CHAPTER XIII. CHRONIC NON-SUPPURATIVE INFLAMMATION OF THE MIDDL2 (Part 1)

CHAPTER XIII. CHRONIC NON-SUPPURATIVE INFLAMMATION OF THE MIDDL2 EAR — Continued. TREATMENT. At tlie beginning of the preceding chapter a table was given, showing at about what time in the history of their dis- ease the patients from whose cases it was made up consulted the writer. It may be safely asserted, that the most of these persons never underwent any serious or rational local treatment until that time ; so that we may assume that the greater number of persons in the United States who suffer from the form of dis- ease under consideration, are in the habit of waiting for a period of from five to twenty years before they attempt to get relief. We must certainly diminish the number of these cases before we can hope for brilliant results. The neglect of aural therapeutics by the last and the preceding generation now recoils upon us. Patients come very late for advice about their ears, because they have been taught, not by the laity, but by wise and skilful physicians, that it is not prudent to meddle with the ear ; that they will outgrow its diseases, as soon as their constitution is invigorated ; if young girls, that, when the menstrual function comes on, they will be all right, and so forth, while, during this time of delay, adhesions between the membrana tympani and the ossicula, and the walls of the cavity of the tympanum, have been forming, and hypertrophy of the mucous membrane and atrophy of the tendons of the intra- auricular muscles — in short, all the changes that we have noted previously — have occurred. In one respect the treatment of the catarrhal may be fairly distinguished from that of the proliferous form. In the ca- tarrhal form we must give a great deal of attention to the'naso- CONSTITUTIONAL TREATMENT. 289 pharyngeal space, while in the other we scarcely need to treat it. Perhaps we may classify the treatment as follows : 1. Constitutional and hygienic. 2. Local blood-letting. 3. Applications to the naso-pharyngeal space (only appli- cable to the catarrhal form of the disease). 4. Applications to the Eustachian tube. 5. Applications to the cavity of the tympanum. 6. Cutting operations upon the membrana tympani and the ossicula. In the text-books of Wilde and Toynbee (books that have deservedly had a wide circulation in this country, and have done much to call attention to the ear) constitutional treat- ment figures very largely in the treatment. The use of mer- cury and iodide of potassium is strongly insisted upon. We, of the present time, have grown very skeptical about the con- stitutional treatment of such affections as chronic catarrhal, and proliferous inflammation of the middle ear. No thought- ful practitioner will attempt to disregard the general indica- tions of a cachexia, or of a debilitated system, in which there is chronic inflammation of the mucous membrane of the mid- dle ear ; but the time has probably gone by when a person in fair health, suffering from chronic aural catarrh, and who has no constitutional taint, will be treated by alterative doses of the bichloride of mercury, followed by the iodide of potas- sium. Ample experience has shown that we can do nothing for these cases by such a treatment, and I may say, that it has been abandoned in the infirmaries and hospitals, where large numbers of cases of aural disease are seen. The constitutional symptoms of the earliest stages of the disease were usually those of a coryza or acute catarrh, which finally settled down into an insidious and chronic process, when it has become impossible to trace the remote causes. The causes of these forms of disease suggest a kind of con- stitutional treatment however, which should never be lost sight of. Everything that will render a patient more vigorous, and less likely to take cold, will assist materially in curing or alle- viating a chronic aural catarrh. We shall thus find much to do, in the way of correcting improper habits of life, in regard to 19 290 TREATMENT OF THE PHARYNX. bathing, exercise in the fresh air, sleeping apparel, and the like. Hence the Turkish bath,* sponge-bathing, walking, rid- ing, boat-rowing, the general application of electricity, iron and so forth, become prescriptions which the otologist will be called upon to give very frequently, if he properly appreciates cause and effect. It is only against specific drugs, where there is bo specific diathesis, against a routine system of prescrib- ing a constitutional remedy in the vague hope, that it may do good, that I have been speaking. The use of leeches in some cases of chronic catarrhal inflammations that have sub-acute tendencies, is occasionally of value, although they give no such marked relief as that which is experienced in acute inflammation. When there are marked symptoms of congestion, such as fulness and slight pain, a leech may be applied on the tragus once a week, for four or five weeks. TREATMENT OF THE PHARYNX The treatment of the pharynx may be classified as follows : 1. Injections of the naso-pharyngeal space. 2. Gargling. 3. Cauterizations. Pig. 62. Injections of the naso-pharyngeal cavity by means of the naso-pharyngeal syringe, I have found very valuable in the treatment of chronic catarrhal inflammation. The solutions I use are common salt, permanganate of potash, gr. -| ad 3 j, a saturated solution of chlorate of potash, tar-water, etc. Great masses of muco-purulent material are often dislodged by this treatment, even in cases where ordinary inspection does not show that any has collected. The nasal douche is very fre- quently used for the purpose of cleansing the naso-pharyngeal * The Turkish bath is one of the best means of keeping the circulation 30 equable that catarrhs do not readily occur. It is not a good plan, however, to allow the head to be wet, during the shampooing process that follows the hot- air bath, neither should patients disposed to aural disease, take the cold plunge which is often given at the termination of the whole process. TREATMENT OF THE PHARYNX. 