mastoid and great sensibility to the touch, followed by marked
swelling, which may extend far down the neck, involving the lymphatic
glands. Later, pus will be found between the periosteum and bone, and
in a few cases caries of the bone.
2. Inflammation of the Mucous Membrane of the Mastoid Cells is caused
generally by extension of inflammation from the middle-ear cavity,
either of a catarrhal or purulent character, causing the cell-cavities
to quickly fill up with the inflammatory products which escape through
the antrum and middle-ear cavity into the external canal. If this way
is closed, the fluids accumulate in the mastoid cells and form
conditions favorable to involvement of the internal organs.
SYMPTOMS.--Severe pain, tenderness, and redness of skin over mastoid,
but not the marked swelling that is found in periostitis. During such
an inflammation facial paralysis may develop, showing that the
inflammation has extended into the bone itself. Delirium is
occasionally met with, probably due to a more or less circumscribed
meningitis; coma is also occasionally noted, caused by effusion into
the lateral ventricles. In many cases of antrum inflammation there is a
marked swelling of the upper and posterior cutaneous covering of the
osseous part of the external canal, making it a valuable symptom in
determining the degree of the inflammatory action.
Caries and necrosis of the mastoid bone are resultants of the
above-described conditions, and are especially found in early
childhood, and generally caused by retention of pus in the mastoid
cells and breaking down of their walls. This process can be limited to
the cell portion of the bone or can also involve the cortex, with
formation of an external fistulous opening.
TREATMENT.--Use of heat and moisture, either by hot-water fomentations
or warm poultices, like flaxseed, over the entire temporal region of
the head on which the diseased mastoid is located. The flaxseed
poultice is to be covered with oil silk and changed as often as needful
to keep it warm. The use of leeches to the mastoid is indicated by
tenderness of the part to the touch, with heat and swelling of the
tissue covering the bone. Two or three foreign leeches can be used, and
if the abstraction of more blood is desired the after-bleeding is to be
encouraged by warm moist applications. If the disease advances
notwithstanding this treatment, an opening down to the bone is
indicated. The incision is usually described as the Wilde incision. The
length of the cut is to be from a half to one inch, down to the bone,
the point of the knife entering the {835} skin on a level with the
upper wall of the auditory canal, about half an inch behind the
auricle. Occasionally the posterior auricular artery is cut, but
hemorrhage is readily controlled by pressure over the artery. During
the entire treatment the external auditory canal is to be cleansed from
time to time of the purulent secretions, so as to facilitate the
discharge of pent-up fluids from the middle ear and antrum. Also, the
condition of the pharynx is to be noted, and treated if needful.
Finally, if all these measures fail to relieve, and the patient shows
signs of meningeal or brain involvement, together with marked redness,
tenderness, and swelling over the mastoid bone, showing that pus is
being retained in the mastoid cells, there only remains the making of
an opening into the mastoid process and antrum by means of a bone-drill
or gouge. This is best done by a free vertical incision through the
skin and periosteum covering the mastoid process. Examine then the
bone, and a fistulous opening may be found which can be enlarged by a
probe, and so allow the free escape of pus. If such does not exist,
apply a drill to the bone at a point a quarter of an inch posterior to
the external canal and just below a horizontal line drawn tangent to
its upper wall. The instrument is to have a direction inward, upward,
and slightly forward. The depth to which it should penetrate varies:
usually cell-structure is reached at a slight depth, when the drill
should be withdrawn. If sclerosis of bone exists, it will be necessary
to go deeper, but never more than three-quarters of an inch, or about
20 millimeters. This is Buck's rule. Schwarze says, never go deeper
than 25 millimeters, otherwise there is risk of plunging the drill into
the labyrinth. Also, during the drilling process Buck recommends
keeping the fore finger of the operating hand constantly pressed
against the neighboring bone, so as by counter-pressure to reduce to a
minimum the risk of wounding the lateral sinus if it should lie in an
abnormal position in the path of the drill. After-treatment consists in
keeping the canal open by gentle washing. The use of a bone-gouge is
preferred by some to the drill, as being a less dangerous instrument.
