual saturation of the system, as is shown by repeated attacks of lead colic. In either case the amaurosis is usually accompanied by dilatation of the pupils, delirium, and convulsions. The amaurosis generally passes off, and the pupils contract with the return of vision, although it may remain permanent, and leaves the patient with atrophic nerves, as in a case observed by Trousseau, where the patient was subsequently transferred to the Salpêtrière. The only two cases which the writer has had an opportunity of witnessing showed {804} marked choking of the discs and severe cerebral symptoms. One of these cases died and one recovered: both were results of the use of white lead as a cosmetic. Rognetta[307] quotes Vater as reporting a case of hemianopia produced by lead-poisoning, which recovered when the lead colic was cured. Trousseau[308] quotes Andral as giving a case of diplopia due to the same cause, and disappearing as the patient recovered.

[Footnote 307: _Recherches sur la Cause et la Siège d'Amaurose_.]

[Footnote 308: _Thèse de Concours_.]

QUININE.--Over-doses of quinine seriously impair the eyesight, and in some cases have produced temporary but absolute blindness. The usual symptoms are a deterioration of central vision and a contraction of the field. The ophthalmoscopic examination reveals a pallid disc with marked diminution in the size of the retinal arteries and veins. In many of the reported cases it is difficult to decide positively how much of the amaurosis is due to the quinine and how much to the disease for which the patient is under treatment. This is especially true where the patient has been suffering from severe intermittent fever or from exhausting hemorrhages complicating uterine disease, which are well known frequently to produce more or less complete atrophy, with shrinking of the vessels. There are, however, a sufficient number of well-observed cases on record to satisfactorily establish the lesion. One of the most striking is a case of poisoning recorded by Giacomini, where the patient took at one dose three drachms of sulphate of quinia by mistake for cream of tartar. This was followed by severe headache, pain in the stomach, dizziness, unconsciousness, with slow and scarcely perceptible pulse and infrequent respiration. The pupils were widely dilated. On regaining consciousness the patient found that he was almost blind, the weakness of sight lasting a long time. As the poisoning occurred in the preophthalmoscopic era, there is of course no description of the eye-ground. In all recorded cases, while central vision has been either partially or entirely regained, the field of vision has remained permanently contracted.

SANTONIN.--In very large doses santonin produces dilatation of the pupil, amblyopia, and complete color-blindness. Smaller doses produce a shortening of the violet end of the spectrum and cause yellow vision. The disturbance of vision usually lasts only a few hours. The poison seems to be eliminated by the urine, as the sight is said to become normal while traces of the drug can still be seen in the secretion of the kidneys. Rose has given us a most careful study of this subject in his papers entitled "Color-Blindness from Santonin"[309] and "Hallucinations in Santonin Intoxication."[310]

[Footnote 309: _Virch. Arch._, Bd. xx., 1860 (Separat Abdruck, S. 48).]

[Footnote 310: _Ibid._, Bd. xxviii., 1863 (Separat Abdruck, S. 12).]

SALICYLATE OF SODIUM.--Gatti[311] reports a case of transient amblyopia, due to the ingestion of one hundred and twenty grains of salicylate of sodium, in a sixteen-year-old peasant-girl who had acute articular rheumatism. There were no changes in the eye-ground except a fulness of the veins, which persisted after the eyesight had returned. There was mydriasis. No phosphenes could be produced. As the urine did not present any traces of salicylate of sodium, it would seem to show that it was not eliminated by the usual emunctories.

[Footnote 311: _Gaz. d. Ospital Milano_, p. 129, 1880; _Nagel's Jahresbericht_, 1882 (Lit. 1880), p. 245.]

{805}

MEDICAL OTOLOGY.

{806}

{807}

MEDICAL OTOLOGY.

BY GEORGE STRAWBRIDGE, M.D.

In this article on Medical Otology it is proposed to include those diseases of the ear that are frequently seen by the general practitioner, and especially those that exist as sequelæ to some general disease, and where the ear complication would be treated in connection with the general disorder.

Examination of a Patient.

As nearly all ear patients are afflicted with varying degrees of deafness, one of the first points of inquiry will be as to their hearing power. There are three tests commonly employed for this purpose: the ticking of a watch, the human voice, and the tuning-fork.

