OTOMYCOSIS. BY F. J. NEWBERRY, M.D., IOWA CITY, IA. THIS disease is caused by the vegetation and reproduction of a mould within the external auditory canal. The most common form of vegetable parasite affecting the ear is some form of aspergillus, either flavus, glacus or nigricans; the latter being the most frequent. Other varieties of fungi are in rare cases found in the canal. The aspergillus seems to have a peculiar affinity for the ear and is seldom found on any other part of the body. The spores flying in the air find a soil suitable for growth in aural canals in which the integ rity of the tissues has been weakened by disease. As the pseudo-membrane forms the epidermis degenerates, and the mycelium penetrates the deeper layers of the skin; and in the majority of instances produces serous exudation. In many cases the whole canal is covered with the membrane, which is frequently cast off in its entirety only again to reform after a brief interval. The constant separation of the pseudo-membrane soon exhausts the tissues and renders them exceedingly liable to other serious diseases. The occurrence of these parasites in the auditory canal does not seem to receive from the medical profession the attention to which their frequency and occasional serious nature entitle them. I have not been able to gather any reliable statistics in regard to the prevalency of this trouble under different climatic conditions, but I find that in the portion of the Mississippi Valley where my practice is located, this disease makes up not an inconsiderable proportion of ear cases which come under observation. Different observers attribute a dif-. ferent percentage of all ear cases to this trouble. Knapp estimates that it makes up one-tenth of one per cent. of all ear cases, Roosa four-tenths of one per cent. and Herdurger five tenths of one per cent. In my own practice I find it to be nearly two per cent; and as in nearly every case the patient comes for treatment for the first time the charge of infection from instruments cannot be made. In my opinion a great many cases of this disease are treated for dermatitis or other aural diseases, and are passed by unrecognized. By some authors it is asserted that the disease is exclusively prevalent among the lower classes, among the uncleanly and ill-nourished. My experience differs with this, as upon consulting my records I find the disease much more prevalent among the well to do and prosperous classes. It has also been asserted that it is apt to prevail among several members of the same family, but in the cases with which I have come in contact this has not been the case. No season or condition of the weather seems to particularly affect the disease. Decomposing masses of fatty substances seem to hasten the growth of the mould. This diseased condition is never a primary one. The history of the average case is first one of diffuse dermatitis, for which trouble the friendly layman will almost invariably prescribe the oleaginous "ear drops," and thus the right condition is produced for the reception of the stray spore. No case will be found in which a previous aural affection did not exist. It may not always be a diffused dermatitis, it may be circumscribed otitis externa or any of the various inflammatory conditions to which the external ear is subject, but it is rarely found with a purulent discharge from the middle ear. The disease is purely a local one and is not affected by constitutional disturbances. In making the diagnosis the constant shedding of the pseudo-membrane with brief intervals of rest before again forming will at once attract your attention. This membrane is often exfoliated in small pieces mixed with epithelial scales which causes the not infrequent mistaken diagnosis. The membrane cast off may be dark in color or white and fluffy according to the nature of the parasite involving the parts. In most cases the first symptom complained of is an intense burning and itching. There is usually more or less tinnitus aurium, sense of fulness and hardness of hearing. The drum membrane is usually the first point upon which the spores fix themselves. Soon the vessels will congested and later the whole membrane will be hidden by the fungus. A serous discharge is characteristic; this is the most noticeable when exfoliation is taking place. The whole auditory canal often becomes much inflamed and swollen. Pain is present in most cases and is often intense in character and involving the parts about the ear. The pain seems to reach its greatest height just before the pseudo-membrane is cast off. The only positive means of become diagnosis is a microscopic examination. The power used should be from 300 to 400 diameters. The microscope will, in nearly all cases, show without difficulty the nature of the growth, but to be absolutely certain in obscure conditions investigators have found it necessary to resort to artificial culture. The microscope shows that the aspergillus has the characteristics of other fungi in its developement; but the mature growth of the different varieties vary much in appear ance. I find but meagre literature in regard to the involvement of the middle ear by the fungus. The past winter a case came under my notice which had all the appearance of an invasion of the tympanic cavity. The patient was a druggist thirty years of age, who for two years had noticed an irritation of the external anditory canal, and the