the crest of the epiglottis is covered only by the mucous membrane and the submucous tissue, and the glands, which are not very numerous, are imbedded in the cartilage itself. If, therefore, this submucous connective tissue becomes distended by infiltration the fibres which encircle the cartilage become stretched, and act like the cord of a bow, bending the cartilage.

In the examination of ulcerated portions I have invariably found that suppuration began in the infiltrated glands and follicles, and that, although large in extent, these ulcerations were never very deep; that is, I have not found them to go below the submucous connective tissue, destroying the mucous membrane and the mucous glands, but no other or deeper-seated structures. In such cases, where ulcerations attack the epiglottis, however, we find an exception to this rule; for, because the suppurating glands are imbedded in the cartilage, the latter is also affected and destroyed, but not with such rapidity as the softer portions, and therefore an ulcerated epiglottis always presents a serrated edge; the projections being produced by the portions of cartilage not yet broken down, while the depressions are caused by the glands in the crypt having sloughed.

The depots of small-celled infiltration very closely resemble tubercular deposits; but only in a few instances have I been able to demonstrate undeniable evidences of true tubercle, namely, the presence of adenoid tissue and giant cells, and only in such cases where extensive ulceration of the mucous membrane was present.

These deposits, whether mere collections of leucocytes or real tubercles, are more frequently found in the lower part of the submucous connective tissue, and are but rarely seen near the surface. This fact and their small size would go to explain why we cannot see their evidences in the living larynx, and why many eminent authors deny the presence of tubercles in this organ.

Clinically, it has been observed that these lesions in the larynx bear a certain relation to the extent of the lung affection, so that the pyriform swelling is noticed in the earliest stages of phthisis often before physical signs show themselves.

The turban-like swelling of the epiglottis is observed when the lung-tissue has already begun to break down; and the ulcerations show themselves, as a rule, quite late in the course

of the disease, when a considerable portion of the lung has been destroyed.

And, again, we find that the pyriform swelling will in many cases disappear under general treatment in the same ratio as the lung affection improves. The turban-like swelling of the epiglottis rarely improves, while, when ulceration has set in, there is little hope for improvement either of the laryngeal symptoms or of the general health of the patient.

If we ask for an explanation of the fact that the larynx is thus affected in so many cases of pulmonary disease, we might expect the answer that it is because the larynx is, so to speak, in direct communication with the lung, because its mucous membrane is continuous with that of the bronchial tubes. But this, I do not think, is the real explanation. It is much more reasonable to think that, because we are enabled to inspect with comparative ease the larynx, we find changes there which probably occur at the same time in other organs of the body removed beyond possibility of inspection. I think we find in phthisis gastric symptoms as frequently as we find laryngeal symptoms.

But, no matter where we find the evidences of phthisis outside of the lungs themselves, they are caused by something which interferes with the free circulation of the part, and more especially with the free circulation in the lymphatic system. If such interference is once established, the capillary circulation of the part or organ must naturally be disturbed, and consequently congestion and inflammation will be the result, which in the case of the larynx is first communicated to the glands and follicles, as the parts best supplied with capillary circulation. Inasmuch as the lymphatic circulation is interfered with, absorption of the products of this inflammation cannot take place; and consequently we have a crowding of these inflammatory products in different parts, giving rise to the lesions already described.

OBSERVATIONS ON AURAL OR AUDITORY VERTIGO AND TINNITUS AURIUM, WITH DIAGNOSIS AND TREATMENT.

BY LAURENCE TURNBULL, M.D.,

PENNSYLVANIA.

IN various forms of disease of the ear there are associated with the nervous paroxysm vertigo and reeling, with faintness and vomiting. These symptoms may be transient, as from syringing the ears, a sudden pressing of the fingers or speculum into the meatus, violent blowing of the nose, or sudden movement of the body, causing intra-labyrinthine pressure. No doubt other cases depend upon a plug of cerumen, bean, or pea filling up the meatus, or upon some prior disease or irritation of the auditory nerve in its expansion in the labyrinth, or upon some local blood-pressure or reflex disturbances. A still more severe form of aural vertigo is produced by chronic purulent otitis media with the presence of a perforation in the membrana tympani, concussion from firearms, producing a sudden, violent wave of air, which, striking the ears, causes a ringing with deafness and a feeling of vertigo, with a tendency in walking to fall on one side, from congestion and irritation of the fibres of the auditory nerve either by pressure or pulling them.

