A treatise on aural surgery

Front matter

22101968279

*r

Med

Preface

addition to the portions bearing on the throat in the chapters on rhinoscopy, enlarged tonsils, and post-nasal catarrh. To Dr Turnbull of Philadelphia, also, I am indebted for several practical hints on tinnitus aurium, the education of the deaf-mute, and* the influence of sea-bathing in causing deafness.

Dr Kingrose Atkins has rewritten the chapter on othsematoma. To many other workers I am under obligation for assistance or for valuable papers sent to me, more particularly Mr Field of St Mary’s, Dr Woakes, Dr Lennox Browne, Dr J. Patterson Cassells, Dr Burnett (Philadelphia), Dr Charles Turnbull, aud to several others whose writings are referred to in the following pages.

I may here say that the experience on which this treatise is basedfe" has been derived from the examination and treatment of upwards of 5000 aural patients.

I cannot place this edition before the profession without acknowledging the too generous reception accorded to my first effort, as also to the “ Atlas which followed. I shall be more than repaid should a like approval be given to the present work.

H. MACNAUGIITON JONES.

St Patrick’s Place, Cork, November 1881.

Chapter I

Introduction. Neglect of the study of aural diseases. Appliances necessary for diagnosis, ......

Chapter II

Steps of examination : history ; tinnitus aurium : some causes of : cerumen ; other causes : mucus in the tympanum. Meniere's disease; symptoms (see Chapter on). Tinnitus from polypus ; nervine causes ; quinine ; cold bathing ; mental worry, &c. ; vascular tinnitus. Weber Liel on tinnitus. Eustachian collapse. Chronic catarrhal states, accompanying laryngeal troubles. Tinnitus due to foreign bodies. Menstrual irregularities. Alcohol and tobacco. Turnbull on tinnitus aurium. Hallucinations. Character of the tinnitus. Treatment of tinnitus. (For other facts connected with the etiology of tinnitus aurium, consult the chapters on tenotomy of the tensor tympani ; Weber Liel on progressive deafness and nervine deafness),

Chapter III

Steps of examination ( continued ). Hereditary influences.

Gout. Syphilis; syphilitic taint; signs of; examples. Pain. Hutchinson on the teeth. Discharge. Importance of attention to the hearing power ; methods of testing : watch ; nail ; tuning-fork ; Konig’s rods ; the audiometer of Professor Hughes, .....

Chapter IV

Steps of examination ( continued ). Auditory meatus and membrane. Method of examination. The aural probe. The rectangular and alligator forceps. How to examine. Lamp uacje

1-6

7-20

21-31

XU

CONTENTS.

PAGE of Weiss. Specula ; various kinds. The meatus of the child. The meinbrana tympani ; its examination. The otoscope ; the manner of using the otoscope. Siegle’s speculum. Morisson’s speculum. Politzer’s air bag. Allen’s modification and Lennox Browne’s douche. Lucse on the Eaistachian tube. Gruber’s method of insufflating, .

Rhinoscopy and examination of the throat (see remarks on rhinoscopy). Indications of throat complications. Nasal specula. Posterior rhinoscopy ; mode of examination ; parts seen in mirror ; past treatment of case, .

Chapter VIII

Other instruments employed in diagnosis and treatment: syringes ; lever-ring forceps ; alligator form of Ecraseurs of Colin and Keene. Wilde’s snare ; syphon douche for the nose ; hand douches. Mr Lennox Browne’s douche ; gal van isers. Hinton’s trephine ; myringotomes. Woakes’ myringotome. Artificial membranes: Toynbee’s, Yearsley’s, Field’s, Turnbull’s ; advantages claimed for Field’s. Hints in applying and wearing the membrane. Aural probe of author for dressing the meatus and membrane. Messrs Weiss's lamp, •

32-56

57-67

68-79

80-86

7-104

CONTENTS.

