A treatise on the physiology and diseases of the ear ; containing a comparative view of its structure and functions, and of its various diseases, arranged according to the anatomy of the organ, or as they affect the external, the intermediate and the internal ear
Curtis, John Harrison, 1778-approximately 1860. n 88255458
IxmWi UVgffyj JnNtArjfe 1 ui oy 'i yms Sk%<fa / I Digitized by the Internet Archive in 2017 with funding from Wellcome Library https://archive.org/details/b29316340 A 4 ±Jr s TREATISE ON THE #&1?i3tolog£ anD J^tgeasies OF THE EAR; CONTAINING A COMPARATIVE VIEW OF ITS STRUCTURE AND FUNCTIONS, AND OF ITS VARIOUS DISEASES, ARRANGED ACCORDING TO THE ANATOMY OF THE ORGAN, OR AS THEY AFFECT THE EXTERNAL, THE INTERMEDIATE, AND THE INTERNAL EAR. BY JOHN HARRISON CURTIS, Esq, Aurist to His Royal Highness the Prince Regent, Surgeon to the Royal Dispensary for the Diseases of the Ear, Lecturer on the Anatomy, Physiology, and Pathology of the Ear, Fellow \)t the Medical Society of London, &c. &c. ILonOou : PRINTED FOR SHERWOOD, NEELY, AND JONES, PATERNOSTER-ROW, 1817. f H»8TOn»CA'U \ MEDICP.L / S / \</o /8 P r c. G. Sidney, Printer, Northumberland Street, Strand. TO HIS ROYAL HIGHNESS THE PRINCE REGENT, IN TOKEN OF THE AUTHOR’S GRATEFUL SENSE OF HIS ROYAL HIGHNESS’S GRACIOUS CONDESCENSION, IN BECOMING THE PATRON OF THE i&opal Dispensary fijr tlje Diseases of tije Car, AND IN APPOINTING HIM AURIST TO HIS ROYAL PERSON, THIS WORK Is most respectfully dedicated, by His Royal Highness’s Most obedient and most Devoted Servant, John Harrison Curtis. Soho Square, April 14th, 1817. EXPLANATION OF THE PLATE. a. Healing Trumpet. b. French Artificial Ear, with gold tube ; internal side. c. French Artificial Ear, with gold tube; external side. d. The Tubes. e. Spanish Ears. /. Internal part of the German Silver Ear. g. External part of the German Silver Ear# h. Trumpet Case. b i - . ] -• !. ; - INTRODUCTION. The improvements in Medicine and Sur- gery of late years have been great and im- portant, but more particularly in the latter. In proportion as civilization advances in every state, the number of diseases is aug- mented, and the profession acquires greater respect and estimation from its more exten- sive utility. In former times, Surgery, the most an- cient branch, (for external accidents in savage life, always precede internal disease,) was b 2 via simple, and of limited extent. As improve- ment took place, this department became gradually enlarged ; and in point ot science and principle, as it is now cultivated, it stands on a firmer basis than Medicine. For the benefit of society, it has been subdi- vided, by its professors, into various depart- ments, which, by calling for a more minute attention to particular subjects, has enlarged our views of them, and made us more capable of affording effectual relief, under circumstances formerly considered as beyond the reach of the Healing Art. The benefit which has resulted to man- kind from the exercise of the Oculist’s pro- fession as a distinct branch, is incalculable : the operations on that delicate organ, the eye, are now conducted with a nicety and success unknown in former times : the for- mation of an artificial pupil, as first invented IX by Mr. Gibson of Manchester, and subse- quently improved by the late Mr. Saunders, Sir William Adams, and others, has saved the sight of numbers, on whom former operations had failed, and who, without this discovery, must have continued in total darkness for life. The same happy result to society has been the consequence of the profession of the Dentist. The teeth are essential to the appearance and symmetry of the visage ; without them that contour and harmony of features, which the face ought to possess, is wanting : but the teeth are parts of the body which nature has intended should more quickly decay than the other parts, 't from their greater exposure to external causes, acting upon, and destroying their enamel, and osseous structure. When lost to the constitution, not only is the beauty of the countenance impaired, but the pro- cess of digestion becomes imperfectly car- ried on, the food is no longer comminuted as it ought to be, and stomach complaints, with a decay of general health, are too often the consequence. The hand of the artist has here been the assistant of Nature; the artificial substitutes are equal in their effect to the real organ- ized productions originally implanted ; nay, to such perfection has the art of man been carried, that in cases of syphilitic com- plaints, where the palate or bony arch of the mouth has been destroyed, and the un- happy sufferer has been incapable of utter- ing and articulating, so nicely has mecha- nism, in the hands of a Faleur, a Ruspini, and others, supplied the defect, that no trace of it can be perceived, either in the articulation, or in the reception of food. xi These facts demonstrate clearly the ad- vantage of subdividing the objects of pro- fessional pursuit or study, and bending a close attention to one point : it is applying to Science, that which experience has proved to be so successful in the mechanical arts. In the construction of one small machine, a watch, there are no less than twelve dif- ferent branches employed in order to per- fect it, and to each branch is assigned the making of one separate part ; hence the perfection and cheapness to which it is brought. The same system is conspicuous in all the leading manufactures of this country : and the advantage of the principle has been admirably enforced by