frequent exfoliation of a light colored fuzzy material. He had never had any ear trouble until the commencement of the irritation in the external auditory canal Two or three weeks before coming under observation, he commenced to experience excruciating pains in and about the ear, which continued increasing in intensity, until at the time the ear was inspected they were almost unbearable. The otoscope revealed the external meatus completely lined with what the microscope demonstrated to be a form of aspergillus. A large perforation was found in the drum membrane, and through this was discerned what appeared to be this same growth covering the internal wall of the tympanum and filling up the cavity. The use of a douche of a solution of carbolic acid was at once commenced, which was later supplemented by the use of iodoform. In a few days the growth had completely disappeared from the walls of the meatus and from the tympanic cavity; the pain entirely ceased; and the hearing power increased from contact to four feet. The use of the douche was continued for four weeks, and though several months have elapsed no further trouble has been experienced. The conclusion arrived at in regard to the case, was that the work of the parasite caused the perfor ation of the membrana tympani, allowing the extension of the mould into the middle ear, with the attendant symptoms. Another complication with aspergillus noticed recently was aural polypi. A patient, a man under thirty years of age, had noticed for several months large scaly flakes being cast off from the ear with no other symptoms than an intense burning and itching, but for a few weeks noticed his hearing gradually failing, until at the time he came to my office it was necessary to place the watch in contact with the ear in order that sounds. could be discerned. Upon examination, it was found that a polypus completely occluded the canal in the cartilaginous portion; and upon removal of this growth, I found still another polypus farther in the interior. The canal being cleaned, it was found that almost the entire cavity was lined with what the microscope plainly demonstrated to be aspergillus nigricans. Whether or not there was any connection between the polypi and fungus is not positively certain, although to my mind it seems reasonable, the mould undoubtedly appearing first, that it might have had much to do with the causation of the other growth. The treatment of this disease is not, as a rule, a difficult matter. The destruction of the parasite may be brought about by remedies innumerable. One case was completely cured by the use of a douche of 1-1000 bichloride of mercury alone. Have had equal success with a weak solution. Lately good results were obtained with iodoform and boracic acid, equal parts. Have not had the success with alcohol, a remedy much lauded in certain quarters, as with the preparations referred to. I have come to prefer the application of medicinal agents in the form of a powder as the best measure in both cases. Among other remedies from which good results have been reported are Chinoline, carbolic acid, Tannin, salycilic acid, Argentum nitricum and other agents almost without number. This being a purely local affection, I have not found our Homœopathic remedies particularly of service only so far as they have a bearing upon the eczema or other inflammatory conditions which usually precede the lodgment of the spores in the canal. A SUCCESSFUL CATARACT OPERATION UNDER DIFFICULTIES. BY HAYES C. FRENCH, M.D., SAN FRANCISCO, CAL. IN February, 1894, Dr. J., a Homoeopathic physician of Guatemala, aged about 58, came to the writer with hypermature cataract of the left eye. The lenticular changes commenced about two years previous to his visit, with pains in the globe and temporal region, and what from his description must have been serous iritis, the tension being considerably increased from that time to the period of his visit to me. He had been advised to try various methods of absorption, and warned against extraction as holding out little hope of success. The case was further complicated by chronic catarrhal conjunctivitis. The patient had long been suffering from indigestion and mal-assimilation, owing to the villainous Guatemalan dietary to which his American stomach had been so long subjected, and withal he was an inveterate cigarette smoker. After treating the conjunctivitis and general catarrhal condition for two weeks, on February 28th, assisted by Dr. Ella G. Pease, I removed the cataract by the modified linear method, making a generous iridectomy on account of the glaucomatous history of the case and the increased tension at the time of operation. The operation was smooth and free from complication of any kind, and the toilet was nearly completed when a sudden involuntary spasm of the orbicularis sent a gush of semi-fluid vitreous out through the wound and down the cheek. The cornea was completely collapsed, and the case for the moment seemed to the last degree unpromising. Without further effort to improve matters or clear the pupillary space, the lids were closed and held in position by strips of Johnston and Seabury's silk adhesive plaster, the ill-conditioned vitreous still oozing through the closed lids. Twenty-four hours revealed no inflammatory tendency and the eye had rounded up to a gratifying extent, and the case began to look hopeful. He was allowed the liberty of the room and |