Chapter IX

Weber Liel’s ear microscope ; its purpose ; its construction. Tlie koniontron ; indications for its application ; its purpose and mode of application. Medicated vapours,

Chapter X

Auricle and external meatus. Cerumen; diagnosis; method of removal. Imprudent practices. Abscess in the meatus ; diagnosis. Treatment; its recurrent tendency. Weber Liel on the treatment of abscess (see Chapter XX. on furunculus). Danger of abscess. Exostosis in the meatus. Ivory exostosis. Field on exostosis. Field’s mode of operating. Etiology of exostosis. Cassells on exostosis and hyperostosis. Aspergillus. Lowenbcrg on otomycosis ; mode of development ; decomposing saline solution and oily substances. Burnett on aspergill us. Microscopic features ; Lowenberg on rare forms of ; Turnbull on the difference in the various kinds of ; symptoms of in the ear ; treatment, ....

Chapter XI

Diseases of the auricle and external meatus ( continued ). Polypi ; various kinds of ; mucous ; fibromatous ; vascular; treatment; chloro-acetic acid. Dalby on the histology of polypi ; Whipham on. (See note in Appendix on Alcohol in the treatment of Polypi by Politzer.) Foreign bodies in the meatus. The meatus of the child. Special dangers. Attempts at removal. Danger of instruments. Rules for removal. Examples ; syringing ; other means. Warts. Eczema. Inveterate variety. Treatment ; chaulmoogra oil in,

Chapter XII

Diseases of the auricle and external meatus ( continued ). Othajmatoma. Nature and appearance ; course of. ./Etiology and pathology ; authorities on. Forms of mental disorder in which othajmatoma occurs. Tables. Treatment. Conclusions of Lennox Browne, .

xiii

PAGE

105-113

114-137

138-154

155-167

XIV

CONTENTS.

CHAPTER XIII. page

Adenoid growths of the naso-pharynx ; Lowenberg on.

Etiology and symptomatology ; influence on respiration ; pronunciation ; diagnosis from chronic coryza and hypertrophy of the tonsil. Nasal polypus. Naso-pharyngeal polypus. Method of physical exploration •with finger. Prognosis. Spontaneous disappearance. Influence on the hearing. Breathing by the mouth ; Catlin on ;

Cassells on. Maissiat on the action of the Eustachian tube during deglutition. Effects of nasal closure on deglutition. Rhinoscopy in diagnosis. Digital examination ; advantages of. Zaufal’s nasal method ; treatment, general and local. Cauterisation Precautions.

The gargle ; method of using. Naso-pharyngeal douche.

The curette ; method of using ; hsemmorliage after.

Sessile tumours. Stork’s forceps. Lowenberg’s method of operating. Forceps of Lowenberg and Mackenzie. Naso-pharyngeal injection. Alum. Oral respiration ;

Guye on. Lowenberg’s chin-piece. Snoring. Lowenberg on coryza. Galvano-cautery in. Trouve’s battery, 168-211

Chapter XIV

Post-nasal catarrh ; moist ; dry. Ozoena ; treatment ; iodioform in. Hypertrophy of the tonsil ; etiology ; pathology ; diagnosis ; treatment ; local ; constitutional ; operative,

Chapter XV

Non-suppurative catarrh. Causes of catarrh ; Weber Liel on ; Troltsch on. Simple catarrh. Progressive deafness ; Weber Liel. Eustachian collapse. Innervation. Paresis of muscles. Snapping noises. Mucus accumulation ; diagnosis ; treatment. Artificial perforation. Eustachian obstruction and closure ; causes, Weber Lcil on Eustachian collapse. Treatment of Eustachian closure. Collapse of the meinbrana tympani. Cretaceous deposits on the membrane. Intra-tympanic injections : Lennox Browne on ; W reden and othcf authorities on. Konion-

CONTENTS.

