ARCHIVES OF OTOLOGY.

RE-EXAMINATION OF THE HEARING OF DEAF. MUTES ORIGINALLY TESTED IN 1893.

By Pror. F. BEZOLD or MunicH. With Plates I, and II, of Vol. XXX. of Germ. Ed.

Translated and Abridged by Dr. J. A. SPALDING, Portland, Me.

HE examinations of the hearing of deaf-mutes, which ea I made some years ago in Munich, have been care- fully investigated by the Ministry of the Interior in the Kingdom of Bavaria, and the Minister of Education has lately given me an opportunity to demonstrate before him, personally, by means of the continuous series of tones as well as by the voice, the presence of some remnants of hearing in a number of scholars in our Deaf-Mute Institute. Whilst making this demonstration, I found that twenty-eight of the scholars whom I had tested before still remained in the In- stitute, and it then occurred to me to extend my former in- vestigations into this very interesting province of otiatrics, by means of Prof. Edelmann’s improved series of tones.

It was with a good deal of anxiety that I began this re- examination, for although I exercised ‘the greatest care originally, the possibility of many errors having unintention- ally crept in could not be absolutely excluded. For, in the first place, the tone-series originally employed was imperfect (especially in the twice-scored octave) in comparison with the other octaves, a defect which Prof. Edelmann has avoided by making much more intense the upper portion of the scale, the very space which is so often preserved in deaf- mutes. In the second place, I was afraid of the extreme youth, the defective replies, and lack of self-reliance in those

107

108 F. Bezold.

pupils who were now to face me for re-examination, for all the older pupils had graduated, only the youngest were left, and amongst the notes attached to their names, at the first examination, were such remarks as these: ‘“ Apparently total deafness,” “‘ Answers far from trustworthy,” and so on,

However, in order to verify the condition of those who were then the youngest, to carry the question of the hearing of deaf-mutes still farther along, and for other reasons which shall soon appear, re-examination seemed not only desirable but even a necessity.

The first point to investigate was the different results likely to be obtained by Prof. Edelmann’s new tone-series, with their powerful and reinforced tones in those regions especially in which my former series had been noticeably defective. Some authors, for example, have asserted that equally powerful pure tones do not produce the same results on the hearing when produced by different instruments. The falsity of this assertion I saw plainly enough at my origi- nal examination, and additionally I expressed the opinion that we might later on find some perception still present for a series of tones which had at that time escaped my obser- vation, because in certain regions the intensity of my tone- series was too weak to get all possible results.

Furthermore, we are not positively sure whether the remnant of hearing tn deaf-mutes remains on the average enttrely sta- tionary. We must assume in most cases defects in the per- cipient apparatus, between which a few districts are still preserved, and that the morbid process producing these de- fects has long since terminated. At the same time we can additionally represent to ourselves, that, for example, a cica- tricial contraction, a calcification, or an ossification in the cochlea might, after years, extend in circumference and so destroy farther portions of the hearing spaces, particularly former islands of hearing. The inverse theory of return of the function by later zmvolution must be regarded as ex- tremely improbable, considering the basal morbid process, and the long time which has elapsed since it ceased to be active.

Finally, in answer to the question whether some defects

Re-Examination of the Hearing of Deaf-Mutes: 109

might not depend solely on torpidity of the auditory nerve elements, and might be improved by hearing exercises by means of tones corresponding with the defective regions, we can only reply that, judging from the successful results which Urbantschitsch and others think that they obtained by exercises with speech and simple tones, only practical ex- perience can decide.

From such points of view the results obtained from the re-examination of these twenty-eight deaf-mute children seem important enough to guarantee a graphic representa- tion, and comparison with the results originally obtained.

Much to my gratification, the variations are less than I thought they would be.

Plates I. and II., at the end of this number of the AR- CHIVES, give a plain idea of the hearing remaining, the red lines showing what was originally present, and the blue, the results of the re-examination. The numerals with the ear named at the foot of both tables, as well as those in the re- mainder of this paper, refer to the cases successfully ob- served, and the same numbers refer to both examinations.

The greatest errors were discovered in the fifty-four ears belonging to twenty-seven re-examined children amongst those first noted as totally deaf.’ For amongst these fifty- four ears twenty-five belonging to eighteen deaf-mutes were originally noted as totally deaf, whilst re-examination showed that four were by no means totally deaf, two having an island of hearing, and two an extensive district.

One island in Case 62 R (Plate I., Group I.) extended from a" to a'’, but was only discovered on blowing very forcibly with Edelmann’s organ pipes, and the other one (38 L, Pl. 1., Gr. I.) from f" to e’, and was only discovered by Edelmann’s whistle and Lucae’s forks c'Y to f'¥.