Diseases of the Internal Ear.
ANATOMY.--The internal ear consists of a central cavity, from one end
of which arise the semicircular canals, and from the other the cochlea.
The interior of these contains the membranous portion and fluids of the
internal ear. The cochlea contains the most important part--namely, the
terminal endings of the auditory nerve. Sound-vibrations pass through
the external canal and strike against the tympanic membrane, throwing
it into vibration. The vibrations of this membrane are carried across
the middle ear by the chain of small bones to the membrane closing the
foramen ovale of the internal ear, throwing this and the labyrinthine
fluid also into vibration, and these latter vibrations, impinging on
the terminal endings of the auditory nerve in a way as yet unknown,
produce sound.
Vessels of the Labyrinth.--The labyrinth obtains its blood partly from
the arteria auditiva interna, a branch from the basilar artery which
comes from the vertebral, and partly through vessels communicating with
the middle ear viâ the round and oval windows, and through others
passing {836} through the long walls themselves. The arteria auditiva
interna divides in the internal meatus into a vestibular and cochlear
branch. The former is distributed to the soft structures of the
vestibule and semicircular canals. The cochlear branch is distributed
to the modiolus and layers of the lamina spiralis. The venæ auditivæ
internæ empty into the inferior petrosal sinus or the lateral sinus;
other branches empty into the superior petrosal sinus.
The auditory nerve or portio mollis of the seventh nerve arises by two
roots in the medulla oblongata. One ganglionic nucleus of origin is in
the floor of the fourth ventricle, the other is in the crus cerebelli
ad medullam (Stieda). The nerve winds around the restiform body, and
passes into the meatus auditorius internus, and finally divides into a
vestibular and cochlear branch. The vestibular branch divides into
three branches: the superior is distributed to the utricle and ampullæ
of the superior vertical and horizontal semicircular canals; the middle
to the sacculis, and the inferior to the ampulla of the inferior
vertical semicircular canal. The cochlear branch enters the modiolus
and breaks up into smaller branches, which radiate fan-shaped into the
lamina spiralis, and are then distributed between the two plates of the
lamina spiralis through all its turns.
TINNITUS AURIUM.--It may be assumed that the normal ear is filled with
continuous sound. The blood flowing through the large arteries and
veins in close proximity to it (such as the carotid arteries and
jugular vein), as well as the blood flowing through the vessels of the
internal ear, will give rise to sound by throwing into vibration the
soft tissues surrounding them, including also the walls of the vessels
themselves. This motion is sufficient to excite the auditory
nerve-elements by causing vibrations of the intra-labyrinthine fluids,
and so produce sound; which, being a normal condition, and one to which
the ear is accustomed, will remain unnoticed.[11]
[Footnote 11: To Theobald we are indebted for the vascular theory of
sound.]
The arterial system of the body throws the neighboring tissue into
vibration, but this is not recognized unless our attention is
particularly directed to it; or, in other words, the entire body is
filled with movement as a normal condition, and therefore attracts no
attention. But let this movement be increased--for instance, by violent
muscular exertion, increasing the arterial action--or lessened, as in
syncope, and at once an abnormal condition draws our attention to it.
In the same way the ear is filled with continuous sound as a normal
condition, and therefore it is not perceived, these sound-vibrations
escaping out through the middle ear and external canal. This can be
readily proved. Let the external auditory canal be obstructed
artificially, either by the finger or by a cork. At once a tidal
tinnitus, so called, is produced, this being caused by the normal
sound-vibrations being impeded in their outward passage and being
thrown back again to impress the nerve-elements for a second time.
This, being an abnormal condition, is at once recognized.
