LIST OF ILLUSTRATIONS.

FIG.

1. Cutting Forceps,

2. Malformed right External Ear of a child,

3. The rudimentary Meatus Auditorius Externus of a child, in the form of a fissure posterior to the Condyloid Process,

.

4. The Tympanic Cavity, with the Eustachian tube opening into its anterior and inferior part,

8. A vertical section of the left Meatus Externus, from without inwards, 9. The Orifice of the Meatus Externus, showing its oval shape,

10. The Osseous Meatus Externus of an infant,

11. The mode of examining the Ear by aid of Sunlight,

14. A set of Specula for the purpose of examining the External Meatus,

15. The Surgeon examining the External Meatus by means of Miller's Lamp and the Tubular Speculum,

66

16. Rectangular Forceps,

72

17. The External Meatus greatly dilated by a piece of cotton-wool,

73

18. Cerumen in contact with the outer surface of the Membrana Tympani,

80

19. Meatus greatly dilated by cerumen,

81

20. Anterior wall of the Osseous Meatus partly absorbed, following the pressure of an accumulation of cerumen,

81

21. Cerumen projecting through the Membrana Tympani into the Tympanic Cavity, 22. Syringe and Nozzle,

82

83

23. Ear-spout, fitted on the head,

84

.

24. Epidermis from the External Meatus in the form of a tubular cul-de-sac, and a layer arranged circularly,

25. The Internal Surface of the Temporal Bone, showing two orifices in the Lateral Sinus, filled by cerumen; and also the carious Sulcus Lateralis,

26. The External Surface of the Temporal Bone, showing a carious portion extending from the Mastoid Process to the root of the Zygomatic Process,

27. Raspberry Cellular Polypus,

28. Cellular structure of the Raspberry Polypus,

29. A large Raspberry Polypus, visible at the orifice of the Meatus,

136

137

141

141

143

144

145

148

37. Two Osseous Tumors projecting from the walls of the Meatus Externus,
38. The vertical section of the External Meatus and Osseous Tumor,
39. Three Osseous Tumors projecting from the walls of the Meatus,
40. A large Osseous Tumor and two smaller ones in the Meatus Externus,
41. Two Osseous Tumors of the External Meatus in contact internally,
42. An Osseous Tumor growing from the Upper Wall of the Meatus,
43. Osseous Matter developed from the walls of the Meatus Externus,
44. Molluscous Tumor filling the whole of the Meatus Externus,
45. Cavity in the Meatus Externus from which a Molluscous tumor has been removed,
46. Apertures in the upper wall of the Meatus Externus communicating with the
Cerebral Cavity, produced by a Molluscous Tumor,

47. The Triangular Shining Spot at the anterior and inferior part of the surface of the Membrana Tympani,

48. The Dermoid Layer of the Membrana Tympani continuous with the Dermis lining the upper wall of the Meatus Externus,

49. The Radiate Fibrous Layer of the Membrana Tympani,

50. The Fibres composing the Radiate Fibrous Lamina (magnified),

52. The Radiate Fibrous Lamina, after having been treated with Acetic Acid, 53. The Circular Cartilaginous Band, after having been treated by Acetic Acid, 54. The External Surface of the Circular Fibrous Lamina (slightly magnified), 55. The Internal Surface of the Circular Fibrous Lamina (slightly magnified), 56. The Fibres composing the Circular Fibrous Lamina, .

57. The Fibres of the Circular Fibrous Lamina, treated with Acetic Acid,
58. The Radiate Fibrous Lamina, the Circular Fibrous Lamina, and the Mucous
Membrane of the Membrana Tympani (slightly magnified),.

59. The Attachments of the Tensor Tympani Ligament (slightly magnified),
60. Epidermoid Layer of the Membrana Tympani hypertrophied (magnified), .
61. Granulations on the surface of the Dermoid Layer of the Membrana Tympani,
62. The Membrana Tympani fallen in towards the Promontory (seen in section),
63. The Membrana Tympani fallen in towards the Promontory (seen from without),
64. An Orifice in the Membrana Tympani produced by ulceration of the Fibrous
Lamina,

65. The Fibrous Layers of the Membrana Tympani ulcerated over a small extent at
its anterior part, .

66. Calcareous Deposit in the Circular Fibrous Lamina of the Membrana Tympani,
67. Calcareous Deposit in the Radiate Fibrous Lamina of the Membrana Tympani,
68. The whole of the Membrana Tympani converted into Calcareous Matter,
69. The Artificial Membrana Tympani,

70. Margin of the circumference of the Membrana Tympani remaining after the
destruction of the rest of the membrane,

71. Handle of the Malleus remaining after the destruction of the Membrana Tympani,
72. Body of Malleus remaining after destruction of Membrana Tympani,
73. Surgeon introducing the Artificial Membrana Tympani,

74. An Aperture in the lower part of the left Membrana Tympani, from rupture,
75. An Aperture in the posterior part of the right Membrana Tympani, from rupture,
76. An Aperture in the right Membrana Tympani,

79. The Explorer, and the Eustachian Catheter into which it fits,

FIG.

