Diseases of the ear

Front matter

Book ■ TT4-

Cop}iigtaK°-

GCEZRIGSU DEPOSIT.

Preface To Fifth Edition

It seems hardly possible to the author that a quarter of a century has elapsed since the appearance of the first edition of this work in 1894. Perhaps in no other branch of medicine or surgery have more advances been made than in Otology. Successive editions of this work have appeared from time to time, it having been the purpose of the author, as well as of the publishers, to keep the work fully abreast with the advance of modern medicine and surgery. Since the appearance of the last edition so much advance has been made in diseases of the labyrinth, and the great importance of labyrinthine lesions has been so fully recognized that it has seemed necessary to elaborate upon this portion of the work. For this reason an entirely new chapter on the functional testing of the static labyrinth has been added. This chapter has been fully illustrated by line drawings, and it is the hope of the author that this additional chapter may be of great practical value to his readers. The chapter on specific inflammation of the labyrinth has also been practically rewritten, so as to give the readers the advantages of the latest methods of treatment.

One plate has been added, but aside from this the body of the work remains essentially the same. Lithographic plates 9, 10, and 11 have been omitted from this edition. Plate 11 was practically out of date, and plates 9 and 10, while beautiful specimens of the lithographer's art, and reflecting great credit upon my friend, Dr. W. A. Holden, who was kind enough to draw these plates from nature, do not seem to possess enough practical value to warrant their continuance in this last edition.

Had it been possible to make a complete revision of the work, many illustrations would probably have been omitted, notably figure 28, describing a portable illuminating apparatus, a device of great value and almost a necessity at the time the first edition of the book was written, but which the almost universal introduction of the electric light

IV

PREFACE TO FIFTH EDITION.

has rendered at the present time superfluous. This figure, and some others which appear in the text may perhaps not be entirely out of place, as they show very clearly what advances have been made in our conveniences for examination since the appearance of the first edition of this book. One new plate, which has appeared in an article by the author subsequent to the publication of the last edition, is embodied in this volume. Certain changes have been made in the text where experience has made it necessary for the author to modify opinions previously held. Certain statistics have been changed also so as to include the experience of the last ten years. The main body of the text, however, has not been altered.

The author appreciates most keenly the cordial reception which has always been accorded the previous editions of this work, and hopes that the medical profession may find this last edition as worthy of perusal as its predecessors have been.

Edward Bradford Dench,

15 East 53D Street, New York City

Preface To First Edition

In the preparation of the present work it has been my aim to adapt it to the needs both of the general practitioner and the special surgeon. For this reason minute pathology has not been considered extensively.

In detailing the various manipulative procedures, I have preferred to err on the side of prolixity, for the benefit of those not familiar with the subject. It has also been my purpose to keep constantly before the reader, the fact that many diseases of the ear should not be considered by themselves, for the reason that they are often local manifestations of systemic condition.

Many works upon otology have failed to emphasize the importance of a thorough functional examination ; and none have placed the results of recent investigations at the disposal of the reader in such a manner as to enable him to use them in diagnosis. In consequence, I have written at length upon this subject.

In advocating operative procedures upon the middle ear and in devoting much space to the subject of middle-ear operations, I am aware that I shall not have the support of many distinguished colleagues. As a careful reading of the chapter will show, I have written from personal experience; and if my- results' differ from those of other operators, I suggest that the selection of cases suitable for operation, according to the principles detailed in previous chapters, may account for the favorable outcome of the operations.

In illustrating the gross pathological lesions of the conducting mechanism and the various manipulative measures instituted for their relief, I have adopted the plan of showing the auricle, meatus, and middle ear in the same drawing. The drawings are of natural size, and the technique of the various procedures seems to be made more clear in this manner, thau by any other method.

v i PREFACE TO FIRST EDITION.

In the colored plates of the membrana tympani, the adjacent portion of the meatus is also shown, thus reproducing as completely as possible the picture seen upon speculum examination, and rendering the relative position of the parts more intelligible. In this connection I desire to express my indebtedness to Dr. W. A. Holden for the careful manner in which he prepared these plates from clinical cases. Without his aid, these illustrations would have been impossible.

The absence of extensive bibliographical citations may seem a defect, but in a work intended as a clinical guide, a complete bibliography would be impossible, and unless complete it would be useless. No attempt has been made, therefore, to collate the entire literature of any subject, and the citations have been limited to those necessary to give individual investigators the proper credit for their researches.