1st. The Watch.--By this method of examination the patient is placed with closed eyelids, so as to exclude the visual power as a factor in the examination, as it is a curious fact that many people are apparently unable to distinguish between seeing a watch and hearing its tick, and therefore so long as they can see the watch they will imagine that they can hear it ticking. Bring the watch (held by the physician) from a distance toward the patient until the tick is heard, and note the distance in inches. The plan of holding the watch close to the ear, and then slowly removing it until the extreme limit of hearing is attained, gives an incorrect result as regards the distance that the watch can be heard, due to the fact that the impressions produced on the terminal endings of the auditory nerve by the watch-tick continue a sensible time after the watch-tick has passed out of the nerve-limit, and therefore the watch-tick can still be noted. Prout has prepared a convenient method for recording the hearing power. Note the number of inches that the watch-tick can be heard by a normal ear, and let this serve as a denominator of a fraction, the numerator of which is the number of inches that the same watch-tick can be heard by the ear of the person under examination. For instance: a normal ear can distinguish my watch-tick at a distance of twenty inches; if, now, the patient's ear can perceive the same sound at only five inches, the hearing power would be noted as 5/20. By this it is not meant that the hearing power is one-fourth of normal hearing, as it would be only one-sixteenth of normal hearing, as the volume of sound is inversely in proportion to the square of the distance.

2d. The human voice tells more about the hearing power for practical purposes than does the watch. There are many persons who can readily {808} hear the watch-tick at several inches, and yet who hear very imperfectly ordinary conversation, and also many who hear very well the human voice and very badly the watch-tick. The method of examination is to speak ordinary words in a tone that can be heard by the average ear a given number of feet, and to note the distance in feet that the ear under observation can detect the words that are spoken. In this way can be noted the hearing power of the human voice, the numerator of the fraction being the distance that the word can be heard by the observed ear, the denominator being the distance that the word can be distinguished by the normal ear.

The patient should always be examined with closed eyelids, as deaf people quickly learn by watching the movements of the lips of the speaker to know the words that are being spoken. Another precaution is to have the ear to be tested directly opposite the mouth of the observer, the other ear being firmly closed.

3d. The Tuning-Fork.--Bone-conduction of sound is used by this method. The great use of the tuning-fork is in determining diseased conditions of the auditory nerve and internal ear, and it enables one to make a differential diagnosis as to whether deafness is due to a diseased condition of the sound-conducting apparatus or whether the nerve portion of the ear is at fault. For instance: a patient complains of deafness. This may be due to some obstruction in the external auditory canal, such as impacted cerumen, or it may be due to a diseased middle ear, with thickening of its membranes, or it may be due to a diseased internal ear. The watch and human voice would only show the ear to be defective in its hearing power, and it may be from any of the above-mentioned causes. The tuning-fork, in vibration, placed on an incisor tooth or on the frontal bone, would bring out the fact that if the deafness was due to a diseased middle ear or obstruction in the external auditory canal, the tuning-fork would be heard best by the defective ear; but if due to a disease of the internal ear, it would be heard the least distinctly by the defective-hearing ear. Mack explains this by the supposition that the sound-waves are prevented from freely escaping through the sound-conducting apparatus, and are reflected back on the auditory nerve-elements, and thus make a double impression. Tuning-forks having the note C are best adapted for this examination.

EXAMINATION OF THE EXTERNAL CANAL AND TYMPANIC MEMBRANE.--This can be done by direct or by reflected light, better by the latter. A mirror and speculum are needed. The mirror should be concave, with a focal distance of from 5"-7" and a diameter of 2½"-3", with a ball-and-socket-joint and head-band, so as to allow of the two hands being free, the head holding the mirror in the required position. The mirror should have a central perforation of 2'''-3''', with a brass back, rendering it less liable to break. As a light-source can be used the light from an argand burner, but preferably sunlight reflected from a cloud or white wall.

The Ear Speculum.--The Wilde or Gruber speculum answers equally well. The Wilde speculum is cone-shaped, and best of German silver: it is easily cleansed and has four sizes. The Gruber speculum has a larger mouth and gives a large visual field. It has a parabolic curve, for the purpose of admitting more light; there are also four sizes. The {809} speculum should be warm when in use, and is to be held in position in the canal by the thumb and forefinger of the left hand. Often in the examination of an external canal an angular-toothed forceps is needed to remove foreign substances.