Case 73 R and L (PI. II., Gr. IV. and VI.) was at first with difficulty tested and noted as apparent totally deaf,” and, although now exhibiting an extensive region for hearing, can- not be induced to speak. With exception of these four, twenty-one were totally deaf at both examinations.

'Case 28 was not amongst those first tested, and proved to belong to those having the best hearing.

i F. Besold.

On the contrary, amongst the twenty-nine ears which orig. inally showed a remnant of hearing, only one was found in which formerly an island (c’Y to a'’) was present, but which has at the re-examination given way to total deafness (Case 44 L, Pl. I., Gr. I.).

The right ear of this same patient (44 R, Pl. I., Gr. IL) is very interesting in comparison with the left, because in the former we found in the midst of a remnant of hearing, of about the same extent as originally with exception of a trifle at the lower tone-limit, am island from e" to e™ about as at first. The patient’s trustworthiness past and present, as demonstrated by the similar results obtained in the right ear, shows us that there can be hardly a doubt that the island of hearing originally present in the eft ear ts now totally submerged.

A somewhat similar case is seen in 39 L (PI. I., Gr. I.), in which, at the first examination, two hearing regions were discovered, one from b™ to d’ and one from f*to g', the latter disappearing in the interval between the two examina. tions. For this reason the case was taken from the group of defects and placed in that of islands. The upper end of the hearing region was also abbreviated by seven semitones, despite the more powerful forks employed, whilst in the other ear (39 R, Pl. I., Gr. I.) the island present at both examinations terminated at the second testing, just as origi- nally at the upper end, whilst at the lower end, dependent on the more powerful sources of tone employed, it extended a little lower down.

These new defects probably signify an increased destruc- tive process in Corti’s organs, rather than an error in the examination.

Amongst twenty-eight ears there were but two in which the original upper tone-limit exceeded the later by more than a semitone, a difference which might be ascribed to mistakes in observation. In all the others, owing to the loudness of Edelmann’s apparatus, the newly discovered regions for hearing were a trifle more elongated than the old, not only at the upper tone-limit, but generally at all places where the hear- ing region ts interrupted, as well at the lower as the upper, or even at both ends.

Re-Examinatton of the Hearing of Deaf-Mutes. 111

I here emphasize the fact that despite the great differences in power between the old and the new apparatus, just about the same tone-limits (or within a semitone) were found at both examinations.

Leaving aside the examinations for Galton’s whistle, which cannot be expressed in semitones, we find in twenty- eight ears that the region for hearing ceased at the same tone or within a semitone at the upper limit in seven cases, and at the lower limit in twelve cases, and, in the six cases with defects, twice at precisely the upper end of the defect, and twice at the lower. Moreover, there are eleven coincidences for Galton’s whistle at the upper end of the hearing region. So that, taking all in all, thirty-four regions for hearing coincide substantially. Having found that the re-examination with the new apparatus exhibits the same tone-limits as those in the first examination, we must take it for granted that a district of nerve elements provided with relatively normal functions joins directly on to another district which pathologically and anatomically has lost tts for- mer functions.

These sharply defined pathological alterations are in all probability to be sought for in Corti’s organs. They give us a well-defined picture of the situation of the districts de- stroyed, and we are justified in assuming that these pictures are better defined and more perfect than we could obtain by microscopic examination of the labyrinth, just as the deter- mination of the visual field of the eye teaches us more precisely the form and extent of visual defects than a micro- scopic examination of the retina could do.

In contrast with this uniform coincidence of perception at thirty-four localities in twenty-eight ears, and partly at some other district in the same ear, we find more or less increase in the tone space discovered by the more intense new appa- ratus in twenty-six localities, the excess being but three times, more than one octave, averaging six tones, and from one to two mm by Galton’s whistle.

Variations like these cannot be explained by mistakes in testing, but must be due to the greater power of the new apparatus. This condition must therefore appear at all

112 F. Bezold.

those spots where the transition from the hearing- to the deaf-region in Corti’s organs is gradual, the result of diffuse destructive foci in the percipient organs.

Of the four regions which varied greatly three were in the same person (69 R and L, PI. II., Gr. IV. and V.), and in the fourth (26 R, Pl. I., Gr. I.) Edelmann’s fork and organ pipe were only heard when blown or struck most forcibly, Besides this, the lower portion of the newly discovered region lay in the weakest portion of my first tone-series.