the late Dr. Adam Smith, in his Wealth of Nations, as well as by other celebrated characters. The mind of man, it is clear, though capacious, and possessed of very extensive powers, cannot embrace the whole circle of science, or retain it with that exactness which is necessary to excel; he must select a part of the circle, if he wishes to shine, and must bend his attention to that subject alone, in scientific pursuits. However, it is not intended, by this observation, to convey an idea, that the student should alone endea- vour to get acquainted with the department - he selects, as a mechanical art, or that he should not travel beyond its bounds : on the contrary, a professional education should be so conducted, as to make every one first acquainted with the general prin- ciples and scope of every part of the pro- fession ; and this being once attained, and the general studies completed, then, and not till then, he should limit his pursuit to one subject ; this subject, in consequence of Xlll his previous acquirements, he will then better understand; he will be able to improve by a comparison and illustration of it with the other branches he has studied, and make them all bear on this favourite, or leading topic : his previous acquirements may be considered in the light of scattered rays, which will be all brought home to this centre point or focus. It is on this principle, and with an anxi- ous wish to extend the knowledge of this department of surgery, which has hitherto been undervalued from various causes, that the Author begs leave to call the attention of the Public to the present Work. In estimating the different senses, none will be found of more importance than that of hearing. The ear is the grand medium xiv which connects man with society ; which facilitates all social intercourse, by an unli- # mited interchange of ideas; and which extends information and intelligence far beyond the power of the eye, or any other sense. Through this medium man is enabled to conduct the great and com- plicated business of life; by it, his ha- ranrme is heard in the senate, and his com- mauds in the held. It forms the mutual and unembarrassed communication of all senti- ment and expression. Without this sense, how comparatively useless are the organs of speech ! and where hearing is defective in eaily hie, dumb- ness is too often a consequence. Count de Buffon’s case of the savage boy found in the woods of Ardennes, in France, is a strong proof that the powers of the mind XV could not be developed without this impor- tant sense, and the interchange of ideas % to which it gives rise. But the ear, though the most important of all the senses, has hitherto claimed but little attention from the Profession. The diseases of every other organ are well un- derstood, together with the modes of repair- ing their defects ; but the imperfections of this sense having been little attended to by the regular Profession, the treatment has been, for the most part, confined to the hands of empirics : hence, obscurity and prejudice have prevailed in this branch of practice, and an apathy has taken place on the subject, highly injurious to the interests of society. It has been unfortunately laid down as a maxim, that the diseases of this organ are incurable. But this opinion has no just XVI foundation ; and, in fact, might have been applied with equal propriety to the other organs, on which we daily see such admi- rable cures performed. Indeed, there can be no doubt but experience, joined with an ardent desire to improve, will be attended with the same success in this as in every other branch of the Medical Science. But to such a length has prejudice been carried, on this subject, that in cases of deafness in early childhood, where much might have been done, and the misfortune of settled disease in great measure averted, no attempt has even been made to ascer- tain the defect, or try the smallest means of relief ; while it is well known, that, at the birth, and a considerable time after, a viscid mucus often fills up the passage of the ear, in like manner as the meconium does the intestines ; and when this ori- XVII ginal layer, or deposition, is removed, the hearing soon becomes perfect, as at any other period of life. It has been already stated that dumbness is oiten the consequence of imperfect hear- ing. An institution has been most laudably established tor those labouring under this complicated misfortune. And I have sug- gested to the Committee of that charitable Institution, the Deaf and Dumb Asylum, that every child introduced into it should be first carefully examined, the precise defect, as far as possible, ascertained, and the point settled, whether the imperfection be confined to the organ of speech alone, or be owing to a complicated disease of both organs. By such examination, relief might often be afforded, and the child placed in a situation of recovery. XV111 In the following Treatise it is meant to inquire fully into the functions and diseases of the Ear. The published works on this subject are few in number, and are very incomplete. 