CHAPTER III. THE EXAMINATION OP AURAL PATIENTS. (Part 4)

: 1. Let the patient be seated on a chair, with a little higher back than usual, so that the head may be supported. If the * For a fuller account of Guyot's operation, see Introductory Chapter. 94 INTRODUCTION OF EUSTACHIAN CATHETER. Eustachian Catheters, actual size. patient be a child, it can rest its head against a table or wall, or what is better, be supported by an adult. I seldom use the Eustachian catheter in young children ; for them I prefer Politzer's method of in- flating the middle ear. 2. Let the patient blow his nose, so as to moisten the passage and remove any collections of mucus, while the surgeon takes the catheter thoroughly cleansed and warmed, and forces air through it in order to be sure that it is permeable. 3. The operator, standing a little to one side, draws down the upper lip with the left hand, and with the thumb and finger of his right hand lightly holds the catheter close to the funnel-shaped end, nearly in a vertical position, with the ring looking towards the median line of the body, until it has entered the meatus, when it is quickly turned to an approach to the horizontal position, so that the beak rests on the floor of the nasal mea- tus, close to the septum, with its convexity upwards. 4. The catheter is then to be slid or in- sinuated backwards with a gentle motion, keeping it as close as possible to the floor of the meatus, gradually elevating the han- dle until the instrument becomes perfectly horizontal and the beak rests upon the posterior wall of the pharynx. 5. At this point the funnel-shaped end of the catheter in the hand of the operator is to be raised a little above the horizontal line and at the same time withdrawn a little. 6. Turn the catheter about a quarter on its axis, from within outwards. This mo- INTRODUCTION OF EUSTACHIAN CATHETER. 95 tion lifts the beak of the instrument into the mouth of the Eustachian tube. This latter movement is aided somewhat Introduction, of Eustachian Catheter. by the contraction of tlie soft palate, which performs a swal- lowing movement, raises itself, and lifts the beak of the instru- ment into the tube. Once in position the catheter should not cause the patient any inconvenience in speaking or swallowing. The difficulties that are found in introducing the catheter, simple manipulation as it is, arise from two causes : First, the surgeon does not always hold the instrument in a vertical position (see Fig. 21) until he has got the beak well into the meatus. A failure to do this will often cause the instru- ment to pass between the inferior and middle turbinated bones, instead of along the floor of the meatus, which must be hugged in order that the instrument may get to the mouth of the tube. 96 INTRODUCTION OF EUSTACHIAN CATHETER. Second, the patient is apt to shut his eyes spasmodically and contract his facial muscles, and thus prevent the relaxa- The Eustachian Catheter in Position. tion of the parts that is necessary during the manipulation. This difficulty is only to be overcome by persuading the pa- fig. 23. tient to open his eyes and look about the room, which can be done if the surgeon have a quiet, assuring manner. This difficulty usually passes away with the second or third use of the instru- ment, and sometimes it does not arise. Having introduced the catheter we may force air through it into the cavity of the tym- panum, by means of an air-bag whose nozzle should fit accurately into the funnel-shaped ex- tremity of the nasal instrument. Air may also be blown in from the lungs of the examiner through a slender bit of rubber tubing, the tips DIAGNOSTIC TUBE. 97 of which are placed in the opening of the catheter and the mouth of the examiner respectively. The use of the rubber bag or syringe is to be preferred to this method as being a more cleanly and delicate one. After air has been forced into the middle ear in this man- ner, the membrana tympani should again be examined by the surgeon, to determine if it has become injected, or if it has undergone any change in position ; that is to say, he should see whether the current has actually reached the cavity of the tympanum or not. Most authorities recommend the use of an instrument like the stethoscope, which is placed in the ear of the patient while the air is being driven through the tube, and they claim to be generally able to decide as to whether the air enters by the sound communicated through the tube. I am constrained to think that it is very difficult to distinguish sounds proceed- ing from the pharyngeal mouth of the tube from those pro- duced in the cavity of the tympanum, and I do not, therefore, attach that importance to the use of the stethoscope in this manner, that has been usually ascribed to it ; but I rely more upon the appearances of the membrane of the tympanum after the air has been forced in, with some attention also to the sensations of the patient, as to where the air is felt, than upon the