The chief differences lie in the ower border of the region for hearing, the one in which middle-ear processes, tubal catarrh, etc., in children with hearing, good, bad, or none at all, chiefly exercise their morbid influence, and it may be that this disease was present in some cases at the original examination, or, for reasons cited in my former paper, these deaf-mutes were tested by aérial conduction alone.

The result of the re-examination with new instruments may be summed up in this way: Zhe number of totally deaf ts less than before. Two deaf-mutes, however, lost con. siderable hearing in the interval, and tt would seem as tf we were justified in assuming that some cases always show slow advance of the destructive processes in the cochlea. Two children had more hearing than at first test, which may be ascribed to defective repliés originally in one case, and in the other to the greater power of Edelmann’s apparatus. The other twenty deaf-mutes showed about the same hearing at both tests, or a moderate increase averaging six semitones.

The first and very frequent condition (similar, or nearly similar limit for tones) proves that the boundaries of morbid Joct on the cochlea are often sharply defined. The second con. dition (a moderate increase in the extent of the region for hearing) gives us an approximate idea of the amount to which our results may be influenced by differences in the intensity of the various tone-series employed. Nevertheless, this influence has been much less than I had expected.

Although the re-examination discovered a few sertous errors that had been made at the first testing, yet the number of co- incidences was so great that there can be no doubt that even the youngest deaf-mutes in our Institute can be safely employed

Re-Examination of the Hearing of Deaf-Mutes. 113

for the collection of statistics of the hearing power of deaf- mutes.

Urbantschitsch has expressed the opinion that even if deaf-mutes are exercised exclusively by speech the hearing for musical instruments and speech alike is improved, even without the use of any of the former; but this opinion I cannot endorse.

Methodic exercises with fones were also tried in a very ap- propriate case for three months with an absolutely negative result.

The tests for the voice, vowels, consonants, and words were limited to cases in which the extensive hearing-region ob- tained in the tests for tones seemed to promise some mini- mum hearing forspeech. These cases also had been suggested as suitable for such exercises and had already received some brief instruction by that method through the ear. More or less comprehension for speech was found in about one patient inevery four that is to say, in seven children with nine ears, two belonging to the second group (44 R and 58 L), one to the fifth group (26 L), and six to the sixth group (58 R, 66 R, 78 L, 43 R, 41 R, and 41 L).

At the original examination of these ears four were deaf for all vocal sounds except the consonants P, T, R, which were perceived by tactile sensation; at the re-examination, none were so deaf. Originally, three had hearing for a few vowels and consonants, at the re-examination only two. At the original examination two had hearing for words, at the re-examination seven.

In my first paper I laid down the upper and lower limits in the tone-scale which might be lost for hearing without totally destroying the perception for voice, namely the small space between b‘ and g”, which is indispensable for the un- derstanding of words by the ear. Amongst the scholars re- examined there were but two who had lost perhaps from one to three semitones at the upper border of this little space (58 L and 44 R). The first one possessed the sixth, which I regard as necessary for hearing speech, but lowered a semi-

tone in the scale. He could understand the word Eight and the vowels A and E, with one ear, and with the other

114 F. Bezold.

ear the same vowels and all the numerals except Five and Six.

The other one (44 R, PI. I., Gr. II.), who had lost the ¢hree upper tones of the sixth for speech, and who was also totally deaf in the other ear though having some hearing at the original test, could repeat such numerals as Seven, Nine, Four, Twenty, and so on when spoken directly into the ear, but could not understand any vowel except U. Leaving aside the island from f" to e™, this child has a very extensive range of hearing, and an unusually long duration for sounds, From two points of view the case is interesting ; for, firstly, we see how well speech was understood despite the loss for all vowels but U. We must assume that the numerals were recognized solely by combinations of consonants, despite the fact that all of the hissing sounds must have been more or less lost. The case is suggestive of what can be obtained in attentive children by instruction with the voice.

In the second place, we emphasize the fact that the vowel U was perceived although within the patient’s defective regions lies the district d" e” in which Hermann has lately located* one of the fundamental tones for U, in opposition to Helmholtz, who located the only fundamental tone for U in the small f, which happens to lie inside the child’s region for tones.

I will next refer to the hearing for the voice, in its relation to the situation of the regions for hearing in the tone-scale. For the only case which seemed incomprehensible at the first examination was 39 R (PI. I., Gr. I.), in which both A and O were correctly repeated although the island for hearing lay far away from the fundamental tones for these vowels. The same island was found at the re-examination though elon- gated several semitones downward. Nevertheless A and O were no longer perceived, so that there must have been a mistake at the first test.

