CHAPTER XIX. DISEASES OF THE INTERNAL EAR. (Part 7)

at the same time. Trouble advanced rapidly, and in three weeks he was so deaf that " he couldn't hear anything but loud noises." Never had any pain or discharge. Tinnitus at first was ' ' like somebody tapping on a tumbler; " now it resembles ' 'the wind blowing." Had some dizziness and nausea when first attacked. Never vomited. Never has noticed any unsteadi- SYPHILITIC COCHLITIS. CASES. 529 ness of gait. Has no vertigo now, except when he runs or takes a very long stride in walking. Hearing is worse in a noisy place. Thinks he hears low notes better than high ones. Had a chancre eighteen months ago. Gives no history of any secondary symptoms, except of " sores in his mouth." Has taken mercury and iodide of potash since a week after his aural trouble began, but without benefit. Thinks he took cold a few days before his deafness began, as he had " a stiffness " of his neck and shoulders. H. D. — R., j3 ; L., -fe. Loud voice one foot behind back. Hears words, through speaking-tube, in each ear. Hears all notes of piano, but does not appreciate difference between low and high ones correctly. Tuning-fork heard better on right side. Pharynx looks well. Has ulcer- ations on edges of tongue ; Eustachian tubes pervious ; no effect from in- flation. Right drum-head, pinkish, goo.l 0; left drum-head looks well. Diagnosis. — Syphilitic inflammation of cochlea. Was seen by Dr. Sturgis in consultation, who found "an undoubted his- tory of syphilis," with objective evidences of the disease still apparent. Patient was ordered to take a mercurial vapor-bath daily ; dady mercurial inunction ; iodide of potash, beginning with 60 grs. a day, and gradually in- creasing. April 6th— R., -4\ ; L., & ; voice, 2 ft. April 13th.— R., &-; L., &-; voice, 2 ft. R. E., 6" L. E. April 21st.— R., -4as- ; L., -&- ; voice, 4£ ft. R. E. ; H ft. L. E. Taking 339 grs. iodide potash daily, with mercurial inunction each night. May 25th.— R., -&- ; L., -4%; voice, R., 8 ft. ; L., 4 ft. Taking 118 grs. iodide of potash with 20 drops tinct. iodine, three times daily. Inunction as usual. June 4th.— R., &- ; L., ~ ; voice, R., 4 ft. ; L., 3 ft. With face towards speaker, hears loud conversation 10 ft. Has always shown great difference in hearing power for different letters. Hears now w and c best. June 25th.— R., -& ; L., -^ ; voice, 6 ft. right side; 4 ft. left side. With back to speaker, hears loud conversation at 2 feet. Some sentences at 12 feet and more. Facing speaker, hears ordinary conversation easily at 4 ft., and some sentences at 20 ft. Has great difficulty with sounds of m. ??. b, and p. Says he heard the crickets in the grass at the sea-shore but not the sound of the waves, yesterday. Noises of street disturb him. June 29th. — Left the city, with orders to continue treatment. July 2Qlh. — Writes that he has gained six pounds since June 29th. August 12th. — Writes that he " hears everything quite naturally, except music." Sound of running water in ears continues. Gaining flesh, and feel- ing remarkably well. Thinks his hearing is still improving a little. The record of this case ends here for the present. The patient's highest daily dose of potash was 369 grs. The remedies agreed well with him, and only had to be interrupted a few times, for two or three days, on account of causing disturbance of the stomach. Inflation of the middle ears never pro- duced any apparent effect. 530 SYPHILITIC COCHLITIS. CASES. Syph ills — Sudden Tin n it us — Itecove >'y. CASE VI.— Mr. P., set. 45. July 2, 1877. In July, 1876, noticed a ringing sound in his left ear upon arising in the morning. A few days later noticed the same sound in his right ear. The tinnitus has remained ever since, and has increased in intensity. In October he noticed that his hearing was im- paired. The deafness has been increasing until three weeks ago, since which time it has appeared to remain the same. Has been treated for aural catarrh by two competent aurists (by one for a period of six weeks), without any bene- fit. Has been treated by electricity also, without benefit. Never had any inter- nal medication. Has occasional dizziness. Health good in all other respects. Had a chancre in July, 1876, before tinnitus was noticed. Sore appeared fourteen days after intercourse, healed slowly, and was accompanied by balanitis. Never has been aware of any secondary affection of any kind. H. D.— K, fj; L., -A. Loud voice, six feet at right side of head and twelve feet at left side. Tuning-fork heard alike both sides, as nearly as he can judge. All the notes of a piano "sound alike" to him. Band music sounds very discordant. General appearance of both drum-heads is healthy. Pharynx normal. Tubes open. No effect from inflation. Diagnosis. — Disease of cochlea both sides, of syphilitic origin ? Advised a half-drachm of 20 per cent. sol. oleate mercury rubbed into skin daily, and iodide of potash in increasing doses, beginning with 5 grs. three times a day. Aug. 14, 1877. — H. D. — -^ both sides; heard conversation thirty feet behind back easily. R. E., notes of piano between 6th c and 7th e are not heard. Four uppermost notes heard naturally. L. B., notes sound natural up to 6th g ; from there to 7th e they sound "all alike, and have no music in them ; " above e they are natural again. Hears band music well now ; before it was very discordant to him. Violin music is still discordant to him. His own voice sounds more natural to him. Is sure himself that he hears every- thing much better. This patient left town at this time expecting to return, but did