Different Varieties of Tinnitus Aurium.--I. Tinnitus caused by
obstruction of the normal sound-vibrations in their outward passage
through the middle ear and external canal; tidal tinnitus, so called
from a resemblance to the noise of the ocean. Such obstructions may
exist in the middle-ear {837} cavity, as thickening of the soft tissues
of the middle ear, exudations and adhesions, as found in chronic
catarrh, or in the external canal, as impacted cerumen, a swollen
canal, etc. The effect of such obstruction would be to interrupt the
normal sound-vibrations and cause them to be reflected back again to
impress for a second time the auditory nerve-elements, causing an
abnormal and therefore recognized condition. This is the most frequent
variety of tinnitus, and for the reason that it is produced by the more
ordinary ear diseases.
II. Tinnitus caused by abnormal sound-vibrations produced either by
increase or by decrease of intra-labyrinthine pressure. In a normal
condition the auditory nerve-elements are subjected to a given
intra-labyrinthine pressure; now, if this pressure be altered (either
by being increased or diminished) an abnormal condition ensues, and is
noted as such.
_a_. Tinnitus produced by increased intra-labyrinthine pressure may be
caused by increase of the intra-labyrinthine fluids (by effusions,
hemorrhages, etc., as in Menière's disease), or can be caused by
increase in the amount of blood flowing through the arteries and veins
of the internal ear. In either case there will result an increase of
pressure that is exerted on the auditory nerve-elements. Also, another
result of such increase of pressure on the arteries of the labyrinth
would be to throw them into more active pulsation, and so cause greater
movement on the intra-labyrinthine fluids. These abnormal vibrations
impinging on the auditory nerve-endings would be noticed as such, and
give rise to tinnitus of a pulsating character corresponding to the
movements of the pulsating vessels. Such a condition is noticed in an
eyeball afflicted by glaucoma, or can be artificially produced by
finger-pressure on a normal eye. The veins of the retina will be first
thrown into movement, and as the pressure increases the arteries will
show marked pulsation. Why should not a similar set of conditions in
the internal ear produce similar results?
_b_. Tinnitus produced by a lessened intra-labyrinthine pressure may be
caused either by loss of intra-labyrinthine fluid or by a lessened
blood-supply to the internal ear. The latter cause being the most
frequent, a familiar example of this would be the tinnitus experienced
by a fainting person, a common sensation being a swimming head
accompanied with strange whizzing noises in the ears. The tinnitus of
anæmia is of this class, and frequently of the pulsating variety.
Another explanation might be given: an anæmic heart murmur might be
conveyed along the blood-vessels as through a speaking-tube, and in
that way impress the auditory nerve. In this variety of tinnitus it is
supposed that the sound-conducting apparatus of the middle and external
ear is normal; if any obstruction exists, it would cause increase of
tinnitus of this variety.
III. Tinnitus caused by a diseased condition of the auditory nerve,
either in the part lying between the internal ear and brain or in the
brain-centre itself--pure subjective tinnitus. Here we enter upon a
subject obscure from the fact that so little pathological research has
been made in this direction; but, reasoning from analogy, why cannot
the auditory nerve be subject to as many diseased conditions as the
optic nerve, where the ophthalmoscope has clearly shown the existence
of neuritis, atrophy, and many other pathological changes, caused, it
may {838} be, by disease of the retina, or it may exist as an
inflammation of the nerve itself exterior to the eyeball, or it may be
due to a brain tumor pressing on the optic nerve or optic tracts, also
basilar meningitis? Gummata, osseous growths, etc. have in turn caused
optic neuritis; finally, lesions at the optic nerve-endings in the
brain itself have caused well-defined pathological changes in the optic
nerve, which by the aid of the ophthalmoscope are recognized. Now, if
these changes exist in the optic nerve, why may not the same conditions
be present in connection with the auditory nerve, although from its
anatomical location they are not capable of demonstration, as in the
case of the optic nerve? And, as in the latter phosphene symptoms are
common, due to nerve-irritation, so in irritation of the auditory nerve
tinnitus would be developed, but of a subjective character. (In this
connection it is not out of place to remark that in obscure internal
ear disease examination of the optic nerve will often give valuable
information toward clearing up the ear complication.) This variety of
tinnitus may in some cases be due to a reflex nerve-irritation.