A single case (26 B, PI. II., Gr. V.) with hearing from f" to the middle of Galton’s whistle, and which was at the first examination deaf for speech, now perceived the vowel I and

‘Arch. f. d. Gesammt. Physiolog., vol. liii., 1893.

Re-Examination of the Hearing of Deaf-Mutes. 115

the hissing sound “Sh,” a condition which coincides with the position of the fundamental tones for the hissing sound, and with the upper fundamental tone, at least, of the vowel I,

The sixth group with extensive ranges for hearing is of great importance so far as future practice with the voice in partial deafness is concerned. Here we found six ears in five patients, one case, No. 73, being omitted, as it was not tested originally. Basing our opinion on the extensive regions for hearing, showing only slight defects at the upper and lower ends, it would seem as if such cases did not repre- sent labyrinthine destruction in the least, but cerebral dis- turbances possibly in the auditory spheres in the temporal lobe, and that they therefore indicate word-deafness,” in the actual sense of the term. Experience alone can tell us whether such a central force of deafmutism is accessible to instruction through the ear. The slight results so far ob- tained are encouraging.

Four cases in Group VI. (58 R, 66 R, 78 L, and 43 R) were at first deaf to words, but re-examination shows an ex- tensive comprehension for words, two repeating nearly all the numerals and two all of them correctly. The fifth child (41 R and L), who could originally perceive all the numerals, can now repeat them correctly across aroom and even Latin words which are wholly unknown to him.

This slight experience proves that even the deaf-mutes of the VI. group, characterized by excessively defective comprehension for speech despite extensive perception for the tone-scale, are very accessible to instruction by speech through the ear. We know that wherever a satisfactory remnant of hearing exists, it can be utilized for the comprehension of the voice by well - conducted instruction, no matter whether the pathological alter- ations producing the defects of hearing lie in the cochlea or at any locality beyond.

One of the above-mentioned pupils (66) had on the other (left) side a very extensive region for hearing, with, however, a large defect in the middle, embracing the hearing Sixth (f' to g"), but if he closed with his moistened forefinger the right ear, belonging to the sixth group and hearing all the

116 F.. Bezold.

numerals, he was unable on the side containing the defect to hear or to repeat a letter or word. The same thing was noticed in 43 and 78, who on the other side were not only deaf to tones but to speech.

This observation shows that closure of the meatus with the Jinger in deaf-mutes is sufficient to exclude all hearing from the other ear, even tf it possesses abundant remnant of hearing. So that all tests of each separate ear may be considered as more reltable in deaf-mutes than in those who are partially deaf.

Case 78 shows that a part of the hearing for speech dis. covered at the re-examination is due to the preliminary in- struction with the voice through the ear, for the child had only been educated with units, could for that reason only repeat numerals up to ten, and failed to comprehend the higher numerals, although she possessed a region for hearing from the upper limit for Galton’s whistle to the middle of the great octave.

Small as are the statistics at my command, the results ob- tained for the hearing of speech indicate the surprising achievements in the comprehension of speech which brief in- struction may produce.

SUPPLEMENTARY REMARKS.

A few days after handing in the present MSS. I received from the Minister of Public Instruction an edict of great im- portance for the future instruction of deaf-mutes in Bavaria, dependent on their remnant of hearing and speech.

In brief the edict says that all deaf-mutes newly entering the Institute are to be carefully tested for what remnant of hearing they may possess, as well as for any remaining capacity for the comprehension of speech; that those who still remain in the Institute may at any convenient time be re-examined in similar lines by competent aurists ; and that those who hear a little or who can speak in the least, in ad- dition to general instruction shall, in special hours, receive proper and skilled instruction for the preservation and pos- sible increase of what hearing and speech they still possess. Henceforward, then, we may surely expect that the special

Re-Examinattion of the Hearing of Deaf-Mutes. 117

care thus assured to the partly hearing and partly vocal deaf- mutesin Bavaria will soon be imitated in other parts of Ger- many, and that in a future not distant deaf-mutes of all countries will obtain instruction not only to increase what hearing and speech they may have, but this fraction of the normal hearing power to be utilized as a foundation for un- derstanding spoken language such as now prevails, accord- ing to Mygind, in several institutions in America, France,

and Austria.

FOURTH REPORT ON THE PATIENTS TREATED DURING THE YEAR 1898 IN THE HOSPITAL AND OUTDOOR DEPARTMENT FOR AURAL DISEASES AT THE UNIVERSITY OF STRASS. BURG.

By Dr. F. ALEXANDER.

Abridged Translation by Dr. MAx TorpLitz, New York.