The cotton-holder is a most important instrument, furnishing a means of thoroughly drying the external canal of any fluid with the least possible amount of irritation--much less than that caused by the use of the ear-syringe. It is a slender steel rod 6" long, having a number of serrations at one end to more easily allow cotton to be wrapped around it; the other end has a convenient handle. In using this instrument a small tuft of well-cleansed cotton is wrapped around the holder, so that one half of the length of the cotton tuft projects beyond the end of the instrument. By slight adaptation with the fingers the cotton roll can be made soft or quite firm, and large or small in proportion to the amount of cotton used. The cotton-holder should always be used under the light from the head-mirror.

The curette is of the same length as the cotton-holder, but is made of heavier steel, and terminates at one end in a small ring of a diameter of from 2-3 mm. It is useful in removing scabs, etc. from the external canal, also in loosening impacted cerumen.

Probes are also needful. A good middle-ear probe is made of a single piece of silver, of the same length as the cotton-holder, and tapering down to a slender shank with a small knob-like ending.

The ear syringe, a most excellent instrument, is now made of rubber, holding two ounces of fluid, and has a bulbar extremity, so as to avoid injuring the external canal or tympanic membrane. The syringe has a finger-rest, with the piston ending in a ring, so as to admit of its use with one hand. In using a syringe warm water should be always employed, and at a temperature that the finger would indicate as being quite warm. Also at first force the water very gently into the meatus, so that the patient shall not be startled; also it is well to bear in mind that many patients become very giddy under its use, necessitating either very gentle use or its being abandoned for the time.

EXAMINATION OF THE EUSTACHIAN TUBE.--The main point is as to whether the tube permits the free passage of air up to the middle ear. This can be ascertained by three methods: 1. Valsalva's method; 2. Politzer's method; 3. Catheterization of the tube.

Valsalva's method consists in forcing air through the tube by a forced expiration, the mouth and nasal passages being at the same time firmly closed. The patient can distinctly feel the air pressing against the tympanic membrane, causing it to bulge outwardly, provided the tube is open. This proceeding has certain disadvantages, sometimes causing head congestions and giddiness.

Politzer's Method.--In this proceeding a gum air-bag is used as the means of forcing air into the tube. In the act of swallowing the soft palate is drawn against the posterior wall of the pharynx, and at the same time the pharyngeal mouth of the tube is well opened, so that air forced through the nasal passages at such a moment, being prevented from passing downward by the up-drawn palate, is forced up through the Eustachian tube into the middle ear. The success of this procedure depends entirely upon the inflation being made at the same moment that {810} the soft palate is drawn up against the pharyngeal wall; otherwise the air would naturally pass by the widest passage, in this case downward into the stomach. The usual plan of inflating at the moment that the patient is told to swallow fails, from the fact that patients differ so materially in the quickness with which they respond to an order. Many in their anxiety will swallow before the word is given, others will allow an appreciable time to pass before swallowing, so that the inflation will fail. For this reason I have adopted the following plan: It is well known that in the act of swallowing the larynx is drawn forcibly upward, and also that the moment of the extreme elevation is nearly coincident with the moment that the soft palate is drawn against the wall of the pharynx. The prominence of the thyroid cartilage (the so-called pomus Adami) enables one to easily watch until the maximum elevation of the larynx is reached, and then quickly, by a forcible contraction of the air-bag, to thoroughly inflate the middle ear. The Politzer method so thoroughly accomplishes the object, and with the least possible irritation, that the use of the catheter in the majority of cases is no longer indicated. The method of Politzer is as follows: The patient takes some water in the mouth; the air-bag has attached to it a short piece of gum tubing ending in a nose-piece in shape like an olive, or sometimes a small gum catheter is attached to it. This is placed in the lower nasal passage and the nose held firmly closed over it with one hand, the second hand grasping the air-bag. The patient is then told to swallow, so as to cause elevation of the soft palate (this can also be accomplished by the patient speaking quickly some word like _hoc_), and the air-bag is forcibly pressed. In this way the air is quickly driven, viâ the nasal passage and Eustachian tube, into the middle ear. In little children it is sufficient to quickly inflate, as the crying of the child elevates the soft palate to a certain degree, and so cuts off the downward passage into the stomach.

External Ear Diseases of the Auricle.