4 Duverney, among the French, is the only author who has treated the subject scien- tifically, until our own time, when Dr. i Monro, of Edinburgh, first published his very accurate treatise on the anatomy of the Ear; and then followed the work of the late Mr. Saunders, which, besides the anatomy, elucidated the diseases of the ear, and introduced into this department of surgery considerable improvement. His work, however, is more adapted for the Profession, than for general reading ; and as it is of importance that those who unfor- tunately labour under a defect of hearing. XIX should have some knowledge of the par- ticular causes of the disease, the Author flatters himself that the present Work will be found an acquisition of no small value to those for whom it is more especially intended. The Work is necessarily concise ; but any gentleman desirous of farther investigating this interesting subject, may have an oppor- tunity of so doing, by attending the Lec- tures of the Author, and the practice of the Royal Dispensary.* * Vide page 93. ' « '. , . *#. A TREATISE, &e. CHAP. I. Of the Structure and Uses of the different Parts of the Ear. The Ear, though differently modified in some of its parts, possesses the same general structure in all animals. It is divided into an external and internal part, and in the several classes of animals the difference is greater in the external than in the internal division of it. In quadrupeds this difference of structure is more conspicuous than in the rest, and this dif- ference or variety seems intended to adapt the £ 2 animal the better for its particular circum- stances or mode of life. On examining the external ear in quadrupeds, it is found to resemble the oblique section of a cone, from near the apex to the base. Hares, and other animals exposed to danger, and liable to be attacked by man or beasts of prey, have large ears, and they are particularly directed backwards ; while their eyes at the same time, full and prominent, warn them of any danger in front. Rapacious animals, on the contrary, have their ears directly forwards, as is observ- able in the lion, the tiger, the cat, and others. Where the peculiar nature of animals is such as to require that sound be distinctly heard from a low situation, as, for instance, slow hounds and others, they will be found to have either large hanging-down ears, or have them flexible, since they move their heads with more difficulty than man. Fowls, again, differ from quadrupeds in having no external ear; but in place of it there is a tuft of very fine feathers, which covers the passage to the ear : this covering allows the 3 sound to pass easily through ; and it also prevents any insects, or external matters which mio-ht O prove a source of injury, from getting into it. To them an external ear would have been in- convenient, as causing an obstruction in the course of their flight, in passing through thickets, and other nearly impervious places. In the external ear of the fowl, there is situated a liquor to lubricate it, and, from its disagreeable quality, to prevent the entrance of insects. On examining farther the different tribes of animals, we find that fish have a complete organ of hearing, and equally perfect as that of the other classes. The element, also, in which they exist, is proved to be one of the best mediums for the transmission of sound: thus, in the skate, on dissecting the head, we find placed, at some distance behind the' eyes, a bag which contains a fluid, and a soft creta- ceous substance ; these are the vestibule and cochlea of this creature, corresponding to similar parts of the internal ear in man. There is, also, b <2 4 distributed upon this bag, a part of the auditory nerve, resembling what is termed the portio mollis, or branch of the seventh pair of nerves, in the human subject : they have likewise semi- circular canals, a leading part of the internal ear, filled with a fluid which communicates with this bag , and they have also an external passage, which communicates with this internal part. In the cod species, instead of this soft creta- ceous substance, I have noticed, there is found a hard crustaceous stone ; but there seems no appearance of an external passage, as in the skate. In prosecuting our inquiries farther, the ear has been discovered in insects ; it lies at the root of their antennas, or feelers, and can be distinctly seen in the lobster, and some others of the larger kind. On the whole, this organ of hearing is so constructed, in every class, as to be peculiarly 5 adapted to the mode of life, and other circum- stances connected with the situation of the animal. Man has the most perfect external ear of all animals : as he must hear sounds equally from all quarters, and especially such sounds as are transmitted from his own height, so his external ear is both large, and placed in a vertical manner, turned somewhat forward. But to compensate the animal when compared with man, the former in general possesses, in this respect, a greater power of motion, and is furnished with a greater number of muscles. Thus animals can direct or apply the cone of the ear to the sonorous body without moving the head. When the motion of the external ear takes place in man, which has been known in some rare instances, it does not seem to add any thing to the perfection of the sense, as it does in them. In describing the human car, it is divided by 6 anatomists into three parts, the external ear, the intermediate, and the internal. The outward ear is designed by nature to stand prominent, and to bear its proportion in the symmetry of the head; but in Europe it is greatly flattened by the pressure of the dress. It consists of elastic cartilage, formed with dif- ferent hollows, or sinuosities, all leading into each other, and finally terminating in the concha, or immediate opening into the tube of the ear. This form is admirably adapted for the recep- tion of sound, for collecting and retaining it, that it may not pass off, or be sent too rapidly to the seat of the impression. The intermediate ear displays an irregular cavity, having a mem- brane stretched across its bottom ; and this ca- vity has a communication with the external air, through the tube which leads into the fauces. The tympanum, or drum, which stretches across it, is intended to carry the vibrations of the atmosphere, collected by the outer ear, to the chain of bones which form a peculiar mechanism in the tympanum. 