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pital. For many days he had been in bed alone in the house, while his mother—the only other member of the family—was away attending to her duties as a washerwoman. He had had a discharging ear since an attack of one of the exanthemata in childhood. Inspection showed a moderate discharge of thick, creamy pus from the meatus. The auricle stood out rigid and tense; the meatus was swollen and puckered, so that at a point midway between the membrana tympani and external orifice the calibre was not more than 2 millimetres in diameter. It caused pain to extend the meatus by traction on the auricle, or percussion over the mastoid, and there was some swelling and redness of the tissues over the mastoid process. The meatus was carefully cleansed by syringing with warm water, and a probe covered with a narrow pledget of absorbing cotton carefully carried to the bottom of the meatus. This was followed by an abundant flow of thin, chocolate-colored discharge, very fetid. There was no paralysis anywhere. The case was diagnosticated as one of mastoid disease, with marked meningeal irritation, if not fully developed meningitis. The boy was admitted to the house, placed in bed, warmly covered, and perfect quiet enjoined, and frequent syringing of the ear with warm water directed. Leeches were applied over the mastoid, and a thorough evacuation of the bowels secured. The temperature, on admission, was taken, but unfortunately no record preserved.

Trephining the mastoid was to be done the following day, if there were not a decided amelioration of the symptoms. At the end of a week he was entirely free from all threatening symptoms. The bottom of the meatus, which could now be carefully studied through an unusually large meatus, was found filled with polypoid granulations. The subsequent treatment of the case was conducted at the out-door service, and presented no unusual interest.

There is no room for doubt that this boy's life was saved by the confinement to a warm bed, and the better hygienic surroundings of the hospital.

Many examples of acute purulent inflammation of the middle ear and Eustachian tube, in adults and young children, have served to convince me of the importance of a perfect protection from exposure, especially during the cold damp days of our winter months. It is quite as importaut, for their perfect and

rapid recovery, that they should be confined not only to the house, but in bed, as in an attack of pneumonia or pleurisy.

Although life may not in all cases be in such great jeopardy as in pneumonia or pleurisy, nevertheless the usefulness of the organ is in great danger. By this means alone, with no meddlesome local treatment, a large number of these cases will recover, without permanent injury and without the protracted chronic suppuration. Another lesson taught by this case is that it is not the first duty of the aural surgeon to fly to the operation for opening the mastoid cells even in severe cases of disease evidently involving the mastoid antrum. Case II.—Foreign Body in the External Auditory Meatus; Strange

Nervous Symptoms; Relieved by Removal of the Foreign Body.

II. H., a carpenter, came to the Episcopal Hospital service, complaining of the following symptoms, which he associated with his left ear, since he could relieve them by pressing his finger firmly in the external meatus.

For several years he had suffered from intermittent tinnitus. He complained of loss of memory and gidiliness. The latter symptom was so marked that he was unable to attend to his work. He said he was getting stupid, and was afraid of insanity or suicide. The only way he could get about alone was by thrusting his little finger far into the meatus, or by plugging it with a pledget of cotton-wool, which he made into a long, narrow roll, and thrust it far into the meatus. I removed one of these rolls of cotton, and with the mirror and speculum discov. ered at the bottom of the meatus, freely movable, a dark brown mass. By aid of gravity and fine angular forceps it was removed entire, and with but little difficulty. It was the size of a large pea, very compact, and its surface as smooth as a leaden bullet. It proved to be a mass of inspissated cerumen, hair, epithelial scales, and dust. The tympanic end of the meatus was dilated apparently, and in this the hard bullet-like mass had rolled about with every movement he made, bouncing about against the membrana tympani and malleus handle.

I did nothing further for him, and with difficulty persuaded him to make the attempt to venture homeward without the cotton pledget. He did so, however, and returned, by request, to the clinic at the end of a week, having been entirely free from his symptoms, and able to return to his work.

CASE III.— Impacted Cerumen; Tinnitus Aurium; Simulating

Early Symptoms of Locomotor Ataria.

Mrs. T. consulted me in March, 1880, complaining that for a week she had suffered from a noise, like escaping steam, in the right ear. Her bitterest complaint was the extreme degree of nervousness occasioned by the noise, which aggravated her like the filing of a saw. She had occasional shoots of pain through the ear, which came as suddenly as electric flashes. Several years before she had had a similar attack, which lasted nearly a year and disappeared suddenly. In both attacks there was simply difficulty in differentiating sounds, the voice in conversation being a confused sound. In this attack, however, she complained that she could not feel the floor or ground perfectly, and described the sensation by saying that she seemed constantly walking on deeply padded carpets. There were no shocks of pain in the extremities, and general sensation was perfect.