ECZEMA.--This disease occurs very frequently in infants during dentition, where irritation of the dental branches of the fifth pair of nerves causes irritation in other branches of the same nerve, including those distributed to the skin of the face and auricle, causing acute attacks of the disease. It is also frequently observed that successive teeth penetrating the periosteum will cause fresh attacks of this skin irritation, so that as long as the teething process continues, so long is the eczema apt to continue, and treatment will probably prove only palliative. Eczema occurs also in both the male and female approaching the period of adolescence, a time when other forms of skin disease are especially common.

The aged do not escape this annoying malady, where it is apt to occur in the chronic form, and is due to want of nerve-force in the skin branches of the nerves distributed to this part--a wise provision of nature allowing nerve-power to fail first in the nerves distributed to parts where the harm done is a minimum one, rather than in the nerve-centres, where disease fatal to life would result. The treatment in this class of cases would be radically different from the preceding divisions, where nerve-irritation is the cause.

{811} DIAGNOSIS.--The acute form shows the same diagnostic appearance as does eczema occurring elsewhere--the same redness and swelling of skin, followed by the vesicular eruption with serous oozing and loss of epithelium. In the chronic variety there is marked thickening of the skin, and the auricle is often covered with crusts, but here and there a deep fissure in the skin, from some one of which pus will exude.

Marked itching and burning and a sensation of fulness occur, both in the acute and chronic forms.

COURSE.--The acute variety may last only a few days, but as a rule tends to recur at frequent intervals. The chronic variety can last almost any length of time, and will often prove to be most obstinate.

TREATMENT.--Acute Variety.--The first indication is to relieve the burning and itching. This is often best done by the use of some mild anodyne powder which protects the part from the air and tends to relieve the existing skin irritation. Finely-powdered starch dusted over the part is a good remedy. One of the best anodyne powders is that of McCall Anderson:

Rx. Pulv. camphoræ, drachm iss;
Pulv. zinci oxid. ounce ss;
Pulv. amyli, ounce j.

To be dusted over the inflamed surface.

Often there will be difficulty in preventing the powder from falling off. When this is the case a very thin coating of the skin with the oxide-of-zinc ointment furnishes an excellent ground for the powder to adhere to. The oxide-of-zinc ointment alone is also an excellent application.

In the chronic variety a more stimulating application is needful, and some preparation of tar will prove valuable, such as--

Rx. Ungt. picis liquidæ, drachm j-drachm iij;
Ungt. zinci oxid. ounce j.

The crusts that collect on the auricle are best removed by a poultice of bread and milk, or a cotton pad moistened with olive oil can be bound over it for a few hours, and will serve to cleanse the part. In the very chronic cases, where points of suppuration are found, a caustic application like nitrate of silver is needed. Careful regulation of the diet and habits of the patient is indicated; an outdoor life, abstinence from alcohol and tobacco, nutritious food, will greatly aid. Iron, quinine, cod-liver oil can be used frequently with good results, while in teething children incising of the gums will sometimes give temporary relief.

Diseases of the External Auditory Canal.

IMPACTED CERUMEN.--This disease occurs very frequently, and, as a rule, is considered a matter of very little moment by the profession at large, whereas, in fact, it is often a symptom of grave disorders of the middle ear. Roosa mentions that in 1448 cases observed by him in private practice, only 101 were cases of inspissated cerumen alone, the great majority showing in addition serious disorders of other parts of the organ of hearing. The ceruminous glands are found chiefly in the cartilaginous portion of the external canal, and, according to Kessel, resemble the sweat-glands not only in the time and manner of their development, {812} but also in their external form and minute histology. This is also true of the contents of the ceruminous glands, as far as the microscope allows us to judge, the only difference being that in cerumen masses of very fine corpuscles of coloring matter are found.[1] The ceruminous glands secrete but slowly, and the cerumen tends to harden and become dark in color as it grows older. The removal of the secretion is probably effected by several factors. Numerous experiments prove that the epithelial lining of the external canal has a constant motion from within outward; necessarily any substance resting on it will move with it. Cerumen could in this way be constantly extruded from the external canal; and the cerumen, becoming dry and hard by exposure to the air, would tend to separate from the skin by curling itself into small rolls, and so drop out from the external meatus. The question naturally arises, Why does the cerumen form such impacted masses as are met with? We submit the following explanation:

In many of these cases the secretion is largely above the normal, and catarrh of the naso-pharynx is found associated with it. Pomeroy first noticed this connection, and suggested the probability that the ceruminous function is greatly affected in catarrhal disease, on the theory that the earlier stages of catarrh would result in hyperæmia, and consequently augmented function, of the ceruminous glands, which if continued may result in atrophy with abolition of function, precisely as results in inflammation of the mucous membrane lining the fauces.[2]

[Footnote 1: Vide Stricher, _Textbook_, p. 951.]