Another form, in which the patient is giddy when leaning too far backward or forward. Often this class of symptoms depends on contraction of the tensor tympani-a muscle which in action. is associated with the masticatory muscles. In almost all these cases there is more or less deafness. There are four other varieties of vertigo which you are no doubt familiar with, and it is not necessary to enter into their symptoms at this time: they are (1), stomachic; (2), nervous, often from sexual exhaustion; (3), ocular; (4), epileptic. These four may be associated with aural or auditory; and great care must be given to be certain

of the diagnosis; but the occurrence of deafness will do much to assist us in arriving at a correct knowledge; and this should always be attended by a careful examination of the ears, and testing the hearing by the watch, tuning-fork, and Politzer's acumeter. Attention must also be paid to the limitation of the field of audition: to the loss of perception of certain notes, as recommended by Knapp.

The following are the conclusions, as to the modus operandi of the nervous symptoms of ear disease, by an able authority on diseases of the brain. "There are two sets of symptoms: (a), vital (faintness, perspiration, irregularity of the pulse, etc.); (b), locomotor (vertigo, with or without reeling)." He attributed the former to disturbance of, or actual disease in, the cochlear division; the latter to disease or disturbance of the semicircular canal divisions. The former division was, he suggested, chiefly afferent to the medulla oblongata, the auditory nucleus having close connection with the vagal and spinal accessory nuclei; the latter division, he thought, represented that part going, according to Lockhart Clarke, to the cerebellum. The vital and locomotor symptoms were due to disturbance of the medulla oblongata and cerebellum respectively. Pierret has recently spoken doubtfully as to the existence of relations betwixt the auditory nerve and the cerebellum. Cyon has recently found that irritation of each of the semicircular canals is followed by a particular ocular movement a very significant thing towards the interpretation of auditory vertigo.

Dr. Edward Woakes, in his work on Giddiness, reports cases in which the auditory apparatus was previously quite healthy, but which may or may not be found affected after the attack. The author traces the connection between stomach-irritation and these attacks of vertigo, and considers them due to a reflex dilatation of the internal auditory artery, causing an increased flow of blood into the semicircular canals. Aural vertigo, the result of secondary inflammation of the labyrinth, is known as Ménière's disease, having received much attention from various authorities. Our ideas of its fatal character and the profound deafness as a result have changed because affections of the ears, with many of the group of symptoms before ascribed to this very serious malady, have been treated with success. But there is still another class of cases in which we have the complex symptoms of Ménière's disease associated with profound brain-symp

toms from injuries of the spine, cerebral tumors, morbid growths of the auditory nerve, either of a fibrous character or true sarcoma or gummata, in which we have added the want of power of controlling the limbs, pain in the head intense and persistent, while the dizziness is increased, with nausea and vomiting, followed by paralysis.

These severe and distressing symptoms are associated with ear disease, especially of a chronic character; and we should be on our guard against being misled by such symptoms in our diagnosis and prognosis. As an instance of how trivial causes can produce Ménière's group, Moos relates the following case: "A peasant was sent to the ear clinic with the diagnosis Ménière's disease;' after the removal of a plug of wadding from the right ear, the vertigo, deafness, tinnitus, and vomiting disappeared entirely."

Dr. Henry D. Noyes reports Ménière's group of symptoms following parotitis, and believes that there was a metastatic inflammation set up in the labyrinth of the right ear, at the same time. that a similar process took place in the testicle; the patient was totally deaf to all sounds in the right ear; when his eyes were shut in walking, he swerved to the left.'

In consequence of disease in the conducting apparatus of the ear vertigo may arise, and in such cases the only explanation is, that intra-labyrinthine pressure has called it forth. Gottestein has stated that we have no right to accept the term "vertigo ab aure laesa" of the neuropathologist (Charcot), because it remains to be shown whether, for a number of cases, the loss of equilibrium has its origin in the ear or brain. We, therefore, can only speak of Ménière's group of symptoms. This same authority agrees with us that there are two forms, the apoplectic and inflammatory. In a number of cases Gottestein found cerebral manifestations, loss of memory, aphasia, eye trouble, and complete destruction of the hearing power on both sides.2

Many of these forms of aural vertigo are readily detected and removed by the proper remedies; but what we have reference to is the persistent and sometimes painful vertigo, which is not always detected by the most careful physical exploration by one who is fully capable of doing so, and must be referred by exclusion to occur in pathological conditions of the middle ear

Trans. Am. Otological Society, 1879, p. 342.

2 Proceedings of German Association, Arch. Otology, p. 13, March, 1880.