“HIS report is based upon the same principles as that ‘| of the years 1896 and 1897. The abundance of the material rendered the writing of a record of the numerous small operations performed at the outdoor department im- possible. The more important cases only will be given in

this abstract. The character of the tumors, which are not classified, was not ascertained by exploratory excision and microscopical examination.

OUTDOOR DEPARTMENT, 1898.’ I.—AURAL DISEASES.

Disease. Right. | Left. | Both. } }

A. EXTERNAL EAR. a. Auricle.

Foreign bodies Otitis externa, circumscribed Otitis externa, diffuse

Periauricular abscess following furuncle 1 Unimportant diseases omitted in the translation.

118

Report of the Strassburg Ear Clinic in 1898. 119

Disease. Right. | Left. | Both. | Total. c. Membrana Tympani, Myringitis HenOrrel, CINE va nin nk oc cece sence I i I Hemorrhages,.....eeccesececcccsecseccsusecs 3 4 . 7 Ruptures os creer eeeceeeceeeeereeeeerercecs ° 3 | 9 12 B. MIDDLE Ear. Heematotympanum... .cececceescees See cee tag 2 ea aM 2 Otitis media, catarrhal acute..........+....00- 49 33 20 102 Otitis media, hemorrhagic acute............. oP ae 5 3 12 Otitis media, catarrhal chronic, and sclerosis.....} § 4 | 285 294 Otitis media, purulent acute.........+++seeee0s 100 97 33 230 Otitis media, purulent acute with ostitis of mastOid PrOCeSS.....cccccscrccccvsvsccces 8 8 oe 16 Otitis media, purulent chronic.........+.....+. gt 93 81 265 Otitis media, purulent chronic with polypi...... 22 12 5 39 Otitis media, purulent chronic with caries....... 4 13 I 18 Otitis media, purulent chronic with cholesteatoma.| 10 | 8 I 19 Sequel to Otitis media purulenta.............. mt we 28 44 C. INNER EAR AND NERVOUS DISTURBANCES, | Otalgia....... eecces teen e eres sees eeeeeeees 14 15 7 36 Neuralgia of the mastoid process............... ia) Sool I 2 Injury to labyFtME,. 6. es ccc cccescvccocseces hand I 4 5 Other labyrinthine diseases.............ee200% 2 | 17 19 Fracture of base Of skull... .cccecscccccecceses un 3

II.—DISEASES OF THE NOSE AND PHARYNX. A. EXTERNAL NOSE.

Disease

i

HEN DERE ss KhOe ban ads onavehewWrdseaRiseanmses 9

EARS ican sie aac ooh s 0 teed nanebediween Pep awe E Nae 2

BEND sd i cccwierctecndssvendecves ce skebeceecs swans I

POP Noes dh oscccacoseuneesksdosgad i lids its Milani ia I

CURSING 6'o.< cise sieccenssGtveaens cobs bpearRewenaeeS I

B. NASAL CAVITY. Rhinitis, catarvhal chromie¢. .. 2. icc iccsccseces Bare ae 113 113 Rhinitis, hypertrophic chronic. ..........++-++ 4 ee 76 80 Rhinitis, atrophic chronic............0. ere eee I 2 82 85 ORRNR, 5 Peds PAF EN Re ON eh wie TERRE EOE en <i 64 LUCS WAGs cies ReRCOE EW aaie Cae eas vauae ees eaaes a < II° II Lues BAM COMIN Sic ccs sdcvccccddescusee as we | 4 4 Papilloma of the turbinated bodies............. i 2 I 3 eh ERE ee OPE TT EP PPPOE CORR ET OCR TET EL 6 12 | 19 37 Hypertrophy of the turbinated bodies :

a, of the middle turbinated body. ........... ps at ge 2 II b, of the inferior turbinated body............ as ae ee I 4 c, of the posterior extremities.............+.. Ps WERK oe 4 6 Empyema of Highmore’s antrum.............. | 3 | 6 I 10 Empyema of all accessory cavities.............. et soe I 5

F.. Alexander.

Disease.

C. NAsSO-PHARYNX AND PHARYNX.

Rhino-pharyngitis, chronic

Rhino-pharyngitis, chronic atrophic

Pharyngitis, chronic

Pharyngitis, granular

Lues of pharynx

RE IIS 5 oe ob v0.2 soe olny tee ns teee’s Congenital luic defect in the soft palate

Uvula bifida

Paresis of velum palati

Papilloma of the soft palate

Cavernoma of the soft palate

Diphtheria of nose and pharynx

Hypertrophy of faucial tonsils................. Hypertrophy of faucial and pharyngeal tonsils. . . Hypertrophy of the pharyngeal tonsil Hypertrophy of the lingual tonsil

to

ouwm Ow wnat

“~~ NWS Ne

HOSPITAL OPERATIONS.