It gives me pleasure to thank the W. F. Ford Surgical Instrument Companv for the care which they have bestowed upon the illustrations ot various instruments and appliances which appear in this volume.

17 West 46TH Street, New York City,

CHAPTER I. The Anatomy of the Ear 3-47

The auricle — The external meatus — The bony meatus — The tympanic cavity — The ossicles — The intratympanic ligaments — The membrana tympani — The epithelial investment of the conducting apparatus — Intratympanic folds — The muscles — The arteries — The veins — The lymphatics — The nerves — The bony labyrinth — The membranous labyrinth — The saccule and utricle — The membranous cochlea — The vascular supply of the labyrinth — The auditory nerve.

CHAPTER II. The Physiology of the Ear 48-72

Sound — Function of the membrana tympani — Function of the ossicles — Function of the muscles — Function of the cochlea and semicircular canals — Effect of tympanic changes upon the labyrinth — Effect of stimuli upon the auditory nerve — Reflex phenomena — Secondary phenomena — Hyperesthesia and paresthesia.

CHAPTER III. Physical Examination . 73-141

Preliminary observations — Source of illumination — The Reflecting Mirror — Specula — Technique of Examination — Appearance of the meatus and membrana tympani — Obstacles to examination — Tympanic topography — Politzerization — Catheterization — Auscultatory sounds — Obstacles to catheterization — Dangers of catheterization — The examination of the nose and throat — The history.

CHAPTER XI. Circumscribed External Otitis 217-237

Acute Circumscribed External Otitis or Furuncle. ^Etiology — Pathology — Symptomatology — Diagnosis — Prognosis — Treatment — Bloodletting — Cold — Instillations — Heat — Incision — Internal medication. Chronic Circumscribed External Otitis. Significance in diagnosis of mastoid inflammation.

CHAPTER XII. Diffuse External Otitis 238-266

Chronic Diffuse External Otitis. ^Etiology — Pathology — Superficial — Cellular — Desquamative — Parasitic — Consecutive —

CONTENTS. ix

Symptomatology — Diagnosis — Prognosis — Treatment of the various varieties of the disease. Acute Diffuse External Otitis. ^Etiology — Dependence upon the chronic form — Pathology — Symptomatology — Diagnosis — Involvement of middle ear — Prognosis — Treatment — Local depletion — Irrigation — Cold — Incision. Croupous and Diphtheritic External Otitis. Hemorrhagic External Otitis.

CHAPTER XIX. Acute Catarrhal Otitis Media 3-7-340

^Etiology — Pathology — Superficial structures alone affected — Symptoms in adults — Symptoms in children — Inspection of discharge — Bacteriological examination of discharge — Diagnosis — Physical examination — Functional examination — Prognosis — Treatment — Depletion — Dry heat — Instillations — Incision — Irrigation — Topical applications.

CONTENTS.

Chapter XX

^Etiology — Pathology — Bacteriological infection — Involvement of the connective tissue in the vault of the tympanum — Secondary involvement of the lower portion of the cavity — Extension to bony structures — Symptomatology — Evidences of mastoid involvement — Evidences of extension to the cranial cavity — Diagnosis— Physical examination — Bulging of membrana flaccida — Functional examination — Prognosis — Subsequent functional condition — Chronic purulent otitis — Mastoid and intracranial involvement — Fatal cases — Treatment — Depletion — Early incision — Irrigation — Abortive treatment when mastoid symptoms appear — Ice coil and local bloodletting — Second incision unnecessary — Treatment of persistent discharge — Drainage.