[Footnote 2: _American Otological Soc. Trans._, 1872.]

The pneumogastric nerve by its pharyngeal branch is connected with the pharynx, and by its auricular branch with the external auditory canal, so that irritation of the pharyngeal branches of the nerve, as would occur in pharyngeal catarrh, could readily excite reflex irritation in the auricular branch, with increase of function of the parts to which it is distributed, causing increase of the ceruminous secretion. Conversely, atrophy of the nerve would be followed by atrophy of function of correlated parts. The external canal often presents a sharp angle in its course near the meatus, and this also would tend to cause an accumulation of cerumen.

It is a well-established clinical fact that the great majority of cases of impacted cerumen are found to be associated with serious diseased conditions of the middle ear especially, and probably the diseased middle ear is often an important factor in causing impaction to take place; so that it frequently happens that the patient will experience no increase of hearing after removal of such an impacted mass, owing to the diseased middle ear that may be present. I remember one case where the hearing was absolutely lessened after removal of a ceruminous plug; doubtless in this case the solid conduction through such a mass was better than through an air-filled auditory canal.

SYMPTOMS.--Sudden loss of hearing: this is due to the fact that the mass grows slowly from the periphery toward the centre, and as long as a small central opening remains the hearing power will remain good. Some sudden jolt or misstep, or some quick-acting force, will cause occlusion of this narrow passage, with consequent sudden loss of hearing. The tuning-fork, placed on the incisor teeth, will be best heard on the affected side by reason of vibrations being impeded by the mass in their passage through the external canal.

{813} Tinnitus aurium and vertigo are often present, both being due to the mass pressing inward the tympanic membrane, with consequent increase of pressure on the labyrinthine fluid by the chain of small bones pressing on the membrane of the foramen ovale. These symptoms are sometimes alarming to the patient, as in his judgment indicative of serious brain lesion.

DIAGNOSIS.--Examination of the external canal with the speculum and reflected light reveals a dark amber-colored mass lying in the external canal, which can be very hard, the result of exposure to the air for a length of time, as well as the union with it of epithelial débris of the skin of the canal; or it may be soft, like syrup, in its consistence.

The PROGNOSIS is to be guarded until the condition of the middle ear is known.

TREATMENT.--If the mass is hard in its character, its removal is best effected by the forceps or curette or blunt hook, it being understood that the external canal is well illuminated, so that the course of the instrument can be carefully watched. The curette or blunt hook will loosen the attachments of the mass to the sides of the canal, and then it can be readily removed by the forceps, care being taken not to injure the tympanic membrane. In such a way a hard plug can be removed at one sitting that otherwise would require repeated efforts to accomplish the same purpose.

If these instruments are not at hand, the next best method is to effect the removal with the syringe and warm water. A caution is to be given in the use of the syringe. There are a great number of people who are not able to have the external ear syringed, even though gently, without becoming giddy, and if the syringing is then continued the vertigo will end in a fainting attack. My rule is to caution the patient of the above fact, and always promptly stop at the first symptom of vertigo. Sometimes a short rest will allow the operator to proceed, but often it is necessary to postpone any further attempt at removal until a succeeding day. Always use quite warm water. If in a fair trial with the syringe it is found that the mass does not soften and break up, it is better to make an application of olive oil to it, and at a subsequent time repeat the attempt at removal. Soft masses of cerumen are best removed by the use of warm water and the syringe.

In some few cases inflammation of the external auditory canal will complicate the treatment, and the question will come up as to whether it is best under such circumstances to attempt the removal of the impacted mass. As a rule, the removal of the mass is the best means of combating such an inflammation, and therefore an attempt at removal should be made unless the inflammation is very acute, when treatment of this complication would be in order, and the removal of the plug deferred for the moment. In all cases the condition of the middle ear and hard pharynx should be noted after the removal of the impacted mass, and these parts often will need treatment.

Furuncle of External Auditory Canal (Acute Circumscribed Inflammation).

