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CASE 39.-Chronic purulent otitis with retention.

K. G., eighteen years old, left otorrhoea since childhood; pain in the ear for several weeks with headache, restlessness and sleeplessness.

Stat. pres. April 1, 1902. Osseous canal completely filled with a large polypus. After its removal abundant pus wells out from above. The improved drainage is followed by noticeable subjective improvement. H.

=

Radical operation, April 24, 1902.

Mastoid sclerosed. Caries and abundant granulations in antrum and attic. No trace of ossicles. Panse plastic, primary suture. Healed June 20, 1902. Last seen January 28, 1903. Ear dry, H = 18.

CASE 40.-Chronic purulent otitis media with caries and symptoms of retention.

H. F., twenty-two years old. Left otorrhoea as long as patient can remember. Has been suffering from headaches on left side, nausea, dizziness, and fainting spells for over a year.

Mt shows large perforation occupying the posterior half. Marked sagging of the postero-superior wall. Foul discharge. H = .

Radical operation, July 15, 1902. Sclerosis of mastoid bone. Antrum full of granulations. Caries of ossicles. Very deep posterior tympanic recess is opened up as much as possible and curetted. Usual plastic, primary suture.

Subsequent healing rapid and uneventful. October 15, 1902.

Completely healed

Last seen January 15, 1903. Patient is in good health and has no more headaches or fainting spells. Hearing improved to 18.

A STUDY OF THE PATHOLOGY OF THE INTERNAL EAR AND THE AUDITORY

NERVE.

BY DR. PAUL MANASSE, STRASBURG, GERMANY.

Translated by Dr. ADOLPH O. Pfingst, Louisville, Kentucky.

(With appended Plate I. from Zeitschrift f. Ohrenheilkunde, Vol. XXXIX., No. 1. Fig. 1. Longitudinal Section of the Auditory Nerve in Case 1.

A

Fig. 2. Section through Cochlear Turn in Case 2.)

NATOMICAL investigations of diseased labyrinths have heretofore been reported in a very limited number, and in most instances only macroscopic relations have been described. This is due in part to the complicated method required to prepare the parts for microscopic section. In the last few years I have had opportunity to examine quite a number of diseased labyrinths and auditory nerves, most of them, however, only from an anatomical standpoint. It was possible in but few of the cases to make the accurate clinical investigations necessary to study disease of the inner ear. But even with vague clinical data the cases offer many points of interest. The two cases selected for this report have, anatomically, little in common. I have been influenced to report them together because in both the ear affection occurred during grave constitutional disturbances, tuberculosis in one and syphilis in the other, because in both cases the ear involvement was bilateral, and because in both the sound-perceiving apparatus only was involved, the conducting apparatus remaining intact. CASE 1.-Multiple disseminated gray degeneration of the auditory nerves.

Both petrous bones of a man forty-three years old, who had succumbed to pulmonary tuberculosis, and who during his illness had suddenly lost his hearing, were submitted to me for examination. They were accompanied by the history that examination of

the auditory apparatus during life failed to reveal pathological lesions. After fixing the specimens in Mueller's fluid and exposing the inner ear, no lesions could be detected. Microscopic sections of the drum-membranes, tympanic walls, and labyrinths disclosed no pathological conditions. Corti's organ and the nerve terminations in the labyrinth and cochlea of both specimens were also normal. However, upon examination of the trunks of the auditory nerves, even with the ordinary double stain of hematoxylin and eosin, a large number of minute pale areas were noticeable between the fibres of the nerve trunks. Most of them were elongated, while some were round and others stellate. The largest of these could be detected with the aid of a simple convex lens. Microscopically, two kinds of tissue were noticeable making up these bodies: a fibrous structure constituting the greatest portion of them, and small spheroidal lamellated bodies, easily recognizable as corpora amylacea. The fibrillar stroma was, with high magnification, seen to consist of fibres of various thickness, arranged in an exceedingly delicate network. The tissue was devoid of cells. These peculiar areas were all situated inside the nerve fibres, although a direct connection of their stroma with the neurilemma could not be traced. Subjected to the Van Gieson stain the fibres took on the garnet red characteristic of fibrous connective tissue. With Weigert's method they took on a bright yellow color, in sharp contrast to the surrounding nerve structure, which had stained the characteristic bluish black (see Fig. 1). Thus the absence of nerve tissue in these disseminated areas was conclusively proven. Although this new tissue was plentiful, it nowhere extended the entire breadth of the nerve trunks. Normal nerve fibres could always be seen between areas of this structure.

