CHAPTER III. THE EXAMINATION OP AURAL PATIENTS. (Part 3)

the examination of the membrana tympani. It has the unequivocal endorsement of such otologists as James Hinton of London, Schwartze of Halle, Politzer and Joseph Gruber of Vienna. It was first introduced to the profession at large by Professor Anton Von Troltsch, in 1855, without pre- Ton TroltscWs Otoscope, actual size. 84 METHOD OF EXAMINING MEMBEANA TYMPANI. vious knowledge that it had been suggested by others, al- though Dr. Hoffman, of Westphalia, had previously, in 1841, used an ordinary shaving mirror with a central opening for the examination of the ear. Professor Edward Jaeger, in his work on Cataract and Cataract Operations, published in 1853, sug- gests that his ophthalmoscope may be used with the concave mirror of four inches focal distance, for the examination of the Fig. 13. Method of Examining the Auditory Canal and Membrana Tympani external auditory canal. I have also been informed by nu- merous practitioners that they have often used the ophthalmo- METHOD OF EXAMINING MEMBRANA TYMPANI. 85 scopic mirror for examining the ear; but in spite of all these statements, and the fact that Frank,* in his work on the Ear, gives a sketch of Hoffman's otoscope, the credit of the introduc- tion into general use of the concave mirror for the examination of the ear as certainly belongs to Von Troltsch, as the inven- tion of the ophthalmoscope to Heinrich Helmholtz. It is somewhat surprising, however, that after the description which Frank gives in his text-book of Hoffman's method, and the drawing which he furnishes of the mirror, no attention was paid to the subject until Von Troltsch revived it, without knowing of Hoffman's apparatus. I introduced the use of the aural mirror, or otoscope as it should be called, into the practice of the New York Eye and Ear Infirmary, in 1863, where it soon superseded all other methods, and whence it has been very generally adopted in the United States. It may be safely said that the adoption of this simple method of examination has done more for the scientific and practical study of aural disease, than any previous suggestion in this department. It has placed within the hands of every practitioner a method by which he may, in a few minutes, learn to examine a membrane which not a few physicians have never seen on the living subject. I deem it unnecessary to describe the numerous methods which preceded that of Von Troltsch, since they are fast be- coming obsolete, and their description belongs rather to the history of otology than to a practical treatise. Even the method of examination by means of the direct rays of the sun, which held out so long in the hands of some practitioners, has at last given way to the use of the mirror and ordinary day- light. It is sometimes convenient for the examiner and the pa- tient to sit during the examination of the membrana tympani, and sometimes both may stand, or, as I usually examine, the patient may sit in a revolving chair, while the surgeon stands. The position of the patient will not be an important matter, so long as a good illumination is thrown into the canal. A * Practisclie Anleitung, zur Erkentniss der Olirenlieilkunde, p. 49. BINOCULAR OTOSCOPE. forehead band is essential in making applications to the ear, and it is often convenient at other times. I cannot see any lfffT^r~^~J great advantage in the various complicated and expensive bands with ball-and-socket joints, but I use a simple screw attachment by which the mirror is fastened to the head-band. The head-band should be of elastic material, such as india- rubber webbed cloth. Dr. Di Mossi* in a very recent paper on binocular otoscopy, proposes the use of a microscopic object-glass set at an angle of 70° in a spectacle frame, as a simple and efficient binocular otoscope. This suggestion has just met my eye as this volume is passing through the press, and I am inclined to think that it is a very useful one.f Dr. Di Rossi 's first instrument X consisted of an arrange- ment of prisms behind a concave mirror. The prisms are plane, one of 90°, the other of 10°. The diameter of the concave mirror is 7 centimetres. Its focal distance is 16 centimetres. The central opening in the mirror is of an elliptical shape. The instrument differs from the binocular ophthalmoscope of Dr. Giraud Teuton in the following respects : 1. The mirror is much larger, inasmuch as ordinary day- light is used as the source of illumination. 2. The focal distance is less. 3. The prisms are of a higher degree. I think the advantages of binocular vision in examining the ear are not sufficient to atone for the loss of simplicity and * Monatsschrift fur Ohrenheilkunde, Jahrgang VI, No. 7. f Mr. H. W. Hunter, optician, will furnish the apparatus. % Monatsschrift fur Ohrenheilkunde, No. 12, 1869. blare's prismatic otoscope. 87 cheapness in the instrument used for examination that occurs when the binocular otoscope is substituted for Yon Troltsch's monocular concave mirror. A little practice enables the sur- geon to judge with sufficient accuracy as to the depth of objects in the canal or upon the drum-head, or beyond it, upon which he is operating ; for it is only in operating, for example, in puncturing the membrana tympani, that I have ever felt any difficulty in judging of the depth of the surface which it was desired to touch. Mr. Edward S. Kitchie, of Boston, at the suggestion of Dr. Clarence J. Blake,* has made an instrument which is designed to overcome the disadvantages attending the exclu- sion of one eye from the visual act in operating upon the membrana tympani : " It consists of a hand rubber speculum (Politzer's) of the largest size, fitted with a metallic