CHAPTER XXI. Chronic Catarrhal Otitis Media 357-396

General considerations concerning pathological characteristics separating the cases into two classes. Chronic Hypertrophic Otitis Media. ^Etiology — Influence of repeated attacks of congestion — Unresolved acute otitis — Affections of' the upper air passages — Sex — General condition — Heredity — Pathology — Tympanic changes — Changes in the drum membrane — In the Eustachian tube — In the tympanic ligaments — In the labyrinth— Symptomatology — Bilateral involvement — Intermittent character of the subjective noises and impairment of hearing — Vertigo — Reflex pain referred to the region of lingual tonsil — Diagnosis — Physical examination — Altered position and density of membrana tympani — Changes in the apparent breadth of malleus handle from rotation — Effusion — Functional examination — Impairment for voice greater relatively than for sharp sounds — Changes in the limits of audition — Condition of organ secondarily involved — Prognosis — Duration of affection — Condition of upper air passages — Degree of bilateral involvement — Age — Secondary sclerotic changes — Treatment — Treatment of the upper air passages — Surgical measures and topical applications — Of the Eustachian tube — Inflation — Irrigation — Dilatation — Electrolytic method — Topical applications — Of the middle ear — Simple inflation — Medicated vapors — Absorption or evacuation of effusion — Lavage of tympanum — Tenotomy of tensor tympani — Mechanical support in relaxation — Surgical procedures. Chronic Hyperplastic Otitis Media. ^Etiology — Secondary to acute inflammations of tympanum or to hypertrophic inflammation — Idiopathic disease resulting from systemic causes — Occurrence in one ear as the result of changes in the opposite organ — Pathology — Sclerotic changes in the tympanic connective tissue — Deposit of new connective tissue — Changes in the membrana tympani — Deposits about oval and round windows — Tension anomalies causing rotation of malleus upon its long axis — Changes in the tympanic vault — Labyrinthine involvement — Condition of the Eustachian tube — Otosclerosis — Symptomatology — Insidious development — Subjective noises without impairment of hearing — Local and reflex pain — " Auditory fatigue " — Neurasthenic manifestations — Diagnosis — Physical examination — Normal appearance of drum membrane — Atrophy of membrane — Malposition of ossicles — Appearance of membrana flaccida in cases secondary to a hypertrophic process — Functional examination — Variation in lower tone limit — Bone conduction — Lateralization of tuning fork — Determination of relative amount of tympanic and secondary labyrinthine involvement in " mixed " cases by means of tuning forks — Changes in upper tone limit and its significance — Otosclerosis — Prognosis — Spontaneous cessation of the affection — Effect of men-

CONTENTS. xi tal and physical exertion — Climatic influence — Age — Treatment — Of tympanum and tube — Passive motion — Massage — Pneumo-massage contraindicated — Vibratory massage — Surgical measures — Of labyrinth — Internal medication — Effect of treatment of middle ear upon the labyrinth — Hygienic measures.

Chapter XXII

Etiology — Development from an acute catarrhal or acute purulent inflammation — Tuberculosis — Syphilis — Pathology — Necrosis of connective tissue and osseous structures — Caries of incus — Cause of its frequent occurrence — Labyrinthine involvement — Cerebellar abscess — Changes in the mastoid — Cholesteatoma — Symptomatology — Discharge — Variations in the amount of discharge — Occurrence of aspergillus — Facial paralysis — Presence of granulation tissue — Secondary labyrinthine involvement — Diagnosis — Physical examination — Classification of conditions usually found upon inspection and their individual significance — Caries — Use of probe — Significance of granulation tissue — Displacement of the ossicles — Auscultatory signs — Functional examination— Variation in tone limits — Effect on upper tone limit — Bone conduction — Electrical reaction — Evidences of mastoid involvement — Prognosis — Probable effect upon audition — Cessation of discharge — Danger to life — Treatment — Use of syringe — Other methods of cleansing — Treatment of the upper air passages — Instillations — Powders — Removal of exuberant granulation tissue — Irrigation of vault of tympanum — Operative procedures — Statistics of operations — Treatment after operation — Internal medication.

CHAPTER XXIII. Otitis Media Purulenta Residua 426-441

Acute Type. ^Etiology — Identical with that of acute inflammation of the normal tympanum — Pathology — Hyperemia of exposed lining of tympanum — Serous effusion — Becomes purulent by infection through canal — Encysted effusion — Bony necrosis with development of chronic discharge — Symptomatology — Interference with function — Discharge — Secondary external otitis — Facial paralysis — Diagnosis — Physical examination — Serous discharge — Exfoliation of superficial epithelium — Thickening of remnant of drum membrane — Signs of mastoid involvement — Prognosis — Mild cases — Severe cases with retention of pus — Treatment — Mild cases — Asepsis — Topical applications — Treatment of upper air passages — Removal of dead bone if present to prevent recurrent attacks — Severe cases — Incision of membrana flaccida with cupping — Irrigation — Cold to mastoid. Chronic Type. Condition one of increased tension — Secondary effects on labyrinth — Pathology — Classification of conditions found in these cases — Symptomatology — Interference with function — Presence of inspissated secretion — Cholesteatoma — Pain in mastoid due to sclerotic changes — Diagnosis — Necessity of combining physical conditions with data obtained by functional examination — Functional examination — Evidences of increased tension in conducting mechanism — Labyrinthine involvement — Determination of the degree to which perceptive and conducting mechanism is affected — Prognosis — Spontaneous improvement — Age — Influence of labyrinthine involvement upon the prognosis — Recent and chronic cases — Treatment — General measures — Attention to upper air passages and Eustachian tube — Prophylaxis against otomycosis — Surgical treatment — Effect of treatment upon function of opposite ear.

xii CONTENTS.