XV tron. Lennox Browne on perforation, and the treatment of inspissated mucus in the tympanum ; Da'lby on. Acute and chronic suppurative catarrh ; appearance of membrane in acute ; brain complications in ; causes ; treatment. Chronic suppurative catarrh in connection with scarlatina and diphtheria. Perforation of the drumhead ; causes. Pulsating perforation ; hearing power with ; in children. Neglect of aural mischief in children. Treatment of acute catarrh. Lozenges. Treatment of perforation. Iodoform. Nitrate of silver. Alcohol and glycerine. Artificial membrane. Mastoid abscess. Mastoid periostitis. Incision. Trephining. Volkman’s scoop in ; Hartmann on mastoid necrosis. Myrinigitis ; Burnet on ; symptoms ; treatment,

Chapter XVI

Incision of the membrana tympani ; Hinton on. Myringotome ; in scarlatina. Aids to keep the perforation open. Politzer’s eyelets; Burnett on,

Chapter XVII

Tenotomy of the tensor tympani ; Dr Urbansschich on ; Dr Miot on. Dr Weber Liel on. Indications. Conclusions. Tenotomes ; Weber Liel’s ; Schwartze’s ; Hartmann’s. Operation ; steps of. Indications for tenotomy • Weber Liel; Dr Paquet on

Chapter XVIII

Some special causes of aural disease and deafness. Bathing; Turnbull on. Intermittent aural affections. Neuralgia • Weber Liel on. Malarial otitis. Dr Cassells on sewer gas. Syphilis. Hereditary syphilis; Pierce on. Nervine deafness Meniere’s disease; Dr A. Guye on.

Etiology of; Mach, Brener, and Crum Brown on. Treatment. Paralytic deafness. Galvanism and electricity in (Woakes). Weber Liel’s intratubal electrode. Field on oloctricity,

PAGE

222-266

267-272

273-291

292-306

XVI

CONTENTS.

Chapter XIX

Deaf-mutism ; Hartmann on ; Turnbull on. Bell’s method. Lip method. Management of deaf mutes. Early attention to mutism ; Dalby on. Causes of deaf-mutism. Naso- pharyngeal catarrh as a cause. Success of teaching by lip method. Education in schools of the deaf-mute. Artificial aids. Results of post-mortem examinations. Artificial aids — ear-trumpets ; audiphone ; Knapp and L.ennox Browne on ; Rhode’s audiphone. Politzer’s new auricle, .........

Introduction

Many years have gone by since Sir William Wilde drew attention to the general vagueness which exists amongst medical men on the subject of Aural disease. Yet to the present day how few medical men do we find who do not view interference with any aural complication, save the simple blocking-up of the meatus with cerumen, as “ meddlesome ” and dangerous ? How constantly do we hear physicians, well informed on other matters, speak of any interference with the ear as “ poking ” and “ meddling ! ” The cause of this is not far to seek. To the same source of ignorance is attributable the want of knowledge of ophthalmic and laryngeal affections. The teaching of all the three organs eye, ear, and throat — is too much neglected in the schools generally : an accurate knowledge of their diseases and pathology is not sufficiently insisted on. Students are satisfied with the most superficial idea of these special branches. Certainly, in this respect, the term “ speciality ” is an unfortunate one. Most students view what they are pleased to regard, and are taught to

A

AURAL SURGERY.

look on, as special studies, as outside the pale of general surgery. They calculate that at most a question or two in an examination is all that they have to fear. They know that most examiners in general surgery are themselves devoid of an accurate special knowledge of these branches. Hence comes neglect in the study of them, and the deplorable result that yearly the great majority of men are obtaining qualifications to practise who are totally ignorant of the advances which have been made in recent years in the diagnosis and treatment of the diseases of three of the most important organs in the body.

The remedy is simple and obvious. Students should be taught practically the stress which the examining bodies lay on a sufficient study of these parts. They can only be brought to feel this by a practical examination in all three branches before they obtain their licence. This would speedily cause a greater interest in, and result in a more diffused knowledge of these subjects. We should not then, as is now frequently the case, meet men starting in practice who have never seen an ophthalmoscope, never looked through an aural speculum, and have never applied a laryngoscopic mirror.