rim, to which is attached a revolving prism and an arm, bearing at its outer end a lens of about an inch focus ; this arm is movable, but sufficiently firm to remain fixed at any angle at which it is placed. The prism is just within the focal dis- tance of the lens, and its incident face is armed with a small metal shield, having an opening in the cen- tre corresponding in its short diam- M eter to the diameter of the pencil of V& light falling upon it from the lens. "The advantage of the prism over a mirror or other reflecting sur- face is, that we have almost total reflection ; and but little of the light concentrated upon the prism by the 1 . i , Blake's Operating Otoscope. " In operating, an assistant is required to draw the auricle upward and backward, and keep the speculum in position, with the pencil of light upon the opening in the shield of the prism. It is not claimed for this instrument that it at all supersedes the head mirror of Von Troltsch, but it is certainly of great advantage in the more complicated operations, where * Late Contributions to Aural Surgery. Boston, 1870. OS EXAMINATION OF PHARYNX. a steady and uniform illumination is indispensable. The instrument, as a whole, weighs only about one hundred and fifty grains, and can be made much lighter ; so that when once firmly inserted in the meatus, it remains in position, and there is no necessity for holding it nor fear of its slipping out of place during the operation." The practitioner will often be obliged to examine the ear and pharynx of a patient who is too ill to get up from the bed. The light from a candle then becomes a very convenient and ample means of illumination. The finest changes on a mem- brana tympani and in the auditory canal may be observed by the aid of the otoscope and such a light. EXAMINATION OF THE PHAKTNX AND EUSTACHIAN TUBES. After having heard the patient's history, and having ascer- tained the amount of hearing, we may proceed to the exami- nation of the pharynx and nares, and mouths of the Eusta- chian tubes. Although the profession has been a long time in coming to an appreciation of the fact, it is now generally conceded that the starting-point of a large percentage of aural cases is in these parts. The pharynx is best examined by turning the patient's face to an open window, and holding the tongue by means of a Turck's or a simple hinge specu- lum. Turck's instrument is to be preferred to others, because the hand of the examiner does not obscure the view in its use. I often, however, use a reflector and ordinary daylight for an in- spection of the pharynx, and it has some advantages over a direct illumination. Some surgeons prefer to use artificial light in examining the pharynx as well as other parts of the body, but I much prefer ordinary daylight for all examinations, when it is pos- sible to use it, to that from any artificial source, or to the direct rays of the sun, since it seems to me that the natural EHINOSCOPY. 89 hues are thus best observed. In the evening, of course, arti- ficial light must be used. A reflector should then be em* Q| w Turck's Speculum. ployed. It is well to have the reflector attached to a forehead band, as in the practice of rhinoscopy or pharyngoscopy, which will be immediately described ; but I may defer any description of what to observe on examining the fauces and pharynx until we come to speak of pharyngeal disease. RHINOSCOPY. Rhinoscopy, as a practical method of examining the pos- terior nares, was suggested by Sir William "Wilde in his treatise on aural surgery, having previously been spoken of by Boz- zini, as a possible method of examining the parts behind the hanging palate, in a book published in Weimar in 1807. Professor Czermak, of Prague, following up Turck's inves- tigations on the larynx, was the first to actually introduce rhinoscopy into anything like general use ; while Br. Semel- eder, Surgeon to the Gumpendorf Hospital in Vienna, and afterwards Surgeon to the Archduke Maximilian, while in Mexico, gave us the first full account of what was to be ob- * Laryngoscopy and Rhinoscopy. By F. Semeleder. Translated by Dr. E. T. Caswell, 1866. 90 EHINOSCOPY. served by this means, with some interesting cases. Vottolini, of Breslau, has also added much to our knowledge of the value of this means of diagnosis. It is by no means necessary that every aural patient should be examined with the so-called rhinoscope, nor will the most accomplished manipulator be able to see the mouth of the Eustachian tubes' in every case ; but every one who attempts to treat the disease of the organ of hearing will find his diag- nosis very often facilitated by an inspection of these parts ; for example, when any unusual difficulty is experienced in enter- ing the mouth of the Eustachian tube. For the practice of rhinoscopy we need a lamp, or other source of artificial illumination, a small mirror, a tongue spa- tula, and a concave mirror that may be attached to a forehead band or placed on Semeleder's spectacle frame. Any brightly burning lamp, or a good Argand gas-burner, will answer as a source of illumination. Various kinds of costly apparatus for the purpose of con- Tobokfs Lamp. After Tobold. densing the light have been suggested and employed. If the surgeon be not satisfied with an ordinary lamp, perhaps the RHINOSCOPY. 