IV. DISEASES OF THE MASTOID PROCESS.

Chapter XXIV

Variations in presence and location of pneumatic spaces — Location of antrum — Relations between superficial landmarks and cranial contents — Topographical variations dependent upon age.

CHAPTER XXV. Inflammation of the Mastoid Process 449-462

yEtiology — Secondary to middle-ear inflammation — Idiopathic cases — Pathology — Sclerotic changes — Caries and necrosis — Purulent inflammation — Avenues of exit of secretion — Intracranial complications and channels of infection — Possibility of infection through outer surface of squama — Cholesteatoma — Symptomatology — Pain — Temperature not characteristic — Cessation of discharge — Evidences of intracranial involvement — Evidences of extension of thrombus from sinus into internal jugular vein — Diagnosis — Local tenderness — Method of eliciting symptom — Involvement of meatus close to membrana tympani — Evidences of external rupture — Of rupture into digastric fossa — Prognosis — Importance of early recognition — Chronic cases — Influence of diathetic conditions — Gravity of operative measures — Treatment — Free drainage through canal — Cold to mastoid — Abortive treatment by ice coil — Statistics — Irrigation of canal — Objection to Wilde's incision — Early and radical operation.

CHAPTER XXVI. Intracranial Complications of Tympanic Inflammation . 463-478

Otitic Meningitis. Manner in which inflammation extends to meninges — Serous meningitis — Symptomatology — Variations dependent upon location of lesion — Ocular symptoms — Symptoms of serous meningitis — Diagnosis — Temperature — Headache — Vomiting — Choked disk — Prognosis — Advisability of operative interference — Treatment — Cold applications — Internal medication — Surgical treatment. Sinus Thrombosis. Avenues of infection — Extension to internal jugular — Secondary deposits — Symptomatology — Rigors and sweating — Intermittent temperature — General sepsis — Evidences of secondary deposits — Diagnosis — Value of frequent thermometric observations — Meningitis — Extension of thrombus — Involvement of lymphatics — Examination for choked disk — General condition of patient — Prognosis — Apparent recovery — Statistics of results of operative treatment — Extension to internal jugular — Statistics — Latent cerebral deposits — Treatment — Operative treatment — Medication — Alimentation. Extradural Abscess. Nature of the process — Symptomatology — Localized headache — Temperature changes — Mental condition — Prognosis — Latent deposits — Spontaneous evacuation — Value of operative treatment — Treatment — Necessity of surgical interference. Cerebral Abscess. Origin — Site — Latent deposits — Symptomatology — Dependent upon location — Aphasia and agraphia — Constitutional symptoms — Asthenia — Sleeplessness — Temperature — Diagnosis — General asthenic symptoms — Sleeplessness — Low temperature — Difficulties in Diagnosis due to complicating lesions — Prognosis — Natural progress when not interfered with — Proper time for surgical interference — Results of operative treatment — Treatment — Evacuation by operation. Cerebellar Abscess. Frequency — Pathological changes — Symptomatology — Vomiting — Dizziness and unsteadiness in gait — Dullness and apathy — Headache — Temperature — Diagnosis — Difficult be-

CONTENTS. xiii cause of absence of pathognomonic symptoms — Choked disk maybe present — Symptoms may be those of serous meningitis — Prognosis — Chances of recovery if recognized in time — Treatment — Evacuation by operation.