7 The internal ear may be considered as the actual seat of the organ : it consists of a ner- vous expansion of high sensibility, the sentient extremities of which are spread in every direc- tion, and in the most minute manner, in oscu- lating with each other, and forming plexus, all for the purpose of increasing sensation. Here also the sound is collected and detained, which the mastoid cells and cochlea present. To this apparatus is added the pre.sence of a fluid, contained in sacs and membranes ; and as this fluid is in large quantity in some animals, there is no doubt it is intended as an additional means for forcing the impression; and the known influence of water, as a powerful medium, or conductor of sound, strengthens the idea. The internal ear of man, therefore, has all the variety of apparatus which is only partially present in the other classes of creation; and its perfection is best judged of, by considering the variety which the internal ear of other animals exhibits. The internal ear of some animals, we find, con- sists of little more than a sac of fluid, on which 8 is expanded a small pulp of nerve; according to the situation of this cavity, as it lives in water alone, or is partly exposed to the air, so in the latter it has an external opening with the ear or otherwise. All terrestrial animals possess an external opening leading to the internal ear. In fowls, the ear is more of a cartilaginous consistence than real bone. Hence any tremulous motion impressed on the air is communicated merely by the spring and elasticity of these cartilaginous parts, which do not require, in order to render the membrane of the ear tight, the same power or action of the muscles. In the internal ear the semicircular canals appear also very distinct, the same as in man. In all animals the internal ear is composed of a nervous expansion, contained in a hollow or cavity, and assisted in its impres- sion by a sac and fluid also present there. Such being the structure necessary to the collection and reception of sound, the latter, it is observed, reaches the ear at equal distances, I 9 and in an equal time. The common velocity of sound is estimated to be 1142 cubic feet in a second of time. The knowledge of the velo- city of sound is of great use in determining the distance of ships, or other objects, at sea ; 1'or if a ship fires a gun, the sound of which is heard five seconds after the flash is seen, then 1142 multiplied by five, gives the distance 57 10 feet, or one English mile and 430 feet. All sound is conveyed in waves or vibrations; and where these meet with an obstruction in their course, which is hard and of a regular sur- face^ striking against it, they become reflected. If the ear be placed in the course of these re- flected vibrations, it will perceive a sound similar to the original one, which will appear to proceed from a body situated in the same position and distance as the reflecting medium or obstacle, and exactly as the original sounding body was before. This sound is properly termed an echo, or a 10 reflecting one, thrown upon the ear by the ob- structing body. Reflected sounds, like reflected rays of light, may be deflected, that is, magnified or turned off, by contrivances similar in principle to those made to increase the powers and extent of vision. Thus, where there is an elliptical cavity, or sound uttered in one focus or point, it will be heard much magnified in the other focus ; of this a striking example is given by the effect of sound in domes or vaults, as instanced in the Whispering Gallery of St. Paul’s Cathedral. It is on this principle the speaking-trumpet is con- structed, so useful at sea ; which in its form is a hollow parabolic conoid, having a perforation at the top, to which the ear is applied in hear- ing, or the mouth in speaking. This principle of reflected sounds applies to the ear itself. From the hard bodies situated in the internal ear the sound is evidently reflected back to the other parts, so that the organ may be said to com- bine both principles of receiving the impres- 31 sions directly, and again indirectly, by the reflection of the sounds which strike on its harder or bony parts, which are thus applied a second time, as it were, to the auditory nerve. This idea is strengthened by the circular shape of the canals, where the sound striking on one focus will be magnified as it extends to the other. The same may be said in respect to the co- chlea, and all the internal parts of the organ, which are certainly formed for this reflection and reverberation of sound. Indeed, it is only by comparing the structure with the parts we know, that a just idea can be formed of the peculiar and intricate structure we observe, as we cannot suppose any part of the fabric is made in vain. Besides the effect of the hard and bony parts of the ear in increasing the power of sound, the tension of the different membranes seems also an essential requisite. Thus various muscles are so situated as to put the parts on the stretch, 12 that the sound striking upon them, like