The features of interest in this case are the sudden deafness coming on during pulmonary tuberculosis and the peculiar pathological changes in the trunks of both auditory nerves with normal conditions of the nerve terminations and the entire internal ear. It was difficult to determine with positiveness the nature of the pathological lesions. They contained no cells or areas of degeneration to indicate a tubercular process. The absence of nerve structure in their make-up was recognizable and was corroborated by Weigert's stain. The only condition to which they bore resemblance

is that found in the areas of gray degeneration seen in tabes, multiple sclerosis, and other similar affections. This led me to consider these as multiple areas of gray degeneration. The degeneration was so extensive in both auditory nerves that the deafness could well be accounted for by an interruption of the conducting elements.

Steinbrügge has pointed out the difficulty of applying Weigert's method to parts in which decalcifying fluids have to be employed. Why my specimens reacted so successfully to the stain, notwithstanding the use of ten-per-cent. nitric acid for decalcifying, I am unable to explain. The objectionable action of the acids used in decalcifying may account in part for the fact that multiple gray degeneration of the auditory nerve has hitherto been overlooked.

Although in searching the literature I have been able to find a number of cases in which pathological changes of the auditory nerves have been observed, I was unable to find one in which the changes were like those just reported. They resembled those of my case most in cases of ordinary atrophy in which degenerative changes were also present. Such cases have been reported by Politzer,' Habermann,' and others. It is of interest to note that in these cases the changes in the nerve were not primary, as in my case, but were secondary to traumatism, pressure from tumors or aneurysms of the basilar artery, encephalitis, or tabes dorsalis. They were always associated with loss of structure. Politzer, in the description of his case, compared the atrophic area to a delicate strand of connective tissue, while Habermann spoke of an entire absence of nerve structure. In my case the nerve was entire, but was marked by numerous areas in which the nerve structure was replaced by a finely fibrillar connective tissue, on the interior of which small corpora amylacea were noticeable. This tissue had no similarity with the inflammatory connective tissue seen in neuritis accompanying suppuration of the middle ear. The case of Politzer resembles mine in that the pathological changes were limited to the nerve trunk, whereas the atrophy in most of the cases recorded was noticed mostly at the termination of the nerve in the cochlea.

CASE 2.-Disease of the labyrinths and the auditory nerves in a syphilitic subject.

A man thirty-five years old, with history of a syphilitic infection, and who had been under treatment for "nervous deafness " for about a year, died suddenly upon the street. At the autopsy all of the exposed intracranial arteries were found studded with numerous small (2-5 mm), white elevations. The basilar artery presented an aneurysm about as large as a pea, which had ruptured on one side. The entire base of the brain was covered with clotted blood. Gummata were found in both epididymi, and evidences of inflammation in the testicles. The entire auditory apparatus to the naked eye appeared normal. Microscopic examination of the left petrous bone revealed no pathological changes in the tympanum or drum membrane, while in the internal ear rather extensive pathological changes had taken place. Finely granular deposits were noticeable, covering the epithelium of the roof of the scala vestibuli and the under surface of the lamina spiralis ossea, and basilar membrane in the scala tympani. The deposits contained no cells. They readily took the eosin stain. The most marked and peculiar changes had taken place in the scala tympani, close to the modiolus. Bands of new tissue could be seen extending from the periosteum into the lumen of the scala. The new formation was made up of fibres arranged in a coarse network containing stellate connective tissue corpuscles at their intersections. Where these deposits were most extensive, about one tenth of the lumen of the scala was encroached upon. The cells of Corti's organ were swollen, some containing beads of hyaline material. The vestibule and semicircular canals contained numerous small hyaline, highly reflective bodies in the space occupied by the perilymph. Some of these were spheroidal, others elongated, and some flattened. A few connective-tissue strands similar to those found in the cochlea were also found in the space between the osseous and membranous semicircular canals. Evidence of pathological disturbance was also found. in the auditory nerve. Where the nerve entered the labyrinth the fibres were separated by an interposition of round cells and blood corpuscles. At the porus acusticus internus the nerve was so distended that it completely filled the canal. It had been so invaded by cells that the fibres on section appeared very much scattered. More centrally the nerve trunk contained no blood cells but numerous small areas of round cells. They were situ

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