Name of Operation.

Incision of lymphadenitic abscesses. .

Incision of periauricular abscesses after furuncle

Extirpation of auricular tumors

Extirpation of aural polypi

Paracentesis

Chiselling of Mastoid according to Schwartze

Chiselling in perisinuous abscesses

Chiselling in extradural abscess of both cranial fossz

Radical operation according to Zau/fal- Fansen

Radical operation according to Stacke

Radical operation according to Zau/fal-Fansen with opening of sinus..,.. Radical operation in cerebellar abscess

Radical operation with chiselling of labyrinth

Excision of carcinoma of external nose

Extirpation of carcinoma of left nasal cavity

Extirpation of nasal polypi

Extirpation of hypertrophied turbinated bodies

Extirpation of posterior extremities and hypertrophied turbinated bodies. . Incision of perichondritic abscesses of the nasal septum

Ablation of deviations of nasal septum

Opening of Highmore’s antrum through canine fossa

Opening of Highmore’s antrum through alveola

Chiselling of frontal sinus

Curettement of sphenoid cavity and ethmoid cells

Removal of tumors of naso-pharynx with cold snare

Extirpation of faucial tonsils

Extirpation of faucial and pharyngeal tonsils

Extirpation of pharyngeal tonsil

Removal of tumors of vocal cords

Removal of tumor of Santorini’s cartilage (with cold snare by autoscopy). .

I may here add a report on an epidemic of erysipelas, which appeared in the hospital at two different periods

Report of the Strassburg Ear Clinic in 1898. 121

during the summer and late fall. Through an outside physician suffering from erysipelas of the head, the infec- tion had been transmitted into the operating room. All precautionary measures, immediately used (disinfection of the operating room and its surroundings, and also of the patients’ rooms with formaline, etc.), could not prevent the infection with erysipelas of the following nine patients operated upon from April 1, 1898, until April 1, 1899, among sixty-nine Cases:

1, Adele St., et. twenty-one. Admitted April 27, 1898. Diag- nosis: Otitis media, chronic, bilateral, purulent, with polypi and caries of the left temporal bone. April 29th : Radical operation, L. She was seized on May 10, 1898, with erysipelas, which soon assumed a bullous character and was followed by severe nephri- tis. On May 18, 1898: Exitus letalis.

2. Emilie E., et. thirteen. Admitted March 3, 1898. Diag- nosis : Otitis media, chronic, purulent, of R E, with periarticular abscess of the joint of the right jaw. April 11, 1898: Radical operation with opening of the abscess. June 18, 1898: Erysipe- las. June 19, 1898: Transferred to the Children’s Department of the hospital ; thence, after implication of the non-operated side with erysipelas, transferred back on July g9th—after recovery from erysipelas. August 3, 1898: Additional attack of erysipelas on the right side, of mild character and of three days’ duration. August 9, 1898: Discharged for out-of-door treatment. Begin- ning of September: Recovery.

3. Magdalene Sch., zt. nineteen. Admitted on June 23, 1898. Diagnosis : Otitis media, purulent, acute, of R E with mastoidi- tis. June 25, 1898: Chiselling according to Schwartze. In the beginning, the course of the wound was without reaction. July 12,1898: On account of rise of temperature and infiltration of the jugular region, another operation was performed. The sinus (no thrombosis) was exposed and a diseased portion in the apex was removed. July 14, 1898: Erysipelas. She was transferred to the Department of Internal Diseases and thence discharged on August gth for out-of-door treatment. End of September: Re- covery.

4. Magdalene L., zt. forty-seven. Admitted on June 28, 1898. Diagnosis: Otitis media, purulent, subacute, of R E, with acute mastoiditis. July 2, 1898: Chiselling according to Schwartze.

122 F. Alexander.

July 18, 1898: Erysipelas. She was transferred to the Internal Department and thence discharged on August 19, 1898, for out-of. door treatment. Beginning of October: Recovery.

5. Marie B., zt. thirty-one. Admitted November 19, 1898, Diagnosis : Otitis media, purulent, chronic, of L E, with polypi, November 23, 1898: Radical operation. December 5th: Ery. sipelas. She was transferred to the Internal Department of the “* Biirgerspital,” and thence was discharged for out-of-door treat- ment, which is still carried on; however, the wound cavity is now (July, 1899) almost entirely epidermized.

