ated mainly between the fibres as elongated masses, but several large oval masses, resembling nodes of adenoid tissue, were present. A similar infiltration by round cells was also observed in the branches of the auditory nerve in the labyrinth and in the ganglion spirale.

The conditions in the right petrous bone were very similar to those just described, differing only in being more extensive, especially in the cochlea. The middle ear was normal. The entire scala tympani, particularly at the base in the first turn, was filled with a fibrillar network of connective tissue (Fig. 2). In the interior of the tissue the spaces between the fibres were so small that they were hardly perceptible, while near the periphery the meshwork was coarser. The fibres making up the meshwork were extremely delicate, only a few of the larger ones conveying small blood vessels. Stellate connective-tissue corpuscles, situated at the crossings of the fibres, were scattered about in the tissue. The interfibrillar spaces were filled with a finely granular coagulated mass, which contained a few nucleated round cells. A similar granular deposit was also present in the upper part of the scala-media. Corti's organ was easily recognizable, though some of its cells had undergone hyaline degeneration. In the last turn of the cochlea the periosteum, instead of being lined with the normal single layer of epithelial cells, was covered by six to ten layers. The cells were irregularly and loosely arranged and were nowhere united. They appeared swollen, shapeless, and some of them very granular. Toward the interior of the scale they had lost their nuclei and were entirely granular. They had, in fact, lost their identity as cells, and only a granular mass, coalescing with the cellular zone, was recognizable. Changes very similar to the ones described had also taken place in the vestibule. Nodular hyaline masses had been deposited on the interior of the membranous semicircular canals. In the ganglion spirale of the first turn of the cochlea there was an extravasation of blood. The auditory nerve showed the same histological alternation as the left nerve, though less extensive.

The pathological changes of the two ears differed practically only in degree. The sound-conducting apparatus on both sides was normal, almost the entire sound-perceiving apparatus being diseased. The changes were easily recognizable and consisted of the formation of a connective-tissue

network with a few stellate cells. The structure in no way resembled granulation tissue, although it was evidently a product of chronic inflammation, hence the diagnosis of this case as "chronic internal periostitis of the labyrinth." Changes very similar to the above had also taken place in the perilymphatic space of the vestibule. In the auditory nerve the marked infiltration by round cells indicated a chronic inflammatory process of that structure. The cells were abundant between the fibres, having grouped themselves about the blood-vessels. Clusters of cells like the larger ones referred to are usually spoken of as lymphomata.

The question whether these various pathological conditions, directly the result of a chronic inflammatory process, were caused by the constitutional disease, can be determined only by comparing them with other syphilitic conditions. It is known that periosteal inflammation affecting any of the bones of the skeleton is a characteristic accompaniment of constitutional syphilis. It is particularly common in the tibia and the ribs. The formation of circumscribed lymphomata is also a very common occurrence, especially in the liver. There can then be little doubt of the specific nature of the lesions of the labyrinths and auditory nerves in our case. Although ossification, which is common in the advanced stages of syphilis, had not taken place, the disturbance of the auditory apparatus can be construed as a tertiary syphilitic process. It is true that periostitis and neuritis could arise independent of syphilis, yet there was in the described case no evidence of extension of the inflammation either from the middle ear or the meninges. Idiopathic inflammation of the labyrinth has never been observed.

According to Habermann' very little reliable work has been done in the microscopic study of the labyrinth of syphilitics. In most of the cases recorded only a macroscopic report was made, and none of them presented features characteristic of syphilis. Moos' reported a case of a syphilitic who had lost his hearing, in which the external and middle ears were normal but the internal ear had undergone extensive changes. The connective tissue between the membranous and osseous vestibule was hyperplastic and infiltrated with small, round, nucleated cells. The membranous

vestibule itself, the periosteum of the lamina spiralis ossea, and the different portions of the lamina spiralis membranacea were also hyperplastic and infiltrated with cells. Moos and Steinbrügge described periosteal inflammatory changes in inherited syphilis, but their case was complicated by the existence of an old suppurative middle-ear inflammation. Politzer speaks of periosteal bone formation in the labyrinth in advanced cases of chronic labyrinth inflammation of syphilitics. The absence of such formation in our case can probably be attributed to the newness of the process.