To return to the particular organ under discussion, it is my object in these remarks to furnish the student and general practitioner with some brief, but practical, hints on the diagnosis and treatment of aural affections. The many valuable treatises now published on the ear are, of course, replete with information on this branch of surgery ; but from several years’ experience, and from constant consultation with

INTRODUCTION.

medical men, I find that such are not carefully or widely read, and hardly at all by students. Hence, through the medium of these pages some concise rules for practice, and useful hints on treatment, may be acceptable both to the practitioner and student. In order to do this I shall endeavour to make these observations as simple as possible, and deal principally with those diseases of every-day occurrence, for the treatment of which, all practitioners are being constantly consulted. It will not be necessary for this purpose to enter into vexed questions as yet unsettled, but simply to point out the leading principles which should guide the surgeon in arriving at a quick and safe diagnosis in any aural case. Nor is it necessary to distract attention by repeated reference to authorities. The mode of examination which I follow and detail is that usually pursued by aural surgeons ; but more especially is that line of practice recommended which was adopted by unquestionably the leading English aurist since Toynbee s death, the late James Hinton His zeal in the cause of aural surgery, and his anxiety for the spread of knowledge in this department, have attracted many to labour in this field. It was through the same disinterested kindness on the part of Mr Hinton that I was, many years since, first brought to take an interest in aural surgery, and to feel, in his own words, “ that veiy few fields of practice afford subjects of greater interest to study, or give a larger reward to the exercise of skill.”

Those who desire a more extended knowledge of the subject I would refer to the works and papers of Hinton, especially his “ Questions of Aural Surgery,”'

AURAL SURGERY.

published in 1874, and those of Toynbee, Von Troltsch, Dalby, St John Eoosa, Politzer, Burnett, Turnbull, and others.

It is not within the design of this work to devote space to the anatomy of the organ. Those who are deficient in knowledge on this point had better make good their deficiency before tliey attempt the treatment of affections of the middle and internal ear. This, however, they can readily do from any standard work on anatomy, in which study they will be materially assisted by models, and the prepared sections of the petrous portion of the temporal bone : — (1) The section showing the meatus, membrana tympani, ossicles, and middle ear ; (2) the section showing the cavity of the tympanum, and its openings ; the internal ear with its semicircular canals, the cochlea, and the various orifices. (These temporal bones may be obtained from Messrs Matthews, of London, and will be found extremely useful aids in the study of the anatomy of the ear.) The plates of Professor Dr Adam Politzer are those that I use myself in giving clinical instruction.

It is necessary in many cases to combine the treatment of the nasal passages and throat with that for affections of the ear. This frequently happens, and therefore the aural surgeon must have some special apparatus for the exploration of the nose, the posterior nasal orifices, and the throat. In fact, when we reflect on the large percentage of cases of deafness caused by unhealthy states of the throat, it is apparent that one of the main points in the successful management of such is, to see carefully to and correct any morbid state of the latter.

INSTRUMENTS REQUISITE.

It may be well here to mention, in order, the apparatus which it is essential should be possessed by all who wish successfully to diagnose affections of the ear : — Bull’s eye argand burner, and universal bracket (same as that used for the laryngoscope).

Laryngoscope reflector, with spectacle frame, or on handle.

Double otoscope.

Aural specula (three sizes), or Brunton’s auriscope. Tuning-forks (different keys).

Pneumatic speculum.

Eustachian catheters (different sizes).

Two of Noyes’ catheters (right and left).

Bougies.

Politzer’s bags.

Ear syringes.

Small syringe for Eustachian catheter.

Ear forceps; lever ring and rectangular (various kinds). Knife for incising membrane (myringotome).

Jones’ aural probe.

Turnbull’s Eustachian forceps.

Snares for polypus.

Kheophore. (Galvanisation of membrane.)

Artificial membranes.

Absorbent cotton wool.

Tongue depressor.

Nasal specula.

Nasal douches (syphon and bag).

Laryngeal mirrors.

Mirror for rhinoscopy.

Laryngeal brushes.

Mackenzie’s tonsil guillotine (two sizes).

AURAL SURGERY.

Though this to some may appear a formidable list, it must be remembered that it includes most of the instruments requisite, not alone for diagnosis, but also for the treatment of any aural affection, certainly most that would be required in ordinary practice.