CHAPTER XXVII. Middle-ear Operations 481-531

Preliminary Preparations. Instruments — Form — Construction — Sterilization — Field of operation — Necessity of asepsis — Method of securing an aseptic condition of the parts — Anaesthesia — Limitations of local anaesthesia — Conditions demanding general anaesthesia — Position of the patient — Advantages of elevation of head and shoulders. Classification of Operations. I. Operations upon the Membrana Tympani — Myringotomy for evacuation of fluid — For depletion — For exploration — Partial myringectomy — Multiple incisions — Plicotomy. II. Operations involving Section of Intratympanic Tissues — Tenotomy of the tensor tympani — Methods of operating — Division of the anterior ligament of the malleus — Division of adhesions in suppurative and nonsuppurative cases. III. Operations involving the Ossicular Chain — Excision of a portion of the manubrium — Disarticulation and mobilization of the stapes — Plastic operations — Removal of the ossicles — Technique when the membrana tympani is intact — Treatment after operation — Reaction following operation — Reproduction of the membrana tympani — Technique when membrane is partially destroyed — Haemorrhage during operation — Difficulty of securing the remnant of the incus — Curetting of tympanum after removal of ossicles — Subsequent treatment — Details of technique of disarticulation at the incudo-stapedial joint and removal of the incus — Frequency of caries of incus — Control of haemorrhage — Possible accidents — Stacke's operation — Author's operation — Statistics — Stapedectomy — With intact drum membrane — With drum membrane partially destroyed — Statistics of author's operations showing the effect upon the function of audition in cases operated upon.

CHAPTER XXVIII. The Mastoid Operation 532-545

Instruments — Preparation of field of operation — Incision — Separation of sterno-mastoid muscle — Removal of cortex — Removal of softened bone — Accidents during operation — Opening of lateral sinus — Treatment — Laceration of dura — Treatment — Dressing — After-treatment — Technique of operation in young children — Technique in mastoid sclerosis — Destruction of osseous tissue — Trautmann's operation for closure of opening — Mosetig-Moorhof s method — Paraffin treatment reported by Frey — Technique of injection.

CHAPTER XXIX. Radical Operation for Chronic Otorrhoza — Stacke

Schwartze Operation 546-563

Necessity for free drainage — Combination of the methods of Kiister, Bergmann, and Stacke to form Stacke-Schwartze operation — Technique — Situation of incision varies with operators — Structures to be avoided in operating — Lining of cavity with flaps — Pause's modification — Koerner's modification — Jansen's modification — Ballance's xvi CONTENTS.

— Treatment — Acute stage — Depletion — Rest — Revulsives — Chronic stage — Reduction of labyrinthine pressure — Prophylaxis.

CHAPTER XXXVII.

Labyrinthine Embolism and Thrombosis ..... 629-630

^Etiology — Metastasis — Inflammation of contiguous structures — Pathology — Results in local anaemia — Local necrosis — Inflammation — Symptomatology — Function of organ usually not much disturbed — Spontaneous improvement — Prognosis — Condition not progressive — Treatment — Removal of cause — Reduction of labyrinthine pressure — Relief of subjective symptoms — Stimulation of impoverished nerve tissue.

CHAPTER XXXVIII.

Specific Inflammation of the Labyrinth 631-634

Etiology — Hereditary or acquired syphilis — Pathology — Chronic inflammatory changes — Hypertrophy — Changes in walls of vessels — Necrosis — Symptomatology — Sudden access . in acquired form — Invasion less sudden in hereditary cases — Diagnosis — Physical examination — Recognition of concomitant tympanic disease — Functional examination — Deficient bone conduction — Lowering of upper tone limit — Differential diagnosis in "mixed" form — "Hutchinson teeth" — Examination by the Wassermann or Noguchi methods — Prognosis — Influence of heredity — Age of local process — Spontaneous quiescence — Treatment — Antisyphilitic medication — Salvarsan — Pilocarpine — Iodide of potassium — Strychnine in advanced cases — Tonic treatment in hereditary cases.

CHAPTER XXXIX.

Inflammation of the Labyrinth secondary to Chronic Suppurative and Nonsuppurative Inflammation of the Tympanum 635-645

Pathology — Inflammatory changes — Atrophic changes — Extension of inflammation from tympanum — Condition of oval and round window — Results of suppuration — Functional disturbances — Symptomatology — Subjective noises — Significance of disappearance of tinnitus — Vertigo — Sympathetic involvement of opposite ear — Diagnosis — Physical examination — Absence of physical signs in certain cases — Value of inspection in residual purulent cases — Functional examination — Evidences of obstruction to sound conduction — Necessity of repeated examinations — Determination of relative importance of tympanic and labyrinthine lesion — Electrical tests— Importance of examination upon both sides to determine secondary involvement of apparently healthy organ — Prognosis — Residual purulent cases usually progress but slowly or not at all — Dangers of sympathetic involvement — Treatment — Relief of cause in middle ear — Preservation of organ involved secondarily — Special measures directed toward labyrinth — Pilocarpine — Strychnine — Specific treatment — Persistent stimulation by sonorous vibrations — Relief of subjective noises — Treatment of the upper air passages — Danger of treating middle ear in advanced cases.

