CHAPTER XIX. DISEASES OF THE INTERNAL EAR. (Part 9)

. 3 542 PATHOLOGY OF LABYRINTH DISEASE. Pus in canals, 1 Calcareous matter in canals, 1 Hemorrhage into canals, ... .... 1* Hypertemia of cochlea and semicircular canals, f Ecchymoses in vestibule and cochlea, seen by Politzerf accompanied by ecchymoses of the tympanic cavity and osseous tube, . . . Hemorrhage into the whole labyrinth, after the action of the poisons of gout, typhus fever, scarlatina, measles, or mumps, observed by Toynbee, § Fibro-muscular tumor in the infundibulum of the cochlea was found by VoltoliniJ Phosphate of lime on lining of the meatus auditorius in- ternus, Boettcher,^[ Atrophy of membranous labyrinth, . . . . .16 Soft and swollen, 10 Fatty, 2 Endolymph opaque or red, . . . . • . 7 Labyrinth containing pus, . . . ■ . . . . 1 Labyrinth containing cholestearine, ..... 1 Bcny degeneration of saccule, ...... 1 Thickened lamina spiralis, 1 Fibrous mass in cochlea, ....... 1 Excess of pigment, ........ 3 Extravasation of blood, 2 Bony deposit in meatus auditorius internus, ... 2 Atrophy of fibres of auditory nerve, 3** Embolus in the auditiva interna artery ff (Friederich of Heidelberg). Hyperemia of the various parts, or of the whole contents of the labyrinth, has been found in typhus and puerperal fever, * The above cases are taken from the tabulated index of Toynbee's cata- logue. Many of them are secondary changes, but they show what may occur in the labyrinth. f Voltolini, Virchow's Archiv, Bd. XVII. ; Schwartze, Archiv fiir Ohren- heilkunde, Bd. I. , p. 206. Schwartze's case was one of acute catarrh of the tympanic cavity after typhoid fever. X Moos, Klinik der Ohrenkrankheiten, p. 311. § Diseases of the Ear, American reprint, p. 377. | Moos, 1. c, p. 316. 1 Von Troltsch, translation, p. 499. ** Hinton, Nervous Deafness, reprint from Guy's Hospital Reports, 1867. ft L. c, p. 131. PATHOLOGY. TREATMENT. 543 in acute tuberculosis, and in cases of poisoning by carbonic oxide gas; also in meningitis, and in cases of disturbances of circu- lation from disease of the heart, and in emphysema of the lungs. Hypersemia of the labyrinth may result from vaso- motor disturbances of innervation. According to Erb,"" atrophy of the acoustic nerve occasion- ally occurs in tabes dorsalis. Tumors — sarcoma, neuroma, and gummata may enter the meatus auditorius internum. It must be observed that suppuration in the membranous labyrinth is, as yet, among the rarest of pathological changes that has been found in the internal ear, although it is assumed by some authorities that this is the lesion that usually results from cerebro-spinal meningitis. Treatment. — Only general remarks can be made in refer- ence to the treatment of disease of the internal ear. Each case must be studied by itself, and treated according to the symp- toms. If we have to deal with a case of true inflammation of the labyrinth, cold applications to the head and the use of quinine should be avoided, and our reliance must be on leeches and counter-irritation, pediluvia and purgatives. Chronic affec- tions of the labyrinth are, unless of a syphilitic origin, so far as my experience goes, utterly hopeless. Electricity has a much- vaunted reputation, among inexact observers, for its cures of nerve-deafness ; but there are no authentic cases on record of a cure of a true inflammatory affection of the labyrinth by this agent. The only seeming exception to this rule is a case re- ported by Moos,f which he entitles " Recovery from Complete Nervous Deafness." The constant current was used success- fully in what seems to me to have been a case of impairment of hearing occurring in the course of an hysterical affection. The patient had acute articular rheumatism, and in the fifth week hysterical symptoms appeared. There was great sensitiveness of the ear, such as occurs in other parts of the body in hysteri- cal women, and increased hearing power. The patient lay for * Ziemssen's Handbuch, p. 142. f Archives of Ophthalmology and Otology, Bd. I., No. 2. 544 TREATMENT. nine days without moving on the right side, and thus an ulcer of the concha was caused. She took large doses of quinine for these nine days, when impairment of hearing occurred, and continued to increase until the patient was communicated with in writing. In the eleventh week tetanic spasms occurred. The galvanic current was then employed, twelve elements being used. The symptoms, except the deafness, soon subsided, and a thorough course of galvanization of the ear restored the power of the right one perfectly, and of due left in all respects, except the inability to distinguish the highest note of the seven-octave piano. I confess I do not feel the enthusiasm over this case which is exhibited by Professor Moos, which, according to his hopes, is to " toll the knell for all the opponents of the therapeutic value of electricity in aural disease." It has, to say the least, so strong an hysterical element, and so much quinine was given, as to make it doubtful what pathological process was at the basis of the deafness, and yet it is an interesting and impor- tant case. Beard and Rockwell * give their views as to the value of electricity in the treatment of