80. The Surgeon using the Eustachian Catheter and the Explorer,

81. Stricture of the Eustachian Tube,

82. An antero-posterior vertical section of the Temporal Bone through the Tympanic Cavity and Mastoid Cells,

83. The upper Osseous Wall of the Tympanum defective,

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249

250

84. The Canal for the Portio Dura Nerve at the upper part of the Tympanic Cavity incomplete,

260

85. The Internal Surface of the Temporal Bone, the Tympanic Cavity diseased, 86. The lower Osseous Wall of the Tympanum incomplete,

87. The Orifice seen from the Jugular Fossa,

88. Membranous Bands connecting the Ossicles,

89. Membranous Bands connecting the Ossicles to the Promontory (magnified),
90. The whole of the Circumference of the base of the Stapes anchylosed to the
Fenestra Ovalis, the Crura detached,

91. Base of the Stapes expanded, and osseous matter thrown around it and the Crura, 299 92. Expansion of the base of the Stapes, and its protrusion into the cavity of the Vestibule (magnified),

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286

286

295

296

93. Expansion of the Vestibular Surface of the Articulation (magnified), 94. The External Surface of the Temporal Bone of a child,

300

322

95. A Vertical Section of the Temporal Bone of a child through the horizontal portion of the Mastoid Cells,

323

96. The External Surface of the Temporal Bone, showing the irregular-shaped carious portion of bone above the Meatus,

326

97. A Vertical Section of the Diseased Bone,

327

98. The right Petrous Bone, showing the carious condition of the Sulcus Lateralis, 346 99. Caries of the External Semicircular Canal,

398

100. Carious Temporal Bone,

409

THE DISEASES OF THE EAR

CHAPTER I.

INTRODUCTION.

NEGLECT OF THE STUDY OF THE MORBID ANATOMY OF THE EAR, THE CAUSE OF OUR IGNORANCE OF AURAL SURGERY-MODE OF INVESTIGATING THE DISEASES OF THE EAR-METHOD OF DISSECTING THE EAR.

As introductory to this work on the Diseases of the Ear, I may be pardoned the observation, that the subject has hitherto been too much regarded, by the great mass of the profession, as a blank in Medical Science; indeed, to quote from Mr. Wilde's introduction to his valuable treatise on Aural Surgery, medical men are too ready to affirm that "they know nothing about the diseases of the organ of hearing;" and many, looking upon the difficulties that surround the investigation as insurmountable, have tacitly abandoned its pursuit. Yet, if we carefully survey the history of the rise and progress of Aural, as a distinct branch of Scientific Surgery, one main cause of the disrepute into which it had fallen may be traced to the neglect of the pathology of the organ of hearinga neglect that doubtless led also to the ignorance which has prevailed as to the structure and functions of some of the most important of its parts.

It is a question, however, whether the inherent difficulties of Aural Surgery are of a nature to prevent its being as thoroughly understood as the other branches of surgery. This question has been answered in the affirmative by some, on the ground of the deep and hidden situation of the larger part of the organ, and the extreme

intricacy of its structure. But surely the organ of hearing is not so much concealed from view as several others (the heart, for instance), of whose diseases we have a very clear knowledge; nor is its structure more complicated than that of the eye. The result of my own experience, and I think also of those who have carefully attended to my practice at St. Mary's Hospital, is, that the diseases of the ear are not more difficult to diagnose, nor are they on the whole less amenable to treatment, than those of the eye, the joints, or almost any other organ that can be named.

When my attention was first turned to the study of the diseases of the ear, I resolved to prosecute researches into the pathology of the organ. From that time to the present, I have made nearly 2000 dissections; and although it must be manifest that this number is small, compared to that which is required for the thorough elucidation of the subject, still I feel it is a sufficiently solid foundation upon which to build a rational system of Aural Surgery.

Fully aware of the difficulties in the way of procuring specimens from those deaf persons who had been inspected during life, and whose histories had been recorded, I determined at once to dissect every ear that I could obtain, in order to ascertain what are the most common morbid conditions to which the organ of hearing is subject; in fact, to secure one step first, by ascertaining something of the morbid anatomy of the ear, before advancing to a consideration of its pathology. The result of my investigations established this general fact, that the existence of some of the most important affections of the ear had not even been imagined. Having advanced thus far with the morbid anatomy of the ear, my next step was to pursue its pathology. This was effected, in the first place, by prosecuting inquiries into the history of the patients whose ears were found to be diseased; secondly, by dissecting the ears of deaf persons supplied to me by medical men, and comparing the morbid appearances observed with the notes accompanying the cases; and thirdly, by availing myself of the opportunity, during some years, of inspecting all the deaf persons in an institution containing more than 2000. individuals, of recording their cases, and then of making dissections of the organ of hearing in those who died. By these means, and by the facilities offered at the public institutions to which I have been attached, of conducting post-mortem inspections of the patients attended by me, I have been able in many cases to compare the symptoms occurring during life, the appearances of the organ,