Finally, tinnitus may be noticed in cases of inflammation of the middle
ear where fluid has collected, and is caused by the bursting of
air-bubbles in their passage through this fluid, the air gaining access
to the middle ear by way of the Eustachian tube. Tinnitus so produced
resembles a bubbling or crackling sound. Hinton draws attention to
certain cases where the tympanic membrane has lost its normal
elasticity and become stiff, any movement of such a membrane causing a
crackling sound. Also, there are some cases of tinnitus produced by
foreign bodies being deposited on the tympanic membrane, such as
cerumen, pieces of hair, etc., making a rustling or rasping noise.
Tinnitus produced by abnormal contractions of the tensor tympani or
stapedius muscles has been thought to exist. Tinnitus may be
intermittent or continuous. It also has an endless variety of sound,
from one almost unrecognizable to a roar so loud as to render the
patient nearly distracted.
Location of the Tinnitus.--Those varieties due to a diseased external
or middle ear locate the sound, as a rule, in the ear itself.
Subjective tinnitus is often located in the frontal and occipital
regions; often also in the ear itself. It is also to be noted that
marked tinnitus may be associated with a low degree of deafness, and
the converse is true: slight tinnitus may be associated with a high
degree of deafness.
PROGNOSIS.--The removal of tinnitus depends entirely upon the cause of
it and the possibility of its removal. Continuous tinnitus is always to
be regarded as a more pronounced symptom than the intermittent form.
The TREATMENT will be directed to the removal of the cause. If the
disease is located in the external canal or middle ear, or in a
diseased condition of the naso-pharynx, these irritating causes should
be removed by treatment already laid down in previous pages. The
treatment of subjective tinnitus will be guided by the same principles.
Determine the cause and seek for its removal. As to whether any
particular drugs exist peculiarly adapted to the removal of tinnitus, I
would say that in tinnitus of a subjective character or due to
nerve-irritation the bromides are indicated in appropriate doses.
Inflation of the middle ear with air impregnated with ether (a few
drops of ether dropped into a Politzer air-bag {839} and the inflation
made by the Politzer method), at intervals of three or four days, in
some cases proves of benefit.
Deafness after Cerebro-Spinal Meningitis, Scarlet Fever, Mumps, etc.
This opens up a chapter in which our knowledge derived from post-mortem
examination is very limited. In a given number of such cases the
inflammation probably extends from the brain to the labyrinth; in
others the changes that are found exist chiefly in the middle ear, so
that it must be supposed that the inflammation in such cases has
originated in the middle ear, and has secondarily invaded the
labyrinth. In some cases, such as deafness after mumps, Toynbee is of
the opinion that the peculiar poison of that disease affects the
nervous apparatus of the ear, as the deafness comes on suddenly, and is
usually complete, without evidence of disease in any other part of the
ear. In this class of cases the prominent symptoms are deafness--which
is total--and staggering gait, with vertigo. This symptom may last many
weeks, and then cease. As a rule, examination of the tympanic membrane
is negative, and the seat of disease is to be sought for in the
labyrinth, whether it may be an inflammation of the soft structures or
an effusion, causing increased intra-labyrinthine pressure. In many
cases the suddenness of the attack would point to an effusion as the
more probable cause.
Brunner in a comparison of five cases of deafness after mumps[12] gives
the following symptoms and course of the disease: 1. The nervous
deafness after mumps can be one-sided or double-sided, the former being
more frequent. 2. It is complete, and, according to past experience,
incurable. 3. It develops rapidly, with vertigo and subjective noises,
the later symptom lasting a long time. 4. There is little or no fever.
5. Pain is never or very seldom present. 6. Consciousness is not lost;
excessive vertigo a prominent symptom. 7. It happens both in children
and adults.
[Footnote 12: _Archiv Otology_, vol. xi., No. 2, p. 103.]
Menière's Disease.