CHAPTER XL.

Acute Inflammation of the Labyrinth secondary to Acute or

Etiology — Ordinary causes of acute purulent otitis media — Virulence of process — Pathology — Tissue necrosis — Avenues of

CONTENTS. xvh infection — Infection of cranial contents — Obliteration of labyrinth from deposit of new tissue — Symptomatology — Not characteristic in young subjects — Evidences of labyrinthine infection in adults — Importance of facial paralysis as a symptom — ■ Disturbance of static function — Retrogression of symptoms — Haemorrhage — Permanent impairment of audition — Diagnosis — Physical examination — Not characteristic of labyrinthine involvement — Evidences of caries of internal tympanic wall — Functional examination in children unsatisfactory — In adults — Upper tone limit much lowered — Bone conduction absent or greatly reduced — Vertigo — Prognosis — Unfavorable for complete restoration of function — Often fatal in children — In adults not as great a menace to life — Danger of absolute deafness less common in adults — Danger of causing deaf -mutism in children — Treatment — Prophylaxis against infection by asepsis from the first — Relief of tinnitus — Procedures to combat extension to meninges — Cold locally — Purgation — Value of pilocarpine after acute stage has been passed.

CHAPTER XLI.

Involvement of the Perceptive Mechanism in the Acute Infectious Diseases . . . . . . . . 654-660

Introductory remarks— Direct infection of labyrinth — Concomitant middle-ear inflammation — Pathology — Inflammatory changes — Increase of tension by effusion — Occlusion of vestibular and cochlear aqueducts — Symptomatology — Impairment of function — Tinnitus — Influence of age of patient upon manifestations — Resultant mutism in children — Diagnosis — Simple if middle ear is normal — Determination of labyrinthine lesion if tympanum is also affected — Value of functional examination in differential diagnosis — "Tone gaps" — Prognosis — Not grave in recent cases — More amenable to treatment in children than in adults — Treatment — Reduction of labyrinthine pressure by pilocarpine — Strychnine in chronic cases — Value of persistent education of power of audition. Effect of Certain Particular Diseases of this Class. Mumps. Metastatic infection of labyrinth — Prognosis excellent in cases subjected to medication at an early period. Typhus and Typhoid Fever. Probably causes changes in cortical centres — Usually disappear during convalescence. Epidemic Influenza; Diphtheria. Probable involvement of nerve trunk — Impairment in audition for middle portion of musical scale — Tone limits unchanged — Galvanic hyperesthesia — Bone conduction not lost, but reduced — Treatment directed toward improving general condition — Value of strychnine after acute stage. Epidemic Cerebro-spinal Meningitis. Pathology — Extension to labyrinth through aqueducts — Inflammatory changes — Extravasation — Deposit of new tissue — Secondary invasion of tympanum — Symptomatology — Vertigo— Severe tinnitus — Hyperacusis — Paralytic symptoms — Diagnosis — Physical examination — Negative unless tympanum is secondarily involved — Functional examination — Profound impairment of audition — Upper tone limit greatly reduced as a rule — Exceptions — Effect of hyperesthesia on the perception of low notes — Bone conduction almost or entirely wanting — Prognosis — Complete deafness in severe cases — Significance of disappearance of tinnitus — Danger of mutism in children — Treatment — Prophylaxis impossible — Local depletion and catharsis in early stages — Pilocarpine valuable after acute stage — Cases of long standing — Strychnine — Value of systematic exercise of auditory function by the use of conversation tube, etc.

xvin CONTENTS.

CHAPTER XLII.

PAUBS

Involvement of the Perceptive Mechanism in Acute Meningitis 661-665

Pathology — Labyrinthine lesion — Involvement of nerve trunk — Cortical lesions — Symptomatology — Variations due to location of lesion — In the labyrinth — Subjective noises — Vertigo — Impaired audition — Affecting nerve trunk — Interference with perception of middle notes of musical scale — Limits of audition normal — Significance of unilateral impairment — Cortical lesion — Bilateral impairment — Word deafness — Later symptoms — Diagnosis — Physical examination — Negative frequently — Importance of rupture of membrane in traumatic cases — Functional examination — Characteristics of labyrinthine lesion — Of lesions of nerve trunk — Of cortical involvement — Value of electrical tests — Prognosis — Treatment — Acute stages — Pilocarpine in later stages — Iodide of potassium — Strychnine — Exercise of auditory function.