ETIOLOGY AND PATHOLOGY.--In a great number of cases furuncle is to be regarded as an evidence of general bodily debility. For example, {814} in the richer classes it is often a result of over-dissipation, while in the poorer classes insufficient food, bad clothing, and such like are important factors. Local irritations of the external canal may cause the disease, such as rubbing the canal with a hairpin or toothpick to relieve itching. The use of alum and nitrate-of-silver washes in the canal will cause a furuncle in some cases. Furuncle occurs in the outer third of the canal as a rule, and often develops around a ceruminous gland, and will generally be followed by a number of others.

SYMPTOMS.--Pain is the most marked one--in the beginning of the attack of an intermittent character, with a tendency to increase toward and in the night; but as the attack advances pain becomes more marked, and may extend over the entire temporal region well down into the neck. The jaw movement also becomes very painful. The furuncle will rupture at any time, from the third day up to the tenth day, according to its location. The more deeply seated it is, the slower will be its progress toward maturity. The pain quickly disappears after the rupture, and then a short interval of rest is followed too often by the recurrence of the same disease. A varying degree of deafness is usually present, due to partial closure of the canal by the swollen soft tissues, and also it may be in rare cases through involvement of the tympanic cavity in the inflammation. Fever is often present. The great objective symptom will be the circumscribed swelling found in the cartilaginous portion of the canal and often along its anterior wall, and will show great increase of pain by but slight pressure. The swelling as it matures becomes more circumscribed, and will end in a pus collection and subsequent rupture.

DIAGNOSIS.--The disease most likely to be confounded with it would be an acute middle-ear inflammation, with involvement of the periosteum of the osseous part of the canal; but the history of the case would clear up this point.

The PROGNOSIS is favorable as to hearing, but with great probability of successive crops of the same disease.

TREATMENT.--The local application of heat and moisture is a remedy of great value, and a good method of application is to bend the head into a horizontal position, as by resting the side of the head on a table, and then fill up the external canal with water as warm as the ear will allow without causing pain; then quickly place over the auricle towels that have been dipped in very warm water and wrung dry by being twisted in a second towel, and over this a large pad of warm flannel or some similar covering. The heat and moisture will be retained for quite a time, and then the procedure can be repeated until relief from pain is obtained. In the interval the auricle is to be covered with a pad of cotton. A steam atomizer furnishes a convenient way of applying heat and moisture. Dry heat is sometimes preferred: a flannel bag filled with bran or hops and well warmed in a hot oven would carry out this indication; also a hop pillow moistened by hot whiskey is a good application.

An application of leeches affords great relief from pain. The best point to place a leech (which should be a Swedish leech) is just in front of the tragus. Two or three leeches can be applied at this place, and by encouraging the after-bleeding by warm applications any desired amount of blood can be taken. The after-bleeding can be readily controlled by the use of styptic cotton.

{815} Incision of the Furuncle.--It is a mooted question as to whether an incision is capable of giving relief, and when it should be done. My own experience has been that the application of a leech has given greater relief than the use of a knife in those cases when the furuncle has been deep seated. Later on, when the swelling has become circumscribed and shows evidence of pus, the incision is clearly indicated.

General treatment is to be of a tonic character, and during the acute stage, when the pain is severe, anodynes are indicated.

Foreign Bodies in the External Auditory Canal.

1. VEGETABLE PARASITES.--Aspergillus flavescens and Aspergillus nigricans are found on the inner part of the canal and over the external surface of the tympanic membrane. This growth largely depends for its development upon a diseased condition of the epithelial layer of the skin lining the external canal, such as is found in cases of chronic middle-ear suppuration and in eczema of the skin of the external canal, by furnishing a moist nidus for its development.

SYMPTOMS.--Intense itching in the external canal, with a sense of fulness; also sometimes pain, with tinnitus and difficulty of hearing. The growth is found in the inner part of the canal, or over the surface of the tympanic membrane in the form of yellow or black flakes according to the variety. It may be found in spots or may form a complete covering to the canal-walls, so that when removed it forms a mould of the canal, leaving a raw skin surface, on which the growth rapidly reproduces itself. The disease is found in an acute and a chronic form, and in a few days can attain full development; also there exists a marked tendency to relapse as long as any portion remains undestroyed.

PROGNOSIS.--Favorable.