A. Guye of Amsterdam has published a very full summary of the history
of this disease.[13] The following is extracted from it: Under the head
of Menière's disease is included those cases of inflammatory processes
in the semicircular canals or in the middle ear producing vertigo,
which is either continuous, or caused by normal movements of the head,
or appearing only at intervals of weeks or months; also, that this
disease is of a secondary nature, and is due to inflammatory processes
in the tympanum or antrum. In typical cases the vertigo is accompanied
by sensations of rotation: first a sense of rotation about a vertical
axis and toward the affected side; this is followed by a sensation of
rotation about a transverse axis forward and backward. The vertigo then
becomes complete, and is followed by fainting, with or without loss of
consciousness and vomiting. The attack in some cases may last for a few
minutes to a half hour; in others every movement will tend to produce
vertigo for {840} several days. In chronic cases the feeling of vertigo
to a slight degree persists between the attacks. Guye considers the
causes of middle-ear catarrh as the factors most likely to cause
Menière's disease. Syphilis is also noted in some cases.
[Footnote 13: _Ibid._, vol. ix., No. 3.]
TREATMENT.--In some cases an alterative treatment is most serviceable,
such as iodide of potassium, also the bromide of potassium; quinine is
also by some recommended. The use of alcohol and tobacco is to be
forbidden.
The disease known as boiler-makers' deafness, because generally found
among men laboring in machine-shops, where they are subjected to loud
noises connected with the work they are engaged on, is thought to be
due to a paralysis of the terminal endings of the auditory nerve due to
concussion. The middle ear sometimes shows some thickening of the
tympanic membrane. Treatment is without avail.
In internal-ear diseases a few common symptoms can be noted. All cases
show deafness, and in most of them of an absolute degree. And here is
where the tuning-fork proves a valuable aid in diagnosis of deafness
due to middle-ear disease, in which cases the tuning-fork is heard best
on the deaf side, and to deafness due to internal-ear disease, where
the tuning-fork is heard the least on the deaf side. Vertigo and a
staggering gait are quite common symptoms, probably due to irritation
of the semicircular canals. Prognosis as a rule is bad, as far as
recovery is concerned, and an alterative treatment is often indicated.
Electricity, I would state, in my experience has not proved to be of
any avail.
Deaf-Mutism
may be either congenital or acquired. Two-thirds of all cases will come
under the first class, and often depend upon a mal-development of some
part of the central nervous system or the ear itself, or may be due to
intra-uterine disease of the ear. There is a strong tendency for this
disease to be inherited, and particularly in children where there
exists a blood-relationship between the parents. The acquired cases may
arise from defects in the central nervous system or in the internal
ear, or may be due to diseases affecting the middle ear, such as
purulent inflammation; and this latter cause is to be noted, as no
doubt proper treatment of the middle-ear disease in many cases would
have prevented such a result.
All deaf cases become mute, unless the disease has occurred in adult
life, when the patient has already acquired the power of language. A
deaf-mute does not speak, because he cannot hear, and therefore speech
is an unknown quantity.
The TREATMENT would consist in treating any middle-ear disease that
might exist, such as the sequelæ of purulent inflammation, and the
instruction of the patient in acquiring the power of intercommunication
either by the methods long employed of finger-reading, or, much better,
by the lip method, so called, where the power of speech is given to the
patient. Such cases should attend schools where such instruction is
given, commencing at five years of age, and many cases now attest the
value of the latter method of instruction.
DIFFERENT METHODS OF DETECTING FEIGNED DEAFNESS.--The {841} Moos
Method.--Stop the external canal of the sound ear with a cork; place a
vibrating tuning-fork on the head. If the person under examination
declares that he does not hear the fork with either ear, he is feigning
deafness, as it would be heard well by the sound ear.
The Urbantschitsch method makes use of the human voice. First determine
that good hearing power exists in the sound ear; then shut the external
canal of this ear with a cork and address the individual with a few
loudly-spoken words. If he denies hearing at all, he is feigning, as a
good hearing ear, by simple closure of the external canal, will be
still able to hear loudly-spoken words.
Another method is to determine the distance at which the person can
hear certain words and repeat them correctly. Then have the patient
close the eyes and let the examiner try by lengthening and shortening
the distance, and note the result. Often he will hear and repeat words
spoken at long distances, and apparently not be able to repeat words
spoken at short distances.