the parchment of a drum, may, from this tension, have its influence augmented. The knowledge of reflected sounds has never yet been taken advantage of by the aurist in applying the principle to the construction of artificial means for assisting the faculty of hearing; the only principle attended to has been, to increase the collection of sounds by f extending the canal of the auricle or external ear, in the form of trumpets and cones : but if the farther power of reflected sound were admitted into these instruments, as 1 have now attempted to do, on the plan of the speaking- trumpet, a two-fold advantage would arise, both in a greater collection of the vibrations, and in the more powerful and repeated applica- tion to the organ. Besides the perfection attached to the struc- ture of the human ear beyond that of other animals, its nervous texture internally is of a more delicate and sensible nature. Thus the nerves are even more acute or sentient than in the other parts of the body. All the nerves of the internal ear display a soft pulpy substance, but are never seen in the form of a firm cord. The auditory nerve also as it enters the inter- nal passage of the ear, is accompanied by a larger artery than most of the other nerves, to heighten the sensibility ; for increased circula- tion has everywhere this effect; and it also forms into plexus, or combinations, for the same purpose. From this view, then, the parts essential to hearing are, — First. An external ear ;* for in man, when- ever this part is completely removed, deafness is a consequence. * The external ear can only be considered as accessary in its functions to the internal ; and it was conceived by the Count de Buffon, that hearing could take place without it. This he considered proved by the instances ofdogs, and other animals. 14 Secondly. The membrane of the tympanum, which may be partially injured, but never can be completely removed, without producing deaf- ness. Thirdly. The stapes ; for all the small bones of the ear may be removed without causing deafness ; but the stapes is the only one that prevents the escape of sound from the internal ear. Fourthly. The aperture of the Eustachian tube, as preserving the access of air through the throat to the tympanum, and its renewal and change in the organ. from the whim of their owners, being occasionally deprived of the external ear, and suffering no defect by the operation. But though this fact may be true in young animals, and while the expansion of the auditory nerve on the internal ear pos- sesses its full powers and influence to receive the impression of sound, yet it is clear that in the human subject, such a loss would be severely felt j which is confirmed by the advantage of artificial means, in collecting the sound, and strengthening the power of the impression. 15 Fifthly. The presence of a fluid in the inter- nal ear, which is necessary to heighten the acuteness of impression, and to render it effec- tual. Such, then, as I have endeavoured to describe it, is the complex and minute structure of this important sense; and when we attend to the intricacy of its parts, the delicacy of its texture, t, • the numerous windings and sinuosities it every where displays, we are struck with wonder, and admiration at the nicety of its mechanism, and cannot be surprised that the least change should produce on it a deviation from the healthy state. To conclude : when we contemplate the varied organization of the ear in the different tribes of animals, we shall in all of them find it admirably fitted for their different situations and characters. It is the work of infinite power, \ and modified by a Supreme Being, who has adapted every creature, whether animate or inanimate, for its place. All our researches 16 in Anatomy serve to point out this fact, but none more strongly than the investigation of the different organs of sense. A nervous expansion we find the universal medium, on which the impressions are made, and through which they are conveyed. This being the case, all the senses may be considered in a manner as resembling each other, and only differing in their peculiar modification, and what may be termed the auxiliary organization of the parts that transmit the effect to the mind. 17 CHAP. II. , * Of the Diseases of the Ear. Having in the Introductory Part pointed out the necessity of an exclusive attention to the diseases of the Ear as a particular profession, and of the parts of the organ essential to the exer- cise of its peculiar functions ; I now proceed to examine its leading diseases, or those imper- fections which occasion deafness, or a loss of hearing. For more clearly understanding their nature, they require to be arranged according to the particular parts of the organ in which they are seated ; and they accordingly come to be divided into the diseases of the auricle, or c 18 external ear; diseases ot the tympanum, or drum; and diseases of the labyrinth, or internal ear. Diseases of the External Ear. The; diseases of the external ear are the most simple of any, and have the particular ad- vantage of being open to our inspection, and also to the touch. This being completely within the reach of the eye and the finger, *fe cannot fail in detecting their nature. I. Inflammation. From the exposure of the external ear to cold and other causes, it is liable to inflammation. Where this inflammation is confined to the soft parts, the complaint is not very violent ; but when it passes beyond these bounds, and extends to the bony passage and cartilaginous substance of which it is composed, it is then attended with the most acute pain and general fever, producing great excitement and uneasiness. 