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It often happens that these symptoms of inflammatory excitement entirely escape the observation of the patient, but the difficulty of hearing is never absent: indeed, it is sometimes so great, that the ticking of a watch placed on the affected ear cannot be perceived. The meatus becomes filled with morbid cerumen, so tough that, when the case has been long neglected, it concretes into dirty-grey calcareous masses, the removal of which causes considerable pain, and even slight hemorrhage. The cure is easily affected by injections of warm soap and water; and, should any ulcers remain after this treatment, they are to be touched with the Tr. Thebaïca, or the Tr. Myrrhæ.
Our author observes, with great justice, that the erysipelatous inflammation of the meatus, with its product, the accumulation of morbid cerumen, are well calculated to give reputation to empirical remedies against difficulty of hearing, -such as oily and spirituous substances dropped into the ear; though their success in these instances is apt to induce the erroneous belief that they are of general efficacy against deafness, whereas they are of service only when the disease just described is uncomplicated, and even then watery injections are better.
The following is a good example of our author's clear and sensible manner of narrating his cases.
"H. v. G., aged fifty-four, complained to me of having been deaf of his left ear for the last six months: in fact, he could not hear my watch, even when placed upon it. He had never had tinnitus aurium, and the right ear was perfectly healthy. I found a great mass of dark-brown tough cerumen in the left meatus, which was perfectly cleared out, as early as the second day, by injections of lukewarm soap and water. An ulcer, with elevated edges, was now to be seen at the bottom of the meatus, near' the tympanum, of the size of half a large pea; rather large bloodvessels ran from it to the tympanum. The ulcer was touched with the Tr. Thebaïca simpl., and healed in a few days; when the tympanum also recovered its natural brightness and transparency, and the patient could hear at the normal distance." (P. 25.)
When there is a polypus in the meatus, Dr. Kramer observes, that the symptoms are occasionally mistaken for those of a threatening of apoplexy, and uselessly treated by venesection, &c. In cases of polypus, our author has never seen the membrana tympani penetrated, or the cavity of the tympanum destroyed by caries of the bones; for it would seem that the morbid activity is always directed outwards, and is concentrated in the polypi and their secretion.
The prognosis is almost always unfavourable; for, although
the polypi can be removed in several ways, it is impossible to destroy their roots, especially when they are situated on the membrana tympani, so that new ones are certain to spring up. Moreover, when the membrana tympani itself is the seat of the polypi, it suffers alterations in its structure which unfit it for its office as an acoustic instrument. It is better to remove the polypus with the forceps than by the ligature or the knife; but, should no one of these methods be practicable, recourse must be had to caustic.
In the third subdivision, the inflammation extends to the cellular substance beneath the membrane lining the meatus; there is a purulent discharge, and the meatus, particularly in its deeper parts, is reddened, and, its membrane being swollen, the calibre is necessarily contracted. The process of inflammation and destruction sometimes extends to the membrana tympani, the ossicula auditûs, the substance of the os petrosum, and even to the membranes of the brain and the brain itself. The diagnosis is rendered easy by the speculum auris, but the treatment is generally long, and the result is dubious. The treatment should be constitutional as well as local, says Dr. Kramer: he differs in this point, as he observes, from most practitioners; for example, from Saunders and Curtis, who advise, as in discharge from the ears, to begin and end our treatment with astringent remedies, almost without exception. When the inflammation is considerable, a number of leeches are to be applied round the ear, and repeated, if necessary; but, in such cases, fomentations and vapour-baths are almost always injurious. A very strong tartar-emetic ointment, made with one drachm of the salt to three drachms of fat, should also be rubbed on the mastoid process of the affected side, and the suppuration which arises from it must be kept up for a long time. During the first few days of the suppuration, the discharge from the meatus becomes more copious, but then decreases from week to week, and becomes less sharp, while the inflammatory state of the auditory passage subsides, together with its accompanying symptoms. It is only in the most desperate cases that we are to pass a seton through the back of the neck, cut off the hair, and apply dry friction to the head, as Itard recommends. When the inflammation has been considerably moderated by these means, but the contraction of the meatus still continues, (as it commonly does,) it is time to act directly on the meatus itself. This is done by introducing strips of sponge, the size of which is gradually increased as the passage becomes more and more dilated. The introduction of the sponge must be accomplished with a
light hand, otherwise unbearable headach will be the result. When all the advantage has been derived from dilatation that it is capable of affording, but the discharge still continues, then comes the time for the application of astringent remedies, such as the acetate of lead, alum, and the sulphate of zinc: our author prefers the last.
In the second division of his work, Dr. Kramer treats of only three diseases, namely, 1st. Catarrh of the Eustachian tube, and the cavity of the tympanum; 2dly. Contraction of the Eustachian tube; and, 3dly. Adhesion of the sides of the Eustachian tube. The diagnosis of the first of these diseases is generally certain. The catheter is introduced into the Eustachian tube, in the manner already described, and, on blowing through it, the air either does not penetrate the masses of mucus at all, or does so with great difficulty, and with a rattling noise. If this is not sufficient, watery injections may be used; and, if they again do not suffice, a piece of catgut may be passed through till it touches the membrana tympani, thus distinguishing a mucous obstruction from a perfect closure of the tube.