Inspection revealed the meatus on the right side well filled with yellowish cerumen, soft, and readily removed by the spoon and syringe. A large mass of this was removed, and, somewhat to my surprise, behind it was found a second mass, evidently of an older date, since it was nearly black, its surface concave, and reflecting light strongly from its hard, smooth surface. This was removed with great difficulty after several days of soaking. The meatus was excoriated under it, and there was a small superficial ulcer on the superior anterior quadrant of drum head, which perforated only its epithelial layer.

The tinnitus, pain, and deafness at once disappeared, but the sensation in the feet only gradually grew better, and in teu day's had entirely disappeared.

As examples of reflex irritation, these seemed of sufficient importance to bring them before you. These cases had both been regarded as cases of severe nerve lesion.

It is not my purpose to discuss the complex problem of reflex nervous symptoms, but I desire simply that they should serve to point out the necessity, in obscure symptoms of disease, of examining carefully the ears as well as the other organs of the body.





In all cases of pulmonary phthisis in which laryngeal symp toms are present, and in most of those in which no such symptoms are observed, we find with the laryngoscope certain changes iv the larynx. Having observed these changes in a large number of cases, and found them to stand in a certain relation to the lesions in the lungs, I examined a number of larynxes microscopically in order to find the causes of the peculiar appearances seen during life.

The method of examination adopted is published elsewhere, and it will, therefore, not be necessary to dwell upon it here. All that I would say in regard to it is, that I have examined sections of the larynx made in different directions, and comprising all the parts so that their relation to each other could be studied. The changes observed in the laryngoscope are, first, it pyriform swelling of the arytenoid cartilages and aryepiglottic folds; then a swelling of the crest of the epiglottis, causing it to assume a horseshoe-shape; and, finally, ulceration of various parts. These ulcerations occur earliest in those parts which are exposed to the greatest amount of irritation by motion, viz., the inter-arytenoid space, the vocal cords, and the epiglottis.

I first endeavored to prove that the simple swellings of the aryepiglottic folds and of the epiglottis are not merely caused by infiltration of serum into the submucous connective tissue, as is supposed by some authors, by making incisions in these parts in a number of cases without producing a reduction of


Archives of Laryngology, vol. i. No. 1.

the swelling, or relieving the symptoms caused by them, and by careful measurements of larynxes showing these swellings before and after they had been hardened in alcohol, that is, before and after the water had been extracted. In these latter experiments I found that the amount of swelling was but little reduced by the action of the hardening agent, while it should have been completely reduced thereby, if it were due to simple serous effusion. Such a result we observe in mixomatous tumors, which are largely composed of watery mucus, and which almost entirely shrivel up under the influence of alcoholic hardening

I next took such hardened specimens, and subjected them to microscopical examination, making both transverse and longitudinal sections of the aryepiglottic folds. Thus, I found that the epithelial cells of the mucous membrane were normal, except that they were but loosely attached to the basement-membrane. The submucous tissue was infiltrated with a small-celled infiltration, which in many places had fornied depôts, the centres of which showed cheesy degeneration. The most marked change, however, was found in the mucous glands and their ducts, as well as in the lymphatics. The tubules of the glands appeared in many instances completely filled with proliferated epithelial cells; their diameter was greatly increased; and they themselves were greatly increased in number, so much so that but little of the submucous connective tissue was visible, and the general appearances were those of an adenomatous growth. The ducts of the glands also were filled with a granular débris and proliferated epithelial cells, so as to obstruct them. The lymph-spaces were in many instances seen to be filled with granular matter; while the walls of the blood vessels were intiltrated with cellular elements.

In the turban-like swelling of the crest of the epiglottis the same conditions were noticed under the microscope as were seen in the pyriform swelling of the aryepiglottic folds, with the exception that the glandular elements were not increased in number, and that the depots of inflammatory infiltration were smaller. The loose submucous connective tissue, especially on the posterior face of the epiglottis, was crowded with small cells of inflammatory origin. This latter appearance gives us an explanation of the horseshoe-shape the epiglottis generally assumes when thus affected. The thin and flexible cartilage at

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