19 In attempting a cure, resolution, or subduing inflammation in its first stage, is the primary object ; and for this purpose, a cooling regimen, the use of saline purgatives, and even bleeding, will be at times indispensable ; while cold ap- plications are made to the part to lessen the action of its increased circulation. The success of resolution is known by the gradual abatement of pain: but should the pre- ceding means fail in their influence, then sup- puration must be promoted, and the former plan laid aside, substituting in its stead, warm appli- cations and poultices to the ear; but in some constitutions, it maybe observed, so rapid is the process of inflammation in this part, that sup- puration is unavoidable. The matter when formed is generally evacu- ated between the auricle and mastoid process, or into the meatus, or passage, and not exter- nally. The discharge is mostly by a small open- ing, and, on healing, the granulations are often pressed out through the opening, and appear C2 somewhat like a polypus. If the granulations entirely stop the opening, then the discharge is prevented from escaping, and accumulates be- hind. The patient then suffers a new accession of pain and uneasiness, as if another collection or suppuration were forming; and to give relief in this case, an incision into the sinus must indispensably be made to admit its evacuation. The proper place for this opening is between the auricle and mastoid process, or where the collection exists ; the bone is often destroyed, as a consequence ot the inflammatory process. The external opening of the temporal bone, and the external layer ot the mastoid process, aie § the parts destroyed. The time of teething in young children, is the period when this disease is most apt to oc- cur; and hence its acuteness may be accounted for, requiring often the palliative powers of opium to lull the intense pain it occasions. It is a disease more frequent in scrophulous sub- jects than others, and thus the propriety of early resolution is pointed out. 21 II. Herpes. f Another disease of the external ear, more fre- quent than the former, is Herpes, or an herpetic eruption, affecting it either in the form of an ulcerous sore, or a thickening of the integu- ments; and in the worst cases, these two states are combined, when the passage becomes nearly closed, and temporary deafness is the conse- quence ; the ichorous discharge issuing from the sore, and collected in the passage, hardens and becomes solid, thus obstructing the entrance of sound, and is accompanied also with a dis- agreeable smell, or fetor. This disease is at times a consequence of typhus. The whole ear is often excoriated by it, and covered with a layer of ichorous matter. In the treatment, though the correcting of constitutional acrimony be the principle, the state of the part at the same time requires a primary attention. The inspissated matter is to be removed by properly syringing the pas- 22 sage with soap and water, and, to do it com- pletely, the choice of a syringe is a matter of consequence. A syringe of a moderate size will answer the purpose best, the power of which is not too great ; and the operation should never be trusted to any but a skilful hand. On properly cleansing the ear, an alterative injection is to be employed instead of the soap and water, and the constitution corrected by alterative medi- cines in small doses, until the cure is completed. The period for a cure may extend from two or three weeks to the same number of months, according to the circumstances of the case, in respect to its severity and constitu- tional nature; nnd this treatment should be continued in a regular and steady manner in order to be successful. III. Morbid Septum of the Passage. An unnatural septum sometimes obstructs the passage of the ear, proceeding from an elonga- tion of the common skin. As the sound is 23 hereby communicated no farther than the external ear, and cannot reach the labyrinth or internal cavity, deafness must be the conse- quence. But this defect more frequently arises from a diseased tympanum, than from any other cause, where the suppuration is considerable, and much matter has been forced out into the passage. The following is the usual progress of the disease : — The patient, after a puriform discharge from the ear, feels a sudden and considerable increase of deafness, to which he has been in a certain degree subject in consequence of the original complaint. During this original state of deafness, he has been also sensible, on blow- ing his nose, of air passing at times through the meatus; but the puriform discharge having now ceased, and the patient being also no longer able, on blowing the nose, to feel air escape through the passage, the existence of a septum becomes undoubted. To this may be added the sensation of a particular fulness of the tympanum. i 24 If, under these circumstances, the patient be placed in a clear light, and the ear examined, a septum will be perceived. To remove this impediment, the septum is to be pierced and lacerated ; when the hearing will be restored to the same degree in which it prevailed under the diseased tympanum, and before the septum was formed. So quick is the hearing restored, that, imme- diately after the operation, the ticking of a watch has been heard at a considerable dis- tance, which could not have been perceived before, even when