6. Emil O., zt. twenty-nine. Admitted November 24, 1808. Diagnosis: Periauricular abscess after furuncle. November 26th: Opening of the abscess. December roth: Erysipelas, He was transferred to the Internal Department of the Biirger- spital,” and thence discharged for out-of-door treatment. Begin- ning of February: Recovery.

7. Ignaz B., et. thirty-three. Admitted October 31, 13808, Diagnosis : Otitis media, purulent, chronic, L E. November 3d: Radical operation. December 25th: Erysipelas. He was trans- ferred to the Internal Department and on January 17, 1899, trans- ferred back to the Aural Department ; on March 1, 1899, he was discharged as almost entirely cured for treatment by his own physician.

8. Martha St., et. sixteen. Admitted January 17, 1899. Diag- nosis : Otitis media, purulent, chronic, R E. February 17, 1899: Radical operation. February 19,1899: Erysipelas. The patient was isolated at once. March 23, 1899: discharged for treatment by her own physician. She had then a small granulating portion in the wound cavity, which was otherwise entirely epidermized.

9. Emma L., et. thirteen. Admitted January 21, 1899. _Diag- nosis : Otitis media, purulent, chronic, bilateral, caries of the left petrous bone, abscess behind the L E. January 23, 1899 : Radi- cal operation L. After cessation of the incipient rise of tempera- ture on January 31, 1899, suddenly 40.2° C. On the following day, typical erysipelas of the left aural region ; on February 14, 1899, implication of the right side. On March 18, 1899: Dis- charged for out-of-door treatment ; the wound cavity is now al- most entirely epidermized.

It is superfluous to give a detailed description of the course of the erysipelas in each separate case, since it almost

Report of the Strassburg Ear Clinic in 1898. 123

always presented the same or at least a similar picture. The temperatures varied between 38.8° C. and 40.9° C. The diseased portions of the skin were always intensely swollen, highly reddened, their surface shining and mostly painful to the touch; in one case (No. 3), the sensibility upon pressure was increased to an enormous hyperesthesia. The eruption, which started from the operated wound and, in all cases, had also implicated the scalp, was always de- fined by the well-known sharp, often serrated, boundary line from the surrounding parts. In three cases the hair fell out profusely, in two cases almost entirely. In two cases (Nos. 2 and g), even the non-operated side was im- plicated. The urine contained albumen in three cases; albumen, cylinders, epithelia, etc., in two cases. Vesicles (erysipelas miliare) were present in two cases (Nos. 7 and 9); bullze (erysipelas bullosum), in one case (No. 1). This case, which ended fatally, began and ran its course under the se- verest symptoms. The patient was extremely delirious and apathetic from the third day of sickness. Extreme apathy was also at times present in three cases (Nos. 3, 4, and 5). At any rate the intensity of the disease decidedly decreased during the course of the epidemic. For the treatment of the wound during the erysipelatous disease, dressings mois- tened with a two-per-cent. solution of carbolic acid were almost exclusively used. 7

Ever since the Aural Department, from the beginning of this year, has two rooms which are completely isolated from the other sick-rooms and received the cases of Nos. 8 and 9 as soon as the very first signs of erysipelas presented them- selves, until to-day, no erysipelatous disease has appeared.

A CASE OF BEZOLD’S MASTOIDITIS SECONDARY TO FACIAL ERYSIPELAS; OPERATION; RECUR. RENCE OF THE ERYSIPELAS WITHIN TWENTY. FOUR HOURS; CURE.

By JOHN DUNN, M.D., RicHmonp, Va.

On January 13, 1900, I was asked to see Mr. A., aged fifty- nine. Previous history as follows: about December 10, 1899, facial erysipelas developed. It began at the bridge of the nose, spread across his face, involving finally the whole scalp, including the external ears. About the 2oth of December Mr. A. experi- enced severe pain in the left side of his head ; three or four days later his left ear began to discharge, without, however, being fol- lowed by any diminution of the pain in the aural region. This continued with great severity until I saw him on January 13th. At this time the patient’s general appearance did not suggest grave intracranial complications. Appetite excellent. Pulse 90. Temp. 99$°. He was, however, suffering intensely with pain in the region of the left ear, which was discharging copiously a whitish-gray fluid. The left mastoid region was so swollen and cedematous, and so sensitive to pressure that little information as to the condition of the bone beneath could be obtained by palpa- tion. On either side of the sterno-mastoid was a large swelling extending two inches below the mastoid tip. As the patient had just finished a rather hearty dinner when I first saw him, he was not operated upon until the following morning at g o'clock, at which hour his pulse was 84; temp. 984°. The operation revealed the fact that practically the whole of the mastoid process had been destroyed. A small portion of its external surface was present, and attached to the fibrous portion of the sterno-mastoid about the tip were a few spicules of bone. The inner plate was also exten- sively destroyed, laying bare a large area of dura mater, whose surface was much roughened.

