VOL. XXIII.

Addresses and Original Com

munications.

OERUMEN.*

BY FLETCHER HODGES, M. D., INDIANAPOLIS.

This subject will be considered with regard to its interest to the general practitioner, for among his grateful patients are those seeking relief from deafness caused by masses of ear wax. It is surprising to the average patient, considering himself incurably deaf, to be informed of the cause after examination, and after brief manipulation with syringe or other instrument to be relieved of disagreeable symptoms. The assurance of immediate improvement in hearing, the actual inspection of the plug, and the chagrin at being found so apparently lax in personal cleanliness are factors in making this class of patients satisfied with their treatment.

Anatomy being the mathematics of our science, it will be necessary to mention a few land marks and points of histological interest. The average length of the external auditory canal is about 1 inches, one-third () being cartilaginous, twothirds (4) bony. It is longer on the anterior and inferior wall than the roof because of the oblique position of the Membrana Tympani (e. g. an angle of 45 degrees). Hyrtl's and Sappey's wax moulds and Bezold's casts demonstrate the canal to be a spiral, turning anteriorly inward. and downward. To overcome the curvature the auricle may be pulled upward and backward. The passage is elliptical The passage is elliptical on section, the long diameter being vertical in the cartilaginous part, and horizontal in the bony portion. The narrowest part (e. g. the isthmus) is about midway in the meatus, and is chiefly caused by the

*Read before the Indianapolis Medical Society, November 29, 1904.

No. 7.

elevation of the floor. Foreign bodies are apt to lodge beyond the isthmus and therefore may be difficult of removal.

The epidermic layer of the canal is extremely thin, and is continuous with the outer tunic of the membrana tympani. The lining skin is thick externally, and contains sebaceous and ceruminous glands, being also covered with short hairs. Cerumen (Latin cera, wax, aurium, ear) is an oily substance, light colored and soft in early life, dark and firm in old age (but varying in appearance with the type of complexion), and of bitter taste. It consists of fatty matters mingled with sebaceous materials, epidermic scales, cholesterin crystals, and traces of potash and soda.

Acording to Petrequin's analysis in 100 parts of cerumen there was found to be of Water .10 parts. .26 parts.

Fat

.....38 parts.

Soapy combinations of potash soluble in alcohol... A similar combination insoluble in alcohol..... Entirely insoluble organic matters with traces of chalk and soda ...

Total

14 parts.

.12 parts.

..100 parts.

Relations: In front and below are the parotid glands, externally; the temporo maxillary articulation lies internally. Posteriorly the mastoid cells are separated from the canal by a thin lamina of bone. The posterior wall of the osseous meatus is perforated by canals for the passage of small veins, which run directly backwards into the mastoid cells. The upper wall of the canal is in close relation with the dura mater and middle fossa of the skull. Arteries: (a) The posterior auricular artery supplies the auricle; (b) the deep auricular (from the internal maxillary) gives off branches to the canal.

Nerves: (c) The third (3d) branch of the tri-facial (e. g. 5th) enters the canal between its two portions through its anterior wall; (d) the auricular branch from the pneumo-gastric enters the anterior wall of the bony canal. Stimulation of this by a probe or speculum gives the characteristic "ear cough."

The ceruminous glands are estimated by one authority as from 1000 to 2000 to each canal. They begin within the canal orifice, and extend almost to the circumference of the membrana tympani. At the junction of cartilage and bone are found the greatest number of these glands. They resemble sweat glands in development and secretion, the difference being that ceruminous glands contain coloring matter. Frequently I have noticed that the cerumen of the negro is almost black, while that of a decided blonde is of a light yellow color. Long hairs if abundant may obscure the view of the canal, cause noises of escaping steam if they touch the membrana tympani, and entangle cerumen in their meshes.

Certain birds have the power to close these canals by a valva-like action. The turkey has erectile tissue here, and closes the canal passage when angry by filling the vascular structure with blood. At certain seasons of the year the quail is very fat, and the lining integument of the canal accommodates itself to his condition, and so the channel is kept open.

The length and curvature of the canal prevents it and the membrana tympani from damage by wind and changes of temperature, and cerumen guards against frequent entrance of insects. I believe that its action is mechanical (keeping the parts in a moist condition), and prophylactic (guarding against injury from foreign bodies, animate or inanimate), and not to increase the power of tones, or act as a resonator.

Two conditions will now be considered, e. g. (a) deficiency, (b) excess of ear wax.

(a) Deficiency is not a very frequent condition in my own experience. I have seen it in old people with dry skins, who perspired very little, and whose canals are wide and flabby, and whose cerumen was found in flakes and scales. This is called "the dry ear" by the laity, and associated by them with deafness. It is not infre

quently found by the physician to coexist with deafness or aural disease-e. g. middle ear catarrh or even labyrinthitis. One authority suggests that the dry condition might be a manifestation of trophic disturbance. It has been observed that when the primary disturbance of labyrinth or middle ear improves, the proper function of the ceruminous secretion returns. An eczema should receive attention.