The subject of syphilitic disease of the labyrinth has also been studied by Gradenigo' and by Steinbrügge,' who reviewed the literature on the subject. Not a case was recorded in which the anatomical changes resembled those of our case in the least which were characterized by connectivetissue formation in the labyrinth and cell infiltration and the formation of lymphomata in the nerves. As all of the neighboring parts, the tympanum, bones, and meninges, were intact. and showed no evidence of syphilitic involvement, the process. had evidently not reached the parts by an extension but they were primarily involved. A clinical point of interest in connection with this case is that the deafness on one side was only partial. It had been diagnosed as "nervous deafness."

Both of my cases were characterized by an involvement solely of the sound-perceiving apparatus. Both accompanied a constitutional affection. Anatomically, a vastly different condition had developed. In the first of the two cases the anatomical changes in the inner ear in no way resembled other tubercular processes, and it is questionable whether they could be considered tubercular. In the second case the changes were characteristic of syphilis, and the affection could almost with certainty be regarded as specific.

1 Handbuch d. path. Anat., p. 122.

* Lehrbuch, 3d edition, p. 550.

* Pathol. Anatomie, in Schwartze's Handbuch.

Luetische Erkrankungen des Gehörorgans, Haug's Vorträge, No. 9. 5 Virchow's Archiv, vol. lxix., p. 313.

• Zeitschrift für Ohrenheilkunde, vol. xiv., p. 200.

"Lehrbuch, 3d edition, p. 546.

Arch. f. Ohrenheilkunde, vol. xxv., pp. 46, 237. "Orth's Handbuch.

THE USUAL METHODS OF TREATMENT AND OPERATION IN THE EAR AND THROAT

A

CLINIC AT ROSTOCK.

BY PROFESSOR O. KOERNER

Translated by Dr. ARNOLD KNAPP.

S the views on the most practical method of treatment and operation in certain fields of otology, rhinology, and laryngology still diverge, communications on this subject from various clinics may serve some purpose.

It is my intention to publish a series of papers on the treatment which we have found best in our clinic, especially in regard to those points which are still undecided. We have endeavored to simplify our methods as much as possible and to employ as few instruments as we can, recollecting that our treatment not only consists in overcoming the local trouble, but as much as possible to improve the general health of the patient.

1. PREVENTION OF INFECTION IN THE TREATMENT OF DISEASES OF THE EAR, NOSE, AND THROAT.

In the treatment of these diseases extreme cleanliness is often neglected under the plea that the processes are necessarily septic and that our aseptic endeavors would be useless and attempts at antisepsis would be futile, on account of the inaccessibility of certain parts of the ear and nose. This does not however relieve us from exercising the greatest cleanliness as we frequently have to treat non-purulent affections.

In order to keep a room clean it is very necessary that

broad daylight have access to all corners. In our clinic we have only one dark room; this is used for the transillumination of the accessory nasal cavities. The custom of treating the ear, nose, and throat in dark rooms has been entirely abandoned by us and we are perfectly satisfied with the examination in broad daylight by the aid of strong electric lights.

The out-door patients department is entirely separate from the hospital rooms. The dispensary has a separate entrance. Work in the dispensary and in the hospital is done at different times of the day. It is evident that major operations should not be done in the dispensary in the presence of patients with purulent affections who bring in dirt and dust from the street.

The operating-room is arranged as in any well equipped surgical clinic.

The preparation of the patient for operation is of some. importance. If we are going to operate on the temporal bone we are never sure how far beyond this bone we need to operate. It may be necessary to follow a purulent process deep in the occipital bone or within the cranial cavity, to expose a gravitation abscess in the neck, or ligate the jugular vein-consequently the cleansing and sterilizing must not be limited to the mastoid process.

It is generally customary to shave the hair only in the immediate neighborhood of the ear. The adjoining hair then frequently becomes loosened during the operation and invades the field of operation. This is especially true with the short hair on the temple of women. If then the operation has to be extended we again have to shave and to clean and the danger of infection is present. It is the general practice that in men all the hair of the head be cut short but this is not carried out in women. In the after-treatment, which sometimes takes months, the hair is then liable to become infected with pus and in the packing of the wound it is often carried into the wound, the healing process is retarded, the wound edges become inflamed, and there is eczema in the surrounding parts, infection with the pyocyaneus or erysipelas. This can all be avoided if we cut the hair short.