With a speculum and mirror, tuning-fork, otoscope, Eustachian catheter, and Politzer’s bag, the great majority of aural lesions may be diagnosed with comparative certainty. The remaining instruments are not so much diagnostic as therapeutical, and for the purpose of treatment. We shall consider the method of employment of, and the most improved form of these and other instruments as we are dealing with the various states necessitating their use. We now pass to the best plan of examination, and the steps, in consecutive order, which it is necessary to take in proceeding to form a diagnosis.

Chapter II. Steps Of Examination — History — Symptoms, Etc

The following brief method of examination is that which I usually adopt : —

History of Case, including —

Causes.

Hereditary influences.

Past treatment.

Present Symptoms, including —

Tinnitus.

Pain.

Discharge.

Evidence of constitutional taint.

Hearing distance — watch, click of finger nails, voice.

External meatus (condition of).

Membrana tympani (condition of), with cavity of tympanum. Tuning-fork.

Eustachian tube (state of).

Throat (state of).

Nose (state of).

This ca.n be done in tabular form thus : —

No. of Case — Name — Age.

History, &c.

Symptoms.

Right ear. Left.

if it

ii if

a j j

a ft

ff a

PID

EM

M and TC

TF

ET

Throat.

Nose.

AURAL SURGERY.

Examination. — Having ascertained the general state of health of the patient, the first step is to inquire into the length of time the deafness has lasted, if both ears are affected, and if so, the manner in which each has been attacked ; next to note carefully the manner in which the deafness has progressed, if this progress has been rapid or insidious, with or without pain or discharge. The careful examination and comparison of the hearing power of the two ears is requisite in every instance. Patients constantly affirm that the hearing of one ear is perfect, yet on coming to test it accurately we may find it more or less impaired, the reason of this being that while the conversational power is not interfered with, the hearing distance as measured by the watch is considerably so. We should now seek closely for some cause, making inquiries into the habits, occupation, state of health at the time of, or preceding the invasion of the symptoms. The connection of deafness with the exanthemata is a point which should not here be overlooked, these and the various fevers being frequent causes of deafness. Cold, rheumatism, gout, and syphilis should not be forgotten, the last two particularly, both as a direct and hereditary source of mischief.

Tinnitus. — The occurrence of tinnitus is not a constant symptom. We should inquire then carefully into the history of the noises, if any such be heard, how and when they commenced, their nature, if they have increased of late, if they are periodical or liable to exacerbations. Tinnitus may be caused by almost any abnormal state of the meatus, membrane, middle ear, labyrinth, or Eustachian tube, and therefore it is valuable as a

TINNITUS.

diagnostic sign, and in forming a prognosis, when taken in conjunction with other symptoms and appearances. The most frequent causes of deafness in the external meatus met with in general practice are cerumen, eczema, foreign bodies, abscess, exostosis, aspergillus, polypus. It is surprising the minute portion of cerumen which, if it rests on the membrane, will produce this unpleasant complication. This week I was consulted by a gentleman for noises in the ear; the hearing power was normal, and on examination I found the membrane healthy, and the only discernible cause of the annoyance was a small collection of cerumen which lay close to the membrane, and which perhaps had been pushed further in by that most reprehensible of all practices, namely, attempts to clear out the ear with pieces of rolled paper, or the end of a towel, &c. On gently syringing out the ear I removed with the small atom of cerumen a hay seed, which had escaped my notice, lying, as it did, flat against the wall of the meatus. It is difficult to isolate those states of the membrane itself, which cause tinnitus, for nearly all its abnormal appearances and positions, as increased concavity, dulness, thickening, want of mobility, are secondary results due to faults pre-existing in either the cavity of the tympanum or in the Eustachian tube. The fact that there is a large number of cases in which relief is given when air is forced into the cavity of the tympanum by Politzer’s air bag, and the membrane’s position temporarily restored, or when the tension is lessened by the suction through a tube placed in the external meatus or by the pneumatic speculum, proves the practical importance of noting the position and appear-

AURAL SURGERY.

ance of the membrane in all such cases. We shall have occasion subsequently to consider the effect of spasm of the tensor tympani or chronic contraction of this muscle in producing permanent alteration in the appearance of the membrane, and frequently incurable tinnitus.