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A Case of Bezold's Mastotditts. 125

An incision was made through the skin, including the posterior one fourth of the sterno-mastoid, about two inches below the tip. Through this hole I inserted my middle finger, passing it beneath the sterno-mastoid muscle into the hole left by destruction of the mastoid process. The attic was not examined ; the operation being brought to a close after removal of the remaining roughened pieces of bone about the process, and all the more quickly as there was considerable bulging of the brain membrane into the large hole in the inner-table. I could get no history of symptoms pointing to sinus thrombosis, so left the sinus unexamined. The usual dressings were applied. At eight o’clock the next morning I saw Mr. A., who had passed a fairly comfortable night. At this time his pulse was 90; temp. 984°. At ten o’clock I received a message from the nurse that the temperature had gone up to 102°. [at once went to the hospital and removed the dressings to find that the auricle was immensely cedematous, being nearly half an inch thick and fiery red. Erysipelas had set in. Its blush could be seen to extend about three quarters of an inch over the skin anteriorly to the auricle ; posteriorly it had reached the lip of the wound. The whole of reddened area, including the auricle and the external auditory canal, which was nearly impervious from the swelling, down to the drum membrane, was painted over three times with pure carbolic acid. The whole surface was then left covered for twenty-four hours with gauze saturated in pure alco- hol ; the external auditory canal being filled with alcohol every two hours. Quinine and tincture of iron were administered in- ternally. By four o’clock next morning the temperature was down to 99 °, which point it did not reach again during the course of the convalescence. The discharge from the external canal ceased entirely within forty-eight hours. The dressings of the mastoid wound were changed twice daily for three weeks. The wound, which steadily grew smaller, to-day, March 30, 1900, closed up finally.

The case has been reported because mastoiditis, occurring in the course of erysipelas, is rare, and because of the rapid- ity with which the recurrent attack of erysipelas subsided under the prompt and thorough use of carbolic acid and alcohol.

NASAL EMPYEMA AS AN ETIOLOGICAL FACTOR IN THE ESTABLISHMENT AND CONTINUATION OF POST-NASAL CATARRH AND CATARRHAL IN- FLAMMATION OF THE MIDDLE EAR, WITH AN ESPECIAL CONSIDERATION OF THE ENLARGE- MENT OF THE POSTERIOR END OF THE ‘MID- DLE TURBINATE AS A PREDISPOSING CAUSE.

By CAROLUS M. COBB, M.D., Boston, Mass.

MEMBER OF THE MASSACHUSETTS MEDICAL SOCIETY, MAINE MEDICAL SOCIETY, AMERICAN MEDICAL ASSOCIATION, AND LYNN MEDICAL FRATERNITY.

HE widespread prevalence of catarrhal inflammation

of the middle ear and the relentless course it pursues

when once established, make the study of the disease of fascinating interest. That chronic catarrhal inflammation of the middle ear is caused, or at least unfavorably influenced, by catarrhal diseases of the nose and naso-pharynx is a fact which has been accepted by otologists for many years, and it is the relation, or perhaps identity, of the catarrhal inflammation of the ears to the general, or local catar- rhal condition of the respiratory tract, which we wish to study in this paper. We will not consider in this connection those diseases of the nasal mucous membrane which are closely allied to diseases of the skin, of which the relation between eczema and asthma furnishes an example. This omission is made with a full appreciation of the relation of such diseased conditions of the respiratory mucous mem- brane to the chronic inflammatory process of the membrane lining the middle-ear cavity, but it has seemed preferable at this time to deal with the more common diseased con- ditions which are usually known as catarrhal—z. ¢., accom- panied by a discharge. Nor shall we consider such diseases

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Nasal Empyema. 127

at suberculosis, syphilis, and new growths of the upper respiratory tract only in so far as they are a causative factor in the establishment or continuance of the catarrhal dis- charge. With this brief explanation of the scope of this paper, we will proceed to the consideration of the catarrhal disease condition of the upper respiratory tract and the chronic catarrhal inflammations of the middle ear which are caused by it.

Politzer states what is very probably the general belief among otologists when he says that ‘“‘ The diseases of the naso-pharynx, and of the nasal cavities, are not only fre- quently the forerunners of affections of the middle ear, but