XIII. THE ANATOMY AND PHYSIOLOGY OF THE ORGAN OF HEARING; WITH REMARKS ON CONGENITAL DEAFNESS, THE DISEASES OF THE EAR, SOME IMPERFECTIONS of the Organ of Speech, AND THE PROPER TREATMENT OF THESE SEVERAL AFFECTIONS. By David Tod, Member of the Royal College of Surgeons. Octavo, pp. 147. London, 1832. Ir has long been a matter of complaint that our knowledge of the diseases of the ear is limited and imperfect. The cause is to be found in the intricate arrangement of the organ itself, and the difficulty of procuring accurate and satisfactory examinations of its condition after death. The cultivation of morbid anatomy which has done so much towards advancing our knowledge of the diseases of other parts, has contributed but little to the increase of our information or the improvement of our treatment in acoustic surgery. Mr. Tod, the author of the little work before us, appears to have engaged with much zeal in the investigation of the healthy structure and physiology of the organ of hearing. As such researches do not come within the scope of a medical review, we must content ourselves with recommending such of our readers as take an interest in anatomical questions to peruse the work itself. We can merely notice some remarks on the diseases of the ear. Mr. Tod gives some cases of fungus of the meatus which were cured, as they generally are, by removal of the fungus and the subsequent application of the lunar caustic. We have seen many instances of this description, and, so far as we recollect, all yielded to the application of the lunar caustic, with occasional touches of the kali purum. Mr. Tod observes that he has often witnessed erysipelatous inflammation of the auricle and appendix, and has found it a difficult disease to treat, as well as a common one. His plan appears to consist in attention to the bowels and digestive organs, and an open blister to the nape of the neck. He has frequently found it necessary to continue all the remedies, especially the blister, for twelve and eighteen months after every symptom had apparently ceased. We suspect that many patients would rebel against such discipline. The following is deserving of extraction. "Mr. B., ætat. 30, of a delicate constitution, consulted me on account of being troubled with various kinds of noises in his ears. These he told me were always more severe during the night when in bed, than during the day, and never ceased for more than five minutes at a time. He informed me further, that when the noises ceased, they did so suddenly, and returned in like manner; that when he swallowed his saliva or yawned, he either stopped the noise in one or both ears for a few minutes, or changed its character; and that the sounds were often so loud, that he could not hear when a cart or carriage was driving past him. On examining the Meatus of each Ear, there did not appear the least secretion of wax,—but nothing else of a disordered nature could be discovered. Considering the phenomena which he complained of to be owing to this want of cerumen, and to some faulty function of the secreting vessels of the Labyrinth and Tympanum, producing a sympathetic constriction of the Eustachian Tubes, I directed him to take five grains of blue pill, combined with a quarter of a grain of opium, three times a day, until his gums became affected; to keep the Meatus of each Ear continually plugged with lint moistened in linimentum camphora cum liq. volat. c. c., and to apply a perpetual blister to the nape of the neck, In the course of a week he appeared a little, but not to any great extent, better. He complained of the pills producing great pain in his bowels, and of his mouth being a little sore. I ordered the pills to be discontinued; and as his mouth did not appear to be much affected, directed him, instead, to rub in two drachms of the unguent. hydr. fort. every night. I also punctured the drum of each Ear, and recommended the other remedies to be continued. In the course of another week his mouth became affected, but the noises in the Ears still annoyed him much, although greatly diminished.-I discontinued the ointment, and prescribed a little aperient medicine, combined with infus. rosa, and sulph. quininæ, three times a day. In the course of ten days his mouth got nearly well, bis general health became much improved, and the noises in the Ears had almost entirely ceased. Ordered him to continue the quinine, to omit the aperient, and to take five grains of blue pill every night for a week, then every other night for a month. At the expiration of this period his general health seemed to have undergone a complete revolution, and his hearing became quite restored." 122. In another similar case, a similar plan of treatment ultimately failed. We have only room for one more passage; it exhibits Mr. Tod's mode of introducing a bougie into the Eustachian Tube. "After selecting a bougie of the calibre and shape of the tube, and oiling its extremity, I ascertain by external measurement the distance from the orifice of the nose to the Cavitas Tympani, and then mark the instrument so as to know when I have succeeded in reaching the posterior extremity of the canal: I then bend the point a little, and pass it along the floor of the nose, with the point touching its outer and under surface, to the part at which the membrane of the nose is about to ascend to form the external wall of the cavity, until I have reached the fauces: I then gradually raise the point of the bougie, so as to touch the lateral surface of the faucial cavity as I push it backwards, turning it in its course first a little to one side and then to the other; and when I find that it becomes loosely fixed, and does not descend towards the pharynx, I conclude that it has entered the Eustachian Tube: I then continue pressing the bougie gently onwards until I perceive the mark which I had made has reached the orifice of the nose; and after allowing it to remain a few minutes, withdraw it in as gentle a manner as it was introduced. When, however, I find that the point of the instrument does not get into the faucial extremity of the Tube, I make it a rule to lay it aside for two or three weeks, and to employ a silver probe instead. But sometimes the passing of the latter instrument