Perhaps of all the causes of tinnitus there is no oue so frequent as that of mucus in the cavity of the tympanum. The diagnosis of this condition we will consider presently. It is frequently accompanied by closure or obstruction of the Eustachian tube. The occurrence of tinnitus during ordinary catarrh in the head when the nasal mucous membrane and that lining the faucial orifice of the tube is congested, proves how slight a cause will give rise to this symptom if there is any obstruction to the passage of air or fluid through the natural outlet. Excluding causes existing in the external meatus, the membrane and cavity of the tympanum, and the Eustachian tube, we have to deal with a large class of cases in which the cause is in the labyrinth, the semicircular canals, or cochlea.

Many of these cases have a distinct train of symptoms described so accurately by Meniere under the head of “ labyrinthine vertigo.” The most usual attendants are giddiness, tendency to fall to either side, staggering gait, occasional vomiting, and various degrees of tinnitus. Such symptoms may undoubtedly be produced by other disordered states than those talcing their origin in the labyrinth, and may be secondary from the results of disease in the tympanum, or any cause producing labyrinthine pressure. For example, in those cases in which relief is afforded, and the noise disappears on suction with a tube in the meatus, the cause may be, as pointed

TINNITUS FROM POLYPUS.

out by Mr Hinton, muscular, and the stapedius and tensor tympani are in a state of spasmodic contraction.

There is at present a man, aged forty-eight, attending the hospital, who came on the 20th of October 1876, with the following symptoms : — He for some time past had, as he described it, “ a reeling in his head.” His gait was .staggering, he had to place his hand against the wall to support himself. He was, he said, “ more like a drunken man,” and on his way to the hospital, to which he was assisted by his wife, he thought that he should have been taken for one. He had musical sounds in the left ear. He did not hear the watch on contact in this ear. He had great pain, and had not slept for ten nights previous to his visit. He looked worn and pallid. His tongue was coated with a creamy fur, and he had a difficulty in retaining any food on his stomach. On examining the meatus, I found the orifice occluded with discharge, on washing which out I discovered a large fibroid mass filling up the meatus, quite unlike an ordinary polypus. On closer examination, I found that this sprung from the tympanum. The hearing of the other ear was normal, and the appearance of the membrane healthy. There were no noises in it. I snared the growth as well as I could, and brought away the greater part of the mass. I gave him twenty grain doses of bromide of potassium, vesicated him freely over the mastoid process, and regulated his diet. The meatus was considerably swollen and narrowed. From this until the 27th I kept the meatus clear, cleaning it out daily, and removing the small remaining portion of the polypoid growth with the lever ring or rectangular forceps, and making him continue the bromide of potassium. On this

AURAL SURGERY.

date I have a note that the “ reeling is much better, sleeps well at night.” On walking, he still had to place the hands to the wall, and his wife led him to hospital. I now touched the remaining granulations with chloroacetic acid and chromic acid alternately. On the 3d November the pain was much less, the meatus was still considerably contracted ; it was cleaned out every second day ; the noises were much less, and his gait was improved ; there was great pallor and debility. I now gave him thirty drop doses of the muriated tincture of iron. On the 17th of November I reverted to tbe bromide of potassium. The treatment has been much the same since that date. A twenty-grain solution of nitrate of silver has been occasionally used to the membrane and meatus. All the mass has been removed or destroyed. He has returned to his work. His gait is perfect, he comes to the hospital regularly, there is no pain, the discharge has nearly ceased ; there is still does not hear in the ear, but the tinnitus has gone ; there is a large perforation of the membrane, all pulsation in which has ceased for the past week. In this case there can be little doubt that all these formidable symptoms were caused by pressure, conveyed to the labyrinth by the fibroid mass, which destroyed the membrane, and encroached on the tympanic cavity.