The prognosis is generally favourable. The treatment must be in the first place local, and in the next a general one, intended to amend the mucous and spongy constitution of the patient. In recent cases the first alone is sufficient; and even in old catarrhs the cure is chiefly dependent upon it. The first indication is fulfilled by injections, which have been thrown in by three different methods; namely, through the tympanum, the mastoid process, or the Eustachian tube: but the first two methods are not without difficulties, nay, more, without danger for the integrity of the organ of hearing.
Whether the tympanum has been surgically punctured or been penetrated by suppuration, from its retired position it is impossible to put the point of the syringe exactly on the opening in the membrane. But, if the injection is thrown merely into the external meatus, and that with great force, as Itard recommends, either the opening in the membrane must be considerable if the injection is to have any effect, or the stream of water is much more likely to destroy the membrane entirely, than to force the accumulated mucus through the Eustachian tube into the fauces.
If, in consequence of destruction by caries, there is an opening in the mastoid process, through which injections can be thrown into the cavity of the tympanum, we shall not derive any benefit from this circumstance; for the force of the stream of fluid is so much broken by the cellular septa in
the mastoid process, that the intended effect upon the mucus in the cavity of the tympanum will be nullified. As to perforating the mastoid process, in order to inject the fluid, this is not only useless, for the reason just stated, but also dangerous, as Arnemann has ably demonstrated, in an express treatise, entitled "Remarks on the Perforation of the Mastoid Process, &c." (Bemerkungen über die Durchbohrung des Processus Mastoideus in gewissen Fällen der Taubheit. Gott. 1792.)
We must necessarily omit the rest of Dr. Kramer's very interesting remarks on this particular disease, and content ourselves with giving one of his cases.
"B. E., aged thirty-four, a man of a weakly constitution, slept, during the severe winter of 1829-30, in a cold damp room, where, in the evening, he often found his bed frozen quite hard. From these circumstances, he lost his hearing to such a degree, that he was obliged to give up his situation as servant. In the beginning of May he could no longer hear my watch when placed on his left ear, but he could when it touched the right one. Moreover, he was affected with so violent a tinnitus aurium, that he never had a sound night's rest. Both auditory passages were clear, but the membrana tympani on both sides was dim and opaque. Both Eustachian tubes were obstructed; but an injection (of lukewarm salt and water) made its way through the right one to the tympanum at the very first sitting, and washed out small clots of coagulated blood; after which the patient could hear my watch with his right ear at the distance of two feet. The injection did not penetrate the left Eustachian tube till the third sitting. After the fourth, the tinnitus aurium was entirely gone, and the patient could force the air as far as the tympanum on both sides, and hear the watch at a healthy distance. Two days after this fortunate result had been attained, he suddenly lost his hearing in the right ear, and this occurrence was accompanied by violent pain and a loud tinnitus in it; but these symptoms spontaneously disappeared in a few hours, and his hearing has ever since been perfect." (P. 70.)
When the Eustachian tube is contracted, the cure is to be attempted by dilating it with catgut bougies, the size of which is to be gradually increased; but Dr. Kramer's endeavours have always been fruitless when the stricture has been in that part of the tube which runs in the bony canal. In such cases the perforation of the tympanum is indicated, in order to give access to the atmosphere, and, by thus putting the tympanum on the stretch, to render it capable of transmitting the vibrations of sound to the ossicula auditûs. In spite of the theory, Dr. Kramer has never seen the operation beneficial. The indications for this operation are of rare
occurrence, for it is highly improper to perform it merely as a last resource against obstinate deafness.
The diagnosis of adhesion of the sides of the Eustachian tube is exceedingly difficult; as it depends on the operator being unable to find the entrance of the tube it therefore depends on his consummate dexterity, for an ordinary person may easily fail in finding the aperture. The prognosis is of course unfavourable in the highest degree.
In the last division of his work, the affections of the inner ear, our author treats but of two diseases, irritative and torpid nervous deafness. The latter is to be distinguished from the former by the absence of tinnitus aurium. Although constitutional remedies are not to be neglected, and the health of the patient is of course to be brought into the best possible state; still, says our author, the nervous deafness itself can be cured only by local applications. Now, it is useless to drop remedies into the external passage, as the membrana tympani cuts off the communication with the cavity of the tympanum and the auditory nerve: they must, therefore, be introduced into the Eustachian tube. Gaseous injections alone can be borne; and our author, after experiments with a variety of substances, has found the diluted vapour of acetic ether best adapted to this purpose. He gives several cases in which this method was tried with great advantage; and we must confess it seems rational, as well as ingenious.
Such are the principal points in Dr. Kramer's work; yet we have reluctantly omitted details of considerable importance. In truth, this excellent little treatise is not capable of much abridgment; for to the characteristic merits of German books, depth and fidelity, it adds one which is rarely to be found in them-the most classical brevity.
On the Reflex Function of the Medulla Oblongata and Medulla Spinalis. By MARSHALL HALL, M.D., F. R.S. L. & E., &c. [From the Philosophical Transactions.]-London, 1833. 4to. pp. 31.
In this paper Dr. Hall announces a discovery, which he thinks he has made, of a power resident in the medulla oblongata and spinal cord, not hitherto recognised by physiologists, and to whose action he applies the name of the reflex function.
As we shall have occasion to show, in the sequel of this article, that Dr. Hall has greatly misconstrued the opinions of other physiologists, we must be careful not to fall into the same sin ourselves; we shall therefore, at the risk of being