close to the ear. After the operation, much attention is neces- sary to prevent the closing of the sides of the aperture, and the septum being re-produced. IV. Excrescences of the Ear. The lining of the external passage, like all secreting surfaces, is liable to produce excres- cences, termed polypi, which, in appearance, 25 resemble the common venereal warts ; like them they are also the consequence of irritation, being generally conspicuous where a discharge takes place from a diseased state of the tym- panum. A disease of the tympanum is always com- i plicated with this appearance, although this appearance is a secondary symptom ; yTet at times it appears without any affection of the tympanum, but it is rare. The treatment here is the same as that em- ployed for excrescences elsewhere. *When small, they are best extracted with a pair of forceps, and the root or part to which they adhered afterwards touched with the Argentum Nitra- turn, or Lunar Caustic. In introducing the caustic, care should be taken not to carry it so far as to injure the tympanum; and with this caution the treatment will be generally sue- cessful. 26 V. Inspissated Cerumen. The most frequent cause of deafness, con- nected with the state of the external passage, is that arising from collected cerumen or wax ; a due secretion of the passage is absolutely neces- eessary to keep it in a healthy condition, as well as to preserve it from external injury. A defective, or too profuse, secretion is equally the cause of deafness, and the cerumen frequently becomes indurated and inspissated to such a degree as to cause obstinate dullness of hear- ing. The aetual quantity to produce this effect cannot be determined ; in many persons the secretion is very copious, compared with what it is in others ; but unless it be considerably altered by stagnation, it does not seem mate- rially to affect the functions of the part. When accumulated on the membrane of the tym- panum, it frequently obstructs the sense of hearing. The symptoms that particularly mark this 27 complaint are the following. With the general sense of deafness, there is combined the impression of noises in the ear, consisting eithei of a particular clash or confused sound, or a heavy sensation like the noise of a hammer: these sounds prevail most while eating. On ascertaining the presence of these symp- toms, and following it up by an examination of the ear, the cause of deafness will be easily detected. The best means of relief is simply washing out the passage with warm water, by means of a syringe, which Dr. Haygarth found the best solvent of ear-wax, and the only means neces- sary. On its removal, the complaint is instanta- neously relieved, and the hearing restored* When there is no defect or imperfection of the organ, its removal generally produces a slight irritation of the ear, in consequence of the strong excitement occasioned by forcing the fluid into the passage; but this soon ceases, without any unpleasant effect. This disease, however simple, has been often mistaken or overlooked, and the cause supposed to lie deep in the structure ol the organ, whilst, in fact, it arose merely from the source above pointed out; which shows the necessity, in all cases of deafness, of ascertain- ing, by an accurate examination, that such a mechanical cause does not exist. VI. Accidents. From its situation the external passage is subject to occasional accidents, or other mecha- nical causes acting upon it, than inspissated cerumen. Thus, in cases of children, small bodies, as peas, cherry-stones, pins, &c. have got into the ear, where, exciting inflammation, they often cause considerable pain before they are removed. A number of remarkable cases of such accidents will be found related by authors. The great art in extracting them, is to be cau- tious not to push them deeper ; they are best taken out by a pair of small forceps : a little oil may be dropped into the ear before making the attempt. In the same way, insects at times get into the ear, which produce the most unpleasant feelings in the part, as well as great noise, and often actual pain : the best way of removing them is to drown them, by filling the passage with mild fluids, as water or oil, by means of a syringe, and thus washing them out. Acrid liquors are improper; for, in the endeavour to avoid them, the insect gets deeper. The motion is often so severely felt by children, as to produce a state little short of delirium ; after the removal, a little oil of sweet almonds is the best applica- tion, to soothe the irritated part. Even a little oil, in the first instance, will destroy the insect. 30 VII. Congenital Inspissation of Cerumen. This is a disease more frequent than is gene- rally supposed. All the secreting passages in chil- dren, at birth, are lined with a tenacious layer of this natural secretion; it is seen in the bowels, in the state of meconium; and no less in the ears, in the state of viscid wax : the reason of this is, that the parts of the concha and passage are narrow, and such an accumulation is essential to defend the tympanum from the waters of the amnios. In all apparent deafness of children, the ears should be examined in order to trace whether it is connected with this cause. 