will be attended with as much difficulty as the former; and when this is the case, the same rule should be observed regarding its repetition: for the principles upon which these instruments should be employed are the same as those which ought to guide us in the treatment of susceptible surfaces generally. After subduing the action which has been excited in the diseased part by the means recommended, the instruments should again, but not till then, be employed. The first application of the bougie will in general be accompanied with some pain; but as this sensation does not arise from the presence of any additional morbid cause, it will in a short time subside, and the patient will feel considerable relief. We must not, however, repeat the stimulus too frequently, for by passing these instruments too often, as much harm as good may be done. In treating obstructions of the Eustachian Tubes, we should be guided by the same principles which serve us in the cure of other diseases. When we repeat a stimulus too frequently, we bring on considerable irritation,—and we ought to recollect that irritation was the original cause of the disease. No instrument should be introduced for some weeks after the patient has applied for relief; for this will always be attempted too soon, unless we have succeeded in soothing the irritation by exciting secretion: even after we have begun the use of instruments, once or twice a week should be the extent of our visitations. By introducing the instruments oftener, we have,' to use the words of the late Mr. Abernethy, not only to counteract the irritation which previously existed, but the irritation which we have ourselves produced.' And it is from a want of attention to this circumstance, that the operation which we have been discussing has so repeatedly proved unsuccessful." 131. We repeat that this little work evinces zeal, industry, and perseverance on the part of Mr. Tod. Periscope ; OR, CIRCUMSPECTIVE REVIEW. "Ore trahit quodcunque potest, atque addit acervo." Various Selections from the French Journals. I. REMARKS ON THE FETID ABSCESSES, WHICH FREQUENTLY FORM IN THE NEIGHBOURHOOD OF MUCOUS MEM BRANES. MANY of the laws, which were supposed formerly to regulate and to be peculiar to the actions of living bodies, have been of late years disputed; and physiology has called in the aid of physical science to explain a number of pathological phenomena. The course of the fluid in the different tissues has been found, in many respects, to obey the ordinary rules of chemical and mechanical agency, as it will be illustrated by the transmission both of liquids and of gases, through the medium of imbibition, from one structure to another, without the intervention of the circulatory or absorbent systems. The formation of many abscesses is intimately connected, according to M. Velpeau, with such a process. His attention was first excited, by observing that many collections of matter, situated in the cellular or muscular structures, and apparently the result of active phlegmonous inflammation, are filled with an offensive and fetid pus, although there is no communication between them and any carious bones, or internal viscera. Such abscesses are observed around the mouth, at the sides or in front of the larynx or trachea, at the margin of the anus, and still more often in the abdominal parietes; in short, along the track of all organs which are covered with a mucous coat, and whose walls are more or less soft and more or less extensible. Every surgeon must have remarked the stench of many col No. XXXIV. lections of matter formed in the gums, or round the mouth and anus. A few examples, however, will confirm the truth of this statement. Case 1. A man had a large diffused swelling on the side of the face; it pointed between the cheek and arch of the upper jaw, and had existed only for six days. On opening it with a lancet, about half a wine-glassful of blackish-yellow pus, excessively putrid, escaped. One of the teeth was slightly carious; the abscess was quite healed in the course of five days. Case 2. A woman, aged 50, had an immense abscess, which occupied all the side of the left cheek and jaw; it broke, and so abominable was the stench of the matter, that few could approach her. The matter continued to flow, and shreds of dead, cellular substance were extracted; in a month she was well. In this case there was no caries of the teeth, nor any disease of the maxillæ, and although there was no communication with the cavity of the mouth, the fetid smell was perceived immediately after it burst, and became less and less offensive when the abscess was thereby exposed to the external air. Case 3. A man, aged 30, had a fluctuating swelling in front, and extending a little to the left side of the larynx. On opening it, the surgeon's attention was struck by the extreme fetor of the contents, and inferred that the os hyoides or laryngeal cartilages were diseased; or else that some communication existed between the abscess and Fr the gastro-pulmonary passages. A careful examination, however, proved quite convincingly that it was a simple, uncomplicated collection of matter, reaching from the parotid gland to the middle of the neck, and was neither connected with any caries or ulceration of the hard parts, nor had any opening into the larynx or oesophagus. The patient died of another disease, and the accuracy of the above account was confirmed by dissection. Case 4. A man, aged 35 years, had suffered much from pain, &c. around the anus for 10 days before he applied for advice. An abscess existed close to the sphincter: it was freely opened, and much blackish, stinking pus, mixed with lumps of putrefied substance, and smelling strongly of fæces, was evacuated. The probe did not enter the gut, and the surgeon concluded that the abscess, in spite of its fetid contents, was simply phlegmonous, and might heal without any operation. The patient was discharged, cured, in 15 days. Case 5. A woman, aged 57, thin, but healthy, was suddenly seized with severe colic in the middle of December, 1831. Two days after, a swelling appeared in the lower and right side of the abdomen; it was painful on pressure, gradually became more circumscribed, and soon attained the size of two