not do so. The remedies disagreed with him sometimes, and he was unnecessarily timid about increasing the doses. He never took more than 42 grs. iodide potash three times a day. A statement from this patient, in March, 1878, says that he considers himself well. Syphilis— Symptoms of Cochlear Disease — Slight Improvement. Case VII. — Mr. C, ast. 30. Seen at Manhattan Eye and Ear Hospital. Patient was perfectly deaf so far as the voice was concerned. Could not hear the watch with which he was tested at all. The vibrations of the tuning-fork were also not heard. All communication with him had to be held in writing. He could hear finger-nails against the left ear after three weeks, and the tinkling of the street-car bells. In five weeks he could hear tuning-fork quite well with the left ear. Later he heard the watch -+& with the same ear. All his symptoms pointed to a disease of the labyrinth, and it was con- SYPHILITIC COCIILITIS. 061 sidered to be syphilitic. He had contracted syphilis a year before, and had been treated for it from the outset ; still he had had secondary symptoms. Six months later he felt so well that he gave up treatment. Then he was taken with violent pains in his head, and observed impairment of hearing and tinnitus. In a week his hearing was " all gone." He resumed anti-syphilitic treatment, but the deafness and tinnitus have remained. This patient was treated by mercury and potash in increasing doses, and carried out all directions faithfully for a long time. His general condition improved, but no change was evident in his hearing except that mentioned above. One day he came, saying that on the day before he had heard the word Mexico. On trial, he was found to hear this word every time it was spoken into his left ear. He did not hear any of the component letters of the word (as x or o) when spoken into his ear, nor was any other word ever found which he could hear. At this time he was taken with pulmonaiy hemorrhages, and specific treatment was stopped. He has been in failing health ever since. It is undoubtedly true that affections occur in syphilitic patients (from suppression of the perspiration, for example), which would have occurred all the same had they not been syphilitic ; and yet the exposure or imprudence having once caused the attack of inflammation, it immediately assumes the character of a syphilitic affection by reason of the syphilitic blood, whose increased flow to the part and the exudation go to constitute the inflammation. The complete failure of the anti- catarrhal treatment, although all these patients showed some catarrhal symptoms, was another striking evidence of the real nature of the cases ; for we seldom meet with cases of catarrh that do not respond to some extent to the use of the catheter, Politzer's method, etc., while, in acute or subacute labyrinth diseases, this treatment often aggravates the symptoms. We do not know as yet what part of the cochlea corres- ponds to the low, and what part to the high notes of a musical instrument ; but we do know, as has been intimated in a pre- ceding part of this chapter, from what has been seen of diseases of the labyrinth — not only in such cases as those just given, but in those resulting from cerebro-spinal meningitis — that the parts tuned for low tones suffer less than the others. The for- mer will remain unhurt, or at least with a certain power of perceiving sound, when the latter have no power at all. 532 MENINGITIS. CEREBROSPINAL MENINGITIS. MENINGITIS— CEREBROSPINAL MENINGITIS. Meningitis and cerebrospinal meningitis lead to disease of the labyrinth by direct transition of the inflammatory action. Disease of the middle ear also results from those affections, and I have seen many cases where the two parts of the ear were simultaneously affected. The deafness is not usually observed until the patient is aroused from the stupor, when, if the laby- rinth be affected, the deafness is profound, and there is apt to be unsteadiness of the gait. Knapp * speaks of some cases, however, where the deafness occurred during convalescence. This is a state of things that we sometimes see in labyrinth disease from scarlet fever, where, after a slight catarrhal in- flammation of the middle ear, the labyrinth becomes suddenly invaded, probably from the middle ear, and secondary, incura- ble disease of the internal ear occurs. Fortunately, in scarlet fever and in the other exanthemata, middle ear and not laby- rinth disease is the variety of aural affection usually found. In cerebro-spinal meningitis, however, the labyrinth is the part of the ear that usually is attacked. Moos,-\ however, reports the post-mortem of a case of cerebro-spinal meningitis, in which the nerve was found to be sound, excepting some congestion of the sheath up to the meatus auditorius internus, while there was extensi'onof the inflammation from the dura mater into both tym- panic cavities. The nature of the lesion in deafness from cere- bro-spinal meningitis is not }Tet fully made out. Suppuration of the membranous labyrinth has been found in some of the very few post-mortem examinations that have been made.:}: It is probable that the seat of the lesion is to be found in the labyrinth proper, and not in the auditory nerve-trunk, for the facial nerve is seldom affected. Yon Troltsch says that a few post-mortem examinations show that the morbid changes causing deafness in cerebro- spinal meningitis, are sometimes found in the fourth ventricle. * Medical Record, vol. vii., No. 15, p. 340. f Archives of Ophthalmology and Otology, vol. iii., No. 2, p. 177. JKnapp, Archives of Ophthalmology and Otology, vol. ii., No. 1, p. 47. CEREBROSPINAL MENINGITIS. CASES. 