31 CHAP. Ill, Diseases of the Tympanum. I. Pur form Discharge of the Tympanum. The first disease of the tympanum is that named, from its leading symptom, its “ Pun- form Discharge,” which has been accurately and minutely described by Mr. Saunders. The appearance of this discharge is ichorous, and it is sometimes tinged with blood ; — if a silver instrument is stained with it, it will turn of a yellow colour. A loss of hearing naturally attends this disease; and the degree of this loss is proportioned to the injury the machinery of 32 the part suffers— —in some cases amounting to total deafness. The leading criterion that marks the exist- ence of this disease, is the passage of air, on blowing the nose, by the meatus externus : wherever this circumstance can be made to take place, it is obvious the discharge is from # _ • • the tympanum, and connected with an injury or destruction of its membrane. But though no air pass by the tympanum, still the latter may be diseased ; for the inflammation, fiist beginning in the Eustachian tube, may obliterate it pre- vious to its reaching the tympanum, and bring on its suppuration : this fact is confiimed by dissection. ■ Although, therefore, air cannot be made to pass at the meatus externus, we are not to con- sider the tympanum sound without farther demonstration ; and this we have in our power by a proper examination. For this purpose, the ear must be placed in a 33 strong light, or in such a position, that the rays of the sun may fall into the meatus, and so illuminate it as to render the bottom visible ; or, instead of this inspection, the ear may be sounded with a blunt probe, when a person acquainted with the particular feel of the mem- brane of the tympanum will be able to ascertain it by the touch : but it requires the tactus eru- ditus , or the touch of experience. The membrane, if defective, will allow the instrument to pass into the tympanum, the bony passage of which is readily distinguish- able. Perhaps both modes of ascertaining the disease should be employed. Such a proper examination and minute in- quiry as I have here recommended, will prevent it from being confounded with the Herpes, or ulcerated state of the external passage. The cure of the Herpes is certain; and as soon as the ulceration heals, hearing is restored. D 34 But in the present complaint, though the dis- charge cease under the use of medicine, its Q issue, in regard to the preservation of hearing, is doubtful. A point on which a practitioner should be cautious in offering his opinion to a patient. This affection of the tympanum is produced by various causes ; diseases of the throat are the most frequent. Thus the Scarlatina Maligna, or Scarlet Fever, combined with an affection ot the throat, frequently occasion the tympanum to suffer, in consequence of the gangrene, or sloughing, which takes place : even the bones of the tympanum are at times thrown off; and the patient, if he survive the fever, is left com- pletely deaf. The disease, also, often succeeds the ear-ache, or inflammation of the passage extending to the tympanum; and if the inflammation is not subdued by resolution, then the tympanum and mastoid cells become filled with pus, or matter. 35 The pus comes to be discharged by ulcera- tion, in large quantity, after the patient has suffered most intense pain. During its progress, the discharge of matter produces, for a time, a relief of symptoms; but, as the disease goes on, fresh matter is formed, and continues to ooze from the passage. The symptoms that peculiarly mark this dis- ease are, an intense throbbing pain in the ear and head, accompanied with symptomatic fever ; and sometimes slight delirium supervenes. The pain is not always equally intense, but fluctuates in degree; and its paroxysms, or fits, are somewhat like those of the tooth-ache. It is this resemblance to the latter that has caused it too often to be neglected, or impro- perly treated. It is a disease that evidently requires the most active antiphlogistic treat- ment; and nothing stimulant, either in the way of general or topical means, should be employed. Hence acrid substances, and stimulating fluids, d 2 36 used under the idea of curing the tooth-ache, aggravate, to a certainty, this disease ; and sup- puration, the very circumstance to be avoided, is hereby hastened. The treatment to be observed here is obvious : to arrest inflammation in the first instance, if early applied to ; and if this be done with energy at the first, all the symptoms will be found to subside. The deafness, which is always great during the inflammation, will gradually lessen, and the deposited lymph, instead of form- ing pus, will soon be absorbed. But if the inflammation has continued for some time, even though resolution may be accomplished, the patient does not always recover his perfect hearing; and the question is,— how far a proper secondary treatment may obviate this imperfect state, which the previous inflammation has left? The defect here chiefly arises from a deposition of lymph, and perhaps, also, from some thick- ening of the parts. We know that, in other parts of the body, a 37 large quantity of lymph can be absorbed by using the proper means for giving activity to the ves- sels. As the deafness, after inflammation of the tympanum, arises from this cause, the object is to prevent the lymph from becoming organized, and any thickening of the membrane from be- coming permanent, which must continue the defect. The point, therefore, should be, even if suppuration is formed, to make an early opening to evacuate the matter, and thus pre- vent the membrane from acquiring that state which renders it unfit for receiving acutely the impression of sound. An opening being once made, and the matter discharged, every pre- caution must be next taken to prevent it from again forming. 