fists. It burst in January, and discharged a large quantity of blackishgrey, grumous pus, smelling very strongly of the intestinal contents; some gas also escaped, and a few pellets of dead cellular substance. A careful examination with the probe could detect no communication with the cavity of the peritoneum, or any part of the gut; and the speedy cure made it certain that the matter had been formed in the muscular parietes. Le Dran has recorded the following case. Case 6. A man, aged 24, was, by his own account, seized with syınptoms of enteritis. A tumor appeared in the right groin, and extended to the umbilicus; it was opened by a bistoury, and discharged much fetid pus. Le Dran thought that this abscess had its seat between the omentum and the muscular parietes; but the successful result sufficiently proves that it was not connected with the abdominal cavity. Case 7. A young woman had a phlegmonous swelling in the hypogastric region. On puncturing it, a milky fluid and an offensive pus were evacuated. The patient died, and the abscess was an enormous sac, situated between the peritoneum and the muscles. -Abscesses in the soft, spongy texObservations on the preceding Cases. tures of the gums are very common; the foetor of the pus has usually been attributed to the co-existence of disease but this explanation is not satisfactory of the teeth, or of the maxillary bones; not exist. M. Velpeau rather ascribes in all cases, for such disease often does it to air having entered by imbibition, and the matter becoming thereby vitiated from the resulting chemical changes; for in what other manner should abscesses, whose symptoms, progress, and maturation, differ in no respect from ordinary phlegmonous inflammations, be filled with a highly offensive pus, before the possible introduction of air from without or within through any opening, and which are not accompanied with any diseased bones. It is very interesting to remark that these abscesses are observed in such regions as are lying close to mucous canals, and separated from these only by very thin walls. In the neck we find them between the fascia cervicalis and the thyro-hyoid membrane, or the pharynx, the œsophagus, or the trachea; under the jaw, between the supra-hyoid aponeurosis, and the inferior wall of the cavity of the mouth; in the face, imbedded deep in the flesh of the cheeks so that the air very probably permeates the texture of the mucous linings, and thus blends with the contents of the sac. The phenomena alluded to are still better observed, when abscesses form round the margin of the anus. Many surgeons deem the stercoraceous smell, emitted from such abscesses, as unequivocally denoting the existence of genuine fistulæ in ano. M. Velpeau assures us that this idea is frequently quite erroneous, and reports a case in confirmation. A man had a very extensive abscess, situated close to the sphincter, and, when opened, every one supposed, from the stench of the discharge, that it must have communicated with the gut. The suppuration, however, speedily dried up, and the sore was cicatrized in a few days. Many analogous cases are narrated. M. Velpeau has, after a careful examination of these, come to the conclusion that a large proportion of true fistulæ ani are originally mere abscesses on the outside of the gut, and that the fistulous aperture into the bowel is a subsequent occurrence. Fortunately, purulent matter has always a tendency to the exterior of the body; else the thin walls of the gut would, in every case, be inevitably diseased. When a fetid abscess forms in the abdominal parietes, M. Velpeau thinks that they are developed originally in, or at least take their start from, the fascia propria, or cellular tissue which unites the peritoneum to the abdominal muscles. The purulent matter being thus deeply lodged, is supposed to receive, by transudation from the bowels, an admixture of gas or of liquids, or perhaps only of odorous effluvia. What induces M. Velpeau to believe that such a transudation does really take place, is, that he has observed that the smell of the pus varies with the situation in the abdominal parietes where the ab scess is formed. Thus, in one case where an abscess existed in the right groin, a strong and distinct stercora ceous odour was emitted from the pus; whereas in another, where the abscess was situated in the epigastric region, the smell was sourish, and not unlike that of imperfectly digested food. Besides, the colour of the discharge is found to vary much in different instances, and may be often observed to be somewhat indicative of the substances which may be contained in the bowel, lying next to the posterior wall of the abscess. The fetid abscesses of the abdominal parietes are of tedious formation, and are preceded by dull, deep-seated pain, by a tumefaction more diffuse than circumscribed, and by symptoms of general feverish irritation. When the skin becomes prominent, still the fluctuation is often very indistinct; because, in consequence of the thickness and toughness of the integuments, the matter burrows deep, separating the peritoneum from the muscular layers. Sometimes, though very rarely, the contents are discharged into the cavity of the abdomen. Le Dran reports such a case. The rarity of the occurrence is to be attributed to the tendency of suppuration towards the surface, and also to the uniform and equable pressure made by the contained viscera upon the posterior wall of the cyst. The agency of this second cause has hitherto been overlooked; but probably it is the more efficacious of the two. In all abscesses, formed in the abdominal parietes, it is necessary to make a free and large incision. M. Velpeau says that the more extensive the opening, the less danger there is from any re-action of the atmosphere, either on the walls of the cavity or on its contents; and also from the occurrence of the fever of "absorp tion," and of those symptoms of pros tration which are not unfrequent in such cases. As to the dressing of the sore, it is to be conducted in the usual manner.*-Journal Univers. et Hebdom. II. CASE OF APHONIA, TREATED BY NITRAS A YOUNG woman had gradually lost * We are not to be understood as implicitly agreeing with M. Velpeau in these views.-Ed. |