diseases of the auditory nerve and labyrinth in the following cautious language : " Cases of nervous deafness, or of deafness resulting from various patho- logical conditions, with which a morbid condition of the audi- tory nerve is complicated, and all cases of tinnitus anrium, whatever, may be their supposed pathology, should only be regarded as hopeless after the failure of persevering and varied treatment by electricity, although perfect or approximate cures will be obtained only in a small percentage of the cases. The treatment of opacity and thickening of the drum, and of chronic inflammation (with the consequent adhesions and other morbid changes) of the middle ear and Eustachian tube, offers a fair and important field for electrical experiment." Dr. Knapp says : f " I have tried it (electricity) in nearly all reported cases, but without a shade of improvement. * A Practical Treatise on Medical and Surgical Electricity, pp. 571-2. •)■ Archives of Ophthalmology and Otology, vol. ii., No. 1. TKEATMENT. OTALGIA. 545 Dr. S. Sexton, of this city, Surgeon to the New York Ear Dispensary, writes me that he has experimented with electricity in aural disease for two years, both in private and public prac- tice. He is convinced of the correctness of Brenner's formula ; but in all his cases, Dr. Sexton says " there was no marked improvement in the hearing." " In a few cases of impaired hearing, where there were the accompanying symptoms of dizziness or nervous headache, the advantages of the treatment were decided." My own experience has been purely negative. I have never seen any improvement, in any forms of nerve-deafness, from the use of electricity in any form. I fear that we must abandon the hopes entertained by some, of the powers of this subtle agent in those as yet mysterious diseases, the affections of the internal ear. The cases that have been quoted in this chapter, and others that I have seen and treated, lead me, however, to lay great stress upon the importance of, and hopefulness for, a thorough course of mercury and iodide of potassium, in all cases of dis- ease of the labyrinth where syphilis seems to have been the cause of the affection. If a doubt exists as to the etiology, and there is even a remote possibility that syphilis is the basis of the disease, a thorough anti-syphilitic course should be instituted. By thus acting, the patient will get the benefit of the doubt. OTALGIA. True otalgia is a very rare affection. After some fourteen years of practice in aural disease I have seen but two cases. In these cases the chief seat of the affection was the tympanic cavity. Otalgia may occur as a consequence of malarial poi- soning, syphilis, or carious teeth. The chief point in the dif- ferential diagnosis is the absence of redness of the auditory canal or membrana tympani, and of impairment of the hearing power. Acute catarrh of the middle ear is sometimes mis- takenly supposed to be otalgia. The ear, especially the tym- panic cavity, is so richly supplied with nerves, that it is sur- prising that so few cases of otalgia have been observed. Bon- 546 OTALGIA. nafont* says that the disease rarely attacks both ears at once, but that it readily passes from one to the other, in consequence of the sympathy between the two sides of the fifth pair. There is apt, according to the same author, to be injection of the conjunctiva and lachrymation, in connection with otalgia. The seat of otalgia may be, according to Bonnafont, in the auditory nerve, the chorda tympani, or the nerve-supply of the tympanic cavity. Bonnafont advises instillation into the ear of a concentrated decoction of poppy-heads, and cataplasms or blisters on the auricle and mastoid process. Gruberf reports a case of typical otalgia cured by the use of iodide of potassium. Quinine was tried, but proved of no service. Gruber thinks it possible that there was an exudation pressing upon the nerve in this case. The symptoms were spasmodic contraction of the left side of the head, with pain in the ear occurring at irregular intervals ; the longest inter- missions were a few days. The hearing power was normal, and there were no pathological objective symptoms. The following case, which I saw but once, but which I heard recovered after treatment, is a fair representation of pure otalgia : Otalgia of Right Side, probably from Syphilitic Exudation on the Seventh Nerve. A. X., set. 27, May 23, 1873. This patient, who is a physician, says that he has suffered from more or less acute pain in the right ear and mastoid pro- cess for three months. Within the last ten days it has been more severe. The hearing is not impaired. On examination the hearing distance is found to be normal, but the tuning-fork is heard better on the right side. The membrana tympani and mastoid process present no abnormal appearances. The pain seems to follow the course of the seventh nerve. The patient had primary syphilis not long ago, and some secondary symptoms. He has never had any malarial affection. Under anti-syphilitic treatment this patient is said to have recovered. * Traite theorique et pratique des maladies de Toreille. Paris, 1873, p. 557. f Monatsschrift fur Ohrenheilkunde. Jahrgang III. No. 9.