CHAPTER XLIII.

The Effect of Diseases of the General Nervous System upon

the Perceptive Mechanism ...... 666-668

Cortical Lesions. Bilateral involvement — Word deafness — Auditory hallucinations — Intermittent tinnitus. Tabes Dorsalis. Degeneration of nerve trunk — Galvanic hyperesthesia — Perception of middle notes impaired — Torpidity of nerve in later stages. Lesions of Vestibular Nerve and of Cerebellum. Disturbance of equilibrium — Diagnosis — Dependent upon general rather than special symptoms — Treatment — Value of bromides — Strychnine — Antisyphilitic medication.

SECTION VI.

COMPLICATING AURAL AFFECTIONS.

CHAPTER XLIV.

Aural Affections complicating the Acute Infectious Diseases . 671-673

Affection of perceptive apparatus — Involvement of conducting mechanism — Character determined by degree of infection — Portions of tympanum involved — Extension to other regions.

CHAPTER XLV.

Aural Affections dependent upon Chronic Visceral Conditions 674-681

Symptoms due chiefly to circulatory changes. Nephritis. Effect due to venous obstruction — Arterial sclerosis and impoverished quality of blood — Tympanic effusion — Extravasations — Labyrinthine haemorrhage — Haemorrhage into nerve sheath. Metastasis. Embolism of labyrinthine vessels from remote suppurative process — Infection of middle ear. Tuberculosis. Tympanic involvement — Absence of pain — Multiple perforation — Constitutional treatment — Effect of tympanic process upon general condition. Leucaemia. Extravasation into labyrinth — Deposit of new tissue — Sudden appearance of symptoms — Diagnostic data. Diabetes. Frequency of inflammation in external meatus — As predisposing cause of middle-ear suppuration — Extravasations in labyrinth, nerve trunk, or centres. Gout and Rheumatism. Cutaneous manifestations in canal — Arthritic inflammation in middle ear — Changes in the blood vessels and the results. Medicinal Substances. Quinine — Effect on middle ear and labyrinth — Salicin and salicylic acid — Conditions contraindicating their administration — Tobacco — Effect upon higher centres.

CONTENTS. xix

CHAPTER XLVI.

Disturbances of Audition dependent upon Functional Nervous

Unimportant physical changes as a cause of manifestations in a particular region — Perversion or impairment of function with no evident lesion. Neurasthenia. "Auditory strain" — Psychological effect — Character of impairment of hearing — General sensory paresthesias — Diagnosis — Physical examination often negative — Functional examination — Perception of high and low notes — Reduction of bone conduction — Variable results obtained by successive tests — Recognition of general neurotic condition — Hyperacusis — Auditory fatigue — Prognosis — Influence of organic changes in ear — Influence of general neurosis — Treatment — Strychnine — Bromides — Rest — Change of habit of life. Hysteria. Degree of impairment — Sudden appearance — Subsequent course — Associated hysterical paralyses — Transference — Absence of subjective noises — Diagnosis — Sudden onset — Absence of physical changes — Cutaneous anaesthesia — Functional examination — Contraction of range of audition — Upper tone limit most affected — Alternate variations in upper limit — Contraction of field of vision — Prognosis — Treatment — Attention to general neurosis — Hypnotic treatment.

CHAPTER XLVII.

Reflex Aural Disturbances 688-693

Vaso-motor changes — Trophic disturbances. External Meatus. Reflex inflammation — Cutaneous hyperesthesia — Haemorrhage. Middle-ear. Reflex otitis media — Otalgia — Angioneurotic oedema of mastoid. Perceptive Mechanism. Paraesthesia — Influence of visceral disorders — Interference with static function — Irregularity and transitory character of symptoms — Absence of local cause — Presence of remote lesion — Effect of one ear upon opposite organ — Physiological interdependence — Pathological correlation — Value of electrical hyperaesthesia in diagnosis — Prognosis — Duration of reflex symptoms — Nature of exciting cause — Treatment — Early administration of bromides — Removal of exciting cause — Antispasmodics — Opium contraindicated — Tonic treatment.