291 space, but it is a means of treatment that is attended with con- siderable danger to the ear, even when all proper precautions are taken. The posterior nares syringe is made of hard rubber. It is a very efficient and safe means of cleansing the pharj nx and nostrils. In cases of acute inflammation of the pharynx at- tended with considerable swelling, it should be used with care, or it will abrade and irritate the mucous membrane of the posterior pharyngeal wall. This abrasion may then lead to an extension of the inflammation along the tube, to the tym- panic cavity. In chronic cases I have never seen or heard of any harm being done by the posterior nares syringe. Dr. Warner, of Ohio, uses an air-bag as the means of forc- ing the fluid through the curved tube, and gives the instrument, instead of the nasal douche, into the hands of the patient. It is, however, a rather dangerous plan to trust an operative or mechanical treatment, such as introducing an instrument be- hind the uvula, to a patient, where it is possible to avoid it. THE NASAL DOUCHE. The author has published several cases that illustrate the dangerous consequences that may result to the ear from the use of the nasal douche. The appliance is, however, so con- venient of application, and it is thought to be so thorough in its work of cleansing the nostrils and pharynx, that the pro- fession are very loth to abandon it. I am of the opinion, how- ever, that its use should be discountenanced by the profession. Various criticisms have been made upon the published cases of injury to the ear from the use of the douche, but I believe that they have been fully met, and that most of the otologists on this side of the water, are agreed that the nasal douche, even when employed with all proper precautions, has produced serious aural symptoms in quite a large number of cases. The harmful results are probably due to the entrance of a large quantity of fluid, in a flood, as it were, into the cavity of the tympanum along the Eustachian tube, and necessarily in a direction contrary to the motion of its ciliated epithelium. The use of the nasal douche was first suggested by Pro- fessor Theodore "Weber, of Halle, Germany, and is based upon a physiological fact that was first promulgated by Dr. E. H. 292 NASAL DOUCHE. Weber, of Leipsic, in 1847. This fact is, that when one side of the nasal cavity is entirely filled with fluid by hydro- static pressure, while the patient is breathing through the mouth, the soft palate completely shuts off the superior naso-pharyngeal space from the mouth, and does not permit any of the fluid to pass downwards. The fluid then passes into the opposite nasal cavity, and escapes through the nos- tril. Prof. Theodore Weber suggested the use of a cup to the bottom of which was attached a bit of rubber tubing, for the purpose of taking advantage of this physiological principle. Such an apparatus is figured on page 124, and is now very much used under the name of Clarke's aural douche for the purpose of cleansing the meatus and stilling pain in the ear. Dr. J. L. W. TAudichum brought this apparatus to the notice of the English-speaking profession,* and made it more con- venient, so that in America it has acquired the name of Dr. Thudichum. It should, however, be called Weber's douche. As early as 1869, I had found that the nasal douche was sometimes a troublesome and dangerous appliance, and I added a note to indicate this, in my translation of Von Troltsch on the Ear (second edition, page 389) ; but I was not fully convinced that it would readily cause acute aural inflamma- tion, until the following case occurred in my practice. The case has been amplified from the first record that appeared,'!' in order to avoid the reiteration of explanations, that the criti- cisms upon the case in the Monatsschrift fur Ohrenheilkunde, and by Professor Elsberg of this city, compelled me to make. Case of Otitis Media Purulenta, and Pyaimia, from the Use of the Nasal Douche. — On the 12th of December, 1868, 1 was consulted by a clergyman, forty- nine years of age, in regard to a sub-acute catarrh of the middle ear, affecting both sides of the head. The history of the patient was as follows : Some years before, he was attacked with what seemed to be hay fevei', or a form of coryza attacking certain persons during the summer. This coryza became a chronic catarrhal inflammation of the naso-pharyngeal space, attended by the usual symptoms — a sense of stuffiness of the nostrils, frequent expectoration of glairy mucus, sneezing, and so forth. For the past two months tbe patient has been in the daily habit of using Weber's nasal douche, for the purpose of cleansing the nostrils and of introducing remedial agents into them. He had once before * On Polypus in the Nose and Ozcena. London, 1869. Lancet, Nov. 24, 1864. f Archives of Ophthalmology and Otology, Bd. I. NASAL DOUCHE. 