533 It is as yet an assumption to say that siipjmration of the laby- rinth is the usual lesion. The following cases are fair specimens of such as come to the aurist after the disease has run its course : Cerebro- Spinal Meningitis — Bilateral Deafness— Both Drum-Heads Sunken. Dec. 30, 1869, It. M. W., est. 13, five years ago this winter, had an inflam- matory disease of the head and joints, and, when he recovered from this affection, became deaf. He does not hear words in any way. He feels the tuning-fork in each ear. The membranaa tympani of both sides are sunken ; the pharynx and nares are in a healthy condition ; air enters both tympanic cavities. Cerebro- Spinal Meningitis — Deafness of Both Sides. A. B., ast. 5, when 15 months old, imitated speech and other sounds; and, at about this period of its life, it went to bed apparently well one evening, but awoke in the morning with a severe attack of vomiting, and for 24 hours had convulsive movements. There were purple spots on the legs and arms. Recovery occurred in two or three months. The patient seemed to be conscious of sounds during its illness, sounds disturbed him. He was soon discovered to be deaf. Cerebro- Spinal Meningitis— Absolute Deafness — Both Drum-Heads Sunken. C. M. , boy, eet. 4 years 8 months, heard and talked well until about a year ago, when he had a fit of sickness, which the parents described very imper- fectly, but which was attended by some loss of power in the limbs. There was at one time some discharge of pus from one of the ears. The child does not seem to hear sounds at all ; the vibrations of a large tuning-fork are not perceived. Both drum-heads sunken and pinkish. Cerebro- Spinal Meningitis - Deaf ness Absolute — Membranes Tympani Normal. May 22, 1872, D. W. K., set. 21, a little more than three months since, was attacked by some disease of the head, and for two weeks was stupid or de- lirious. There were some little spots on the neck. When he became con- scious, he could not hear ; he has remained deaf ever since. There seems to be absolutely no hearing power; cannot hear the voice even when conveyed to the ear through a tube ; and is equally unconscious of the sound of the tuning-fork or the piano. The membrane tympani are of normal color, trans- parency, and position ; air enters the tympanic cavities. Cerebro- Spinal Meningitis — Sunken Drum-Heads. Geo. S., set. 25 months, when 14 months old had congestion of the brain, was unconscious, paralyzed, and had spots on the skin. Was found to be deaf when he recovered. Both membranes tympani are sunken. 534 CEEEBRO-SPINAL MENINGITIS. CASES. Cerebro- Spinal Meningitis — Sunken Drum-Heads. May 31, 1873, John D., set. 9, eight weeks ago to-day was seized with a pain in his head at about 8 o'clock A.M. The pain was said to be across the forehead. At 11 o'clock he hud convulsions. There was spasm, especially of the hands and throat, at 8 P.M. ; complained of headache, and at 11 p M. he vomited. He became unconscious, and remained so until 4 A.M. Ten days after the attacks he was deaf, and still continues to be so. He states that there is a whistling sound in his ears. He took large doses of quinia, and soon recovered from all the symptoms, except a little uncertainty in his steps, and even now he has a somewhat tottering gait. He does not hear the watch at all; but can distinguish sounds conducted into his ear through a tube. The tuning-fork, when placed upon the teeth, produces a buzzing noise. The drum-membranes are very much sunken, and of a pinkish hue ; shows a small light spot. Cerebro-Spinal Meningitis — Normal Membranm Tympani — Slight Amount of Hearing Power as lasted by Piano. March 17, 1874, D. B. , ast. 21, a little more than ten months ago was at- tacked with a chill, which was attributed to sitting upon a stone in the front of the house during the month of May. After the chill the patient became delirious, and his neck was stiff, and he had no use in his arms or legs. This state of things continued for one week. As soon as he became rational he was found to be deaf, and his left side remained paralyzed. He gradually recovered from the paralysis, though his deafness continues, and he staggers in his walk. Hearing distance : right 0, left 0. The tuning-fork is faintly heard in both ears ; he is sensible to the tones of his own voice, and talks in a natural tone, modulating fairly. He thinks his right ear is the better one. By means of a conversation tube connected with the keys of a piano, he ia enabled, through the medium of the right ear, to distinguish the C, D, and E of the treble, as well as all the bass notes. With the left ear he cannot dis- tinguish the treble, the bass notes alone being audible. This is in accordance with the law of acoustics, that the impression of the bass or low notes re- mains longer on the ear, thus proving that the patient had still a slight trace of hearing power remaining in the cochlea, and that the statement that he heard better with the right ear was correct. The membranse tympani are transparent, the pharynx is granular. The patient has been for some weeks under competent treatment, but without perceptible benefit. Cerebro- Spinal Meningitis— Normal Membranai Tympani. May 2, 1872, Virgil T., set. 5, four weeks ago was seized with a severe pain in the head ; soon vomited, and was delirious at times, especially on waking from sleep. He complains of pain in the back and neck, and also of pain in his right ear. Four days after the attack began he was found to be deaf,