91 apparatus of Tobold will be found the best. In some in- stances, although not always, an instrument for holding back the uvula is required. Various appliances have been suggested for this purpose, nooses, hooks, spatulas, and so on, for any of which a surgeon of ordinary tact will find or provide a sub- stitute when wanted. It is above all things requisite that the patient should be tractable, and this tractability is perhaps more common than many surgeons imagine. Those who precede all their mani- pulations by an appeal to their patients to be very quiet, to be sure not to stir, not to mind a little pain, etc., and who at the same time make a great show of instruments, will generally have intractable and timid patients ; but he who goes quietly to work, will find few patients that will not submit with more or less patience to all such manipulations as are required in rhinoscopy, the use of the Eustachian catheter, and the like. The patient being seated in front of the examiner, with a good light at one side, the mouth is well opened, and the tongue held by means of the depressor mentioned above. The surgeon should be careful in placing the tongue depres- sor, so that he may not cause undue pressure, which will pro- duce gagging, and prevent all further manipulations. The light is then turned upon the pharynx by the head mirror, so that it is accurately focused, when the parts will be well illuminated. Having secured a good view of the pharynx, uvula, and tonsils, the throat mirror is to be intro- fig. 19. duced. This instrument is first warmed ,f" T^'T^v by holding it for an instant over the flame of the lamp ; its heat is then tested by placing it on the back of the hand, after which it is gently and quick- ly introduced, with its reflecting face upwards, into the space between the soft palate and cavity of the posterior pharyngeal wall. There are some pa- Anterior Nares s tients, however, in whom it will be impossible to make a rhi- noscopic examination, on account of the small space between the uvula and posterior wall of the pharynx. A very few, also, 92 KHINOSCOPY. have such irritable throats as also to render such an examina- tion impracticable. The examination of the nostrils anteriorly — anterior rhinos- copy, as it is called by Coheir' — is often an important part of the examination of a case of aural disease. It is very often sufficient to place the patient in front of a good light, and open the nares by pressing upon the tip of the nose. If an instrument be necessary, I find that the one fig- ured on the preceding page serves a very useful purpose. I am sorry that I do not know the name of the inventor of this little instrument. EXAMINATION OF EUSTACHIAN TUBE. We may now turn, as the next step in our examination of a case of supposed aural disease, to the investigation of the condition of the Eustachian tube and cavity of the tympanum. The means of this examination may be classified as follows : I. The Eustachian catheter. II. Politzer's method. III. Valsalva's method. IV. Eustachian bougies. * From the date of the promulgation of the use of the Eus- tachian catheter by the postmaster of Versailles, Guyot, until Toynbee's time, the views of the profession as regards the use of this instrument have varied exceedingly. At one time it was almost utterly rejected by the greater number of respect- able practitioners, and at another time has been considered by them as a panacea in the treatment of aural disease. The text-books of Wilde and Toynbee, which attached very little importance to the use of the Eustachian catheter, and which bear intrinsic evidence that the authors did not choose to be very familiar with the details of the proper employment of the instrument, probably did more than anything else to cause the profession in our own country to settle down, until a few years since, into the belief that the Eustachian catheter was always a useless and sometimes a dangerous instrument. I well re- member the discouraging response of a prominent American * Diseases of the Throat, p. .75. INTEODUCTION OF EUSTACHIAN CATHETEE. 93 practitioner, who had then had large experience in aural dis- ease, to my statement, at the beginning of my active profes- sional life, that I proj)osed to use the Eustachian catheter in the treatment of diseases of the ear, that he was glad to say that he never had used the instrument, and this was the com- mon sentiment among our respectable practitioners until a very recent date. In regard to the change in sentiment in this regard, I only need to say, that nearly every American surgeon who now treats aural disease, attaches much importance to the use of this instrument. "We have now to speak of the Eustachian catheter as a means of diagnosis. The material of which the instrument should be made may be either alloyed silver or hard rubber. For diagnosis the silver catheter is to be preferred ; for the injection of warm vapors, the hard rubber instrument is the only one to be used, because the heat will very soon make it impossible for a patient to bear the metal instrument in the nostril. In the method of introduction, we proceed as did Archi- bald Cleland, an English surgeon, who, after Guyot, did the most to demonstrate the utility of entering the mouth of the Eustachian tube with an instrument, and we pass the catheter through the nostril. It is very difficult to imagine how the Versailles layman succeeded in introducing an instrument into the tube, through the mouth. He certainly did not use a catheter such as we now employ, and which is sketched on the next page. This instrument is a delicate tube of about six inches in length, with a slight carve at its extremity. A long and flexible catheter might, it is true, be passed behind the soft palate into or opposite the mouth of the tube, and this is the operation which Guyot demonstrated to the Paris Academicians, and which, by removing mucus from about the trumpet-shaped pharyngeal extremity of the canal, relieved his impairment of hearing.* The various steps in the operation of introducing the Eus- tachian catheter are as follows