There are, however, constantly occurring cases in which the tinnitus depends on no assigned cause, if we except the ambiguous class of “ nervine.” Deafness in such is not a necessary attendant. The only symptom complained of is the constant noise. Hiese cases I find are as a rule incurable, and resist any form of treatment. On examination the membrane is usually

CAUSES OF TINNITUS.

healthy, there is no abnormal sound heard with the otoscope, the throat and faucial orifice of the Eustachian tube are healthy, the deafness may be slight and conversational power not in the least affected, yet the tinnitus is intolerable. Some of these date the origin of their trouble to nervous shock, some to the occurence of fever, the administration of medicine, climatic influences, as residence in India. The sole clue to the mischief usually obtainable is by means of the tuning-fork, which only yields negative results. No good that I am aware of can be effected by any local treatment when such a state supervenes.

That quinine produces analogous symptoms in some persons to labyrinthine vertigo is well known. Though I have in the Cork Fever Hospital, and in private practice constantly administered quinine in remittent fever, and as an antipyretic in ten to fifteen grain doses, as often as every third hour, producing at times headache, tinnitus, and vomiting, I have never known any permanent effects from its administration.

Many years since, while making some experiments in which I was assisted by the late Professor Blyth, I gave a healthy man, a pensioner, thirty grains of quinia (the alkaloid) for the purpose of estimating the total amount of quinia excreted by the kidneys for twenty-four hours subsequently. This man suffered for a considerable time from tinnitus and partial deafness, this continuing for nearly twelve months, gradually becoming less. He died eventually several years later from the effects of alcohol. The tinnitus and deafness never completely deserted him.

I am aware of a case in which the reeling and

AURAL SURGERY.

staggering gait produced by quinine, simulating those symptoms present in labyrinthine vertigo, has been mistaken for drunkenness, with most unpleasant consequences to the sufferer. In inquiring into the origin of tinnitus we must not forget such causes as exposure to cold, bathing, nervous shock, general debility, hysterical temperament, mental excitement and worry, overstrain at business, general depression of spirits, exposure in open boats, the effects of gunnery experiments, and blows on the ear.

It is most important to look to the rhythmic nature of the noises. I have known many cases of vascular tinnitus consequent on over mental strain. It is in these cases of general vascular tension with vasomotor disturbance that we find such benefit from the admistration of the bromides of potassium and zinc, hydrobromic acid, nitrite of amyl. But most readily are these patients relieved and permanently cured by rest and change of air. A trip through Switzerland, or a sea voyage, will frequently dissipate the trouble which has been persistent for months.

A few years since, for a period of eighteen months, I was annoyed by a tinnitus and pulsation in my left ear, that commenced regularly on laying my head on the pillow at night, keeping me awake, and which was also present for a short time after I awoke in the morning. It generally disappeared completely in the day time. The noise could be temporarily arrested by strong pressure on the mastoid and over the styloid process. The sound was of a cooing character, always rhythmical, giving the exact idea of an aneurysmal bruit. I found, on carefully watching my diet, that

PARETIC TINNITUS.

alcohol of an)’’ kind, and tea, always accentuated the noises. The influence of the former was quite remarkable. These noises have now altogether disappeared. A trip through Switzerland, the total abandonment of tea and alcohol for a time cured me. All through the time these noises lasted I was in a low state of health. In Dickens’ language, I felt “giddy, jarred, uncertain shaken,” from great physical and mental strain. The complete abstinence from alcohol and tea I have since found in the case of others similarly attacked to be attended by the happiest results. If a wine is taken, good claret is the best. Thorough attention to the secretions, some mineral acid and vegetable tonic — strychnia — Dusart’s syrup of the hypophcsphates of iron and lime, maltine, with lactopeptine or liq. pepticus at meals, and, if there he a gouty tendency, the effervescing salicylate of lithia are amongst the best remedies to adopt. For myself I sometimes found relief from changing the side on which I was in the habit of lying when asleep, the more so by lying cn the opposite side to that at which the noises were most heard. But for such tinnitus, mental rest and change of air and scene are the best remedies.