293 tried this means of treatment, but it had caused so much unpleasant feelings in the ears that he was obliged to desist from employing it. A warmer solu- tion was always used in the douche, and it was employed under the direction of a physician who was probably well aware of Dr. Thudichum's directions, and took all the precautions which he advises in his pamphlet. This fact is mentioned, because the advocates of the douche claim that it never does harm when properly employed. Dr. Thudichum advises that a solution of salt and water, or milk and water, but never pure water, should be used, as did Profes- sor Weber some time before. The patient was also instructed to breathe through the mouth, and Dr. Thadichum observed that very often patients became confused, struggled, breathed through the nose, and defeated the plan. It is during this excitement, that the accident of entrance of fluid into the ear seems usually to occur. For about two weeks these unpleasant sensations on using the douche have been again experienced. The patient complains of being deaf, and of having a full sensation in both ears, almost amounting to pain. The membrana tympani of each side is found to be reddened. An ordinary ticking watch, heard by a person 'with normal hearing power about six feet, is only heard when placed in contact with the auricle of each side. A leech was applied to each ear on the tragus, the Eustachian tubes were rendered pervious by means of the catheter and Politzer's method. In a few days the membrana tympani assumed a normal appearance, and the hearing was restored by means of this treatment. The patient then desired that an attempt should be made to relieve the trouble in the naso-pharyngeal region. The uvula and tonsils were relaxed, the whole mucous membrane of the upper pharyngeal space secreted excessively, and the patient had contracted a habit of constantly endeavoring to clear his nostrils. Fluids passed through the left nostril, but none through the right. The Eustachian catheter, however, passed without difficulty. The nostrils were cleansed by means of a nebulizer, salt and water being used in it, after which the parts were swabbed out with a solution of arg. nit. gr. x. ad 3 j. The patient improved under this treatment until Jan. 28, when he was for some time exposed to the air of a winter's day, with the head uncovered (at the consecration of a bishop), when the symptoms, which had been to a certain extent relieved, returned. Jan. 31, a gelatinous mass was found plugging up the inferior meatus of the right nostril, seeming to be attached to the floor of the canal. Portions of this were removed by torsion, at intervals of about three days, until Saturday, Feb. 6, when what seemed to be the remainder of this growth was removed. The patient left the office, saying that his nostril was much clearer, and went to Yon- kers, a city about fifteen miles by rail from Xew York. There he again used the nasal douche, and again experienced adecidedly unpleasant sensation in his ears, which, however, did not amount to pain. On Sunday morning and evening the patient performed his clerical duties, but with a great sense of languor and uneasiness. On Sunday night, Feb. 7th, at about eleven o'clock, he was awak- ened by a severe pain in the mastoid region of the right ear, which kept him from sleep. I saw him Monday morning, at about eight o'clock, and noted the following symptoms : The countenance was anxious and flushed, the skin hot, pulse about ninety-six, right mastoid region red and sensitive, right mem- brana tympani reddened, watch only heard when pressed upon the auricle. The patient was asked as to the condition of the left ear ; but he said there 294 NASAL DOUCHE. was no trouble there. An examination of the tragus and mastoid process failed to exhibit any symptoms of inflammation in that ear. Two leeches were ordered to be applied to the mastoid process, and the patient was to take aq. acetat. amm. At five p.m., the pain in the ear had entirely ceased after the application of the leeches. The patient was breathing hurriedly, however, his pulse was weak and frequent — about ninety-six — and he complained of pain and tenderness in the abdominal region. Morph. sulph. gr. £, was ordered to be taken pro re nata, and a poultice was applied over the abdomen. Tuesday, Feb. 7. The patient took two powders of morphine, and passed quite a comfortable night. This morning he complains of pain in the forehead, but has none in any other part of the body. The surface of the body is dry and hot. Ordered aq. acetat. ammon. and nutritious diet. Feb. 8. Last night the patient was attacked by a severe pain and swelling of the left foot, and at about half-past seven A.M. he had a severe chill, lasting about fifteen minutes, not followed by sweating. At about this time a discbarge appeared from the left ear. There has been no pain experienced in this part. He has not slept well, and his general appearance is bad. Countenance anxious. Breathing labored. Pulse about 96. The left ankle and dorsal region of foot are red, greatly swollen, and tender. Left membrana tympani ulcerated and discharg- ing freely. Dr. Foster Swift, of this city, was called in consultation, and the following treatment agreed upon : The foot was wrapped in an alkaline lotion. Vichy water was given ad libitum, with beef-tea and wine ; morphine pro re nata. Feb. 9. Patient does not seem so well. Respiration is hurried. The intellect is somewhat clouded. Pulse about the same. Face of a sallow hue. The stimulants are increased, so that he now takes half an ounce of brandy in milk punch every four hours, clay and night. Quin. sulph. gr. ii., every four hours. The left ear is syringed with lukewarm water, zinc, sulph. applied, and Polit- zer's method used to inflate the drums. The patient is so deaf that he only hears when spoken to near the ear. The patient was treated in this manner, until Feb. 22d, the brandy punch being steadily increased until he was taking fwo ounces every four hours, with beef-tea, eggs, etc. His pulse was never over 100, usually about 96 ; the skin had a saffron hue, and patient lay in a doze, except when the pain from his foot kept him awake nearly the whole time. Dr. George A. Peters, Surgeon to the New York Hospital, was called in consultation a few days ago, in addition to