Treatment: A simple ointment, may be used such as vaseline or lanolin. I do not use glycerine.

STATISTICS OF CERUMEN.

Right. Both. Left. For 1902......527 498 514 For 1903......629 684 528 The above figures were taken at the Massachusetts Charitable Eye and Ear Infirmary. Those for 1902 are from the writer's hospital records, and he was fortunate enough to personally observe and treat probably one-fifth of all cases during that period. Cases for the year 1903 are from the annual report of the institution. It is interesting to note that the right ear, in both periods, is more frequently affected than the left, and that little can be gained from observation of column headed "Both" in regard to frequency when compared with left and right ears.

It is always necessary to examine both ears, for while one is entirely occluded, the other may contain a forming plug of considerable size which would soon give rise to unpleasant symptoms.

Case 1. A young married woman in good health having no symptoms, leading one to suspect a foreign body in the canal, was examined with the aural speculum. Both ears were found to contain masses of secretion, through apertures in which might be seen the normal tympanic membranes. She gave the history of attempting to remove the secretion with the edge of a towel. Syringing brought away the masses without difficulty.

Case 2. A man of 42 of good habits, except that he is an excessive smoker, after a Western trip, noticed that he was gradually getting deafer. No other symptoms were noticed. Examination revealed the characteristic appearance of a mass of impacted wax. Simple tests with the watch.

and the spoken voice showed that sound perception was much reduced.

The impacted cerumen was easily removed by means of the foreign body hook. There has been no return of symptoms after one year.

Case 3. A young man of 24, of decidedly light complexion, was referred to me by his physician with a diagnosis of cerumen. Examination confirmed the diagnosis, and plugs of light colored wax were found in each ear. He was deafer to the usual tests in the right, although the left contained the more solid and dryer mass. First, simple syringing and manipulation with the curette were tried with the result that only bits were removed. He objected so strongly, complaining of pain and sensitiveness in the canals that treatment was postponed for twenty-four hours until softening with a solution of bicarbonate of soda, glycerine and carbolic acid had been tried. This accomplished its purpose, and the offending material was extracted.

Case 4. A school boy of 9 was examined and found to be in a filthy condition, and having eczema of both pinnæ, I was lead to make an examination of his external auditory canals. The right was found to contain a large plug of impacted ceru

men.

Etiology. First we consider the poor shape to the canal; alterations in cerumen; manipulations of the patient as in the use of ear picks, cotton swabs, corners of towels, soap suds, etc.; over secretion of general sweat glands elsewhere; foreign bodies, such as animate and inanimate objects; other co-existing diseases of the ear; idiopathic cases.

Laboring classes naturally perspire freely, and are apt to have excessive secretion of wax. Among the indolent of the upper classes those that perspire quite copiously are more apt to have inspissated cerumen than those who do not. In many cases I have been unable to find a cause for the condition.

Symptomatology. (1) Sudden deafness; (2) tinnitus; (3) tension in the head (or true vertigo); (4) "ear cough;" (5) rarely pain; (6) rarer symptoms (e. g. sneezing, facial paralysis, blepharospasm, mental disturbances with spasmodic twitching, spontaneous discharge of wax.)

A small piece of cerumen on the membrana tympani proper, may cause great discomfort, even though the patient's hearing is normal. Even a small chunk of an otherwise solid mass of wax may be sufficient to allow sound waves to pass to the membrana tympani. Bathing may admit a drop of water, the mass swells, the opening becomes closed, and the patient suddenly becomes deaf.

Movements of the jaws tend normally to remove cerumen. The flexibility of the cartilaginous portion of the canal may be demonstrated by placing the little finger therein and moving the jaws. Whether or not this removal would continue if the jaws were ankylosed, is a difficult question to answer.

I have never seen cases, mentioned by some writers, in which plugs of cerumen were discharged spontaneously like a cork from a champagne bottle. This might be due to some fermentative process going on behind the plug.

Prognosis. As to recovery of hearing, good if cerumen alone exists. In all cases I have seen, decided improvement was noted upon removal. Having discharged patients upon removal of the plug, I have not been able to test P. McBride's assertion that the hearing may not be normal for several hours after removal on account of concussion of the membrana tympani by syringing. I have never seen cases where hearing was diminished after removal. This rare though interesting condition is accounted for by the fact that the wax acted as an artificial drum where perforation co-existed with inspissated

cerumen.

Recurrence. I always advise patients to return in three or four months for reexamination, as the condition is apt to return, especially in those beyond middle age, and it is easier to remove a freshly formed and perhaps incomplete plug than an old, hard, complete one.

TREATMENT.

Indications to be met in all ear diseases are applicable here, e. g., (1) cleanliness, (2) ventilation of the tympanum, (3) a healthy naso-pharyngeal mucous membrane, (4) general health of the patient, e. g., with regard to the blood and arterial nervous systems. Palliation is dangerous. One should always remove the