use of the so-called otoscope — although I would be very 98 DIAGNOSTIC TUBE. far from wholly rejecting its employment, or from denying its value. The otoscope consists essentially of a piece of elastic tubing with a tip on each end, designed for the ear of the patient and that of the examiner respectively. It should not be called an otoscope, but rather, as Kramer suggests, the diagnostic tube. The mirror for examining the ear should be called the otoscope, just as that for examining the fundus of the eye is named the ophthalmoscope ; that for the throat, the laryngoscope, and so on. POLITZER'S METHOD OP INFLATING THE EAE. The next means of examining the condition of the Eusta- chian tube and cavity of the tympanum is named, from the gentleman who suggested it, Politzer's method. It is a means of diagnosis and treatment of very great value, and we owe very much to Dr. Adam Politzer, of Yienna, for this method. of sending air into the middle ear. As is very well known, in the action of swallowing, the uvula rests upon the pharyngeal wall so as to shut off the upper from the lower pharyngeal space ; so that persons affected with cleft palate, who cannot thus separate these spaces, are greatly inconvenienced by the passage of solids and fluids upwards to the posterior nares. It was long ago shown that the pharyngeal orifice of the Eustachian tube opened during the swallowing process. Politzer's method takes advantage of these physiological facts in the following way: the person to be examined takes a little water in the mouth, while the surgeon places the nozzle of an air-bag into one of the nostrils, closes the other with his finger, and causes the patient to swallow the water at a given signal previously agreed upon, when he forces in the air by compressing the india-rubber bag. I usually say " now " ; upon which the patient swallows.. In examining children, I use, as suggested by Mr. Hinton, a piece of rubber tubing, and force the air from my own lungs, on giving a signal by raising the hand. The effect of the air thus forced in upon the inembrana POLITZERS METHOD. 99 tympani is often almost wonderful. A person who has be- come deaf to ordinary conversation sometimes in an instant again hears the familiar tones of human conversation, and feels himself in a new world. In such a case, mucus has usu- ally obstructed the calibre of the tube, and is driven away by the current of air, which must of necessity go against the Method of Using Politzer's Apparatus. {With Inhaler Attachment.) mouths of the tube, and will usually pass on into the middle ear. The patient's own testimony will usually, although not always, be conclusive as to whether the air entered the ear. The exceptional cases are those in which the Eustachian tube and the cavity of the tympanum have become so narrowed by a hypertrophy and sclerosis of the lining mucous membrane that only a very narrow, feeble current can enter. We shall have need to dwell upon the uses of Politzer's method when 100 valsalva's method. we are discussing the affections of the middle ear, and I there- fore content myself with this description of it, while we pass on to Valsalva's method of inflating the ear. VALSALVA'S METHOD. The distinguished anatomist Valsalva, who is well known to the profession by his treatise on the ear, suggested a means of inflating the membrana tympani, which has become so popular as to be used by nearly two-thirds of all the patients who come to physicians on account of their ears. It has been recommended by generations of medical men as a means of curing affections of the ear, or of determining if the Eustachian tube be open, or the drum-head broken. Universal as is its use, I regard it as almost a useless and not an entirely safe method. It consists essentially in forcing air into the ear, after a vigorous inspiration, the mouth and nostrils being closed. It will be observed that when the ear is inflated by this method, a very great use of the muscles of the chest is made ; and just in this lies the danger to the ear. This vigorous expansion of the chest causes a congestion of the ear which is sometimes more or less permanent, and materially harms the part by increasing the flow of blood to it. There is another objection to the frequent employment of the Val- salvian method, or experiment, as it is sometimes styled. It soon ceases to have its momentary effect of increasing the hearing distance, which it does by rendering the membrane of the drum tenser, and then the membrane becomes relaxed and flaccid, so that I have sometimes seen the membrana tympani of patients who have been in the daily and perhaps hourly habit of forcing air into the ears, flap to and fro like a vake on the slightest movements of the nostrils. This latter objection, of course, applies to Politzer's method if it be very frequently practised ; but as it must be done by means of an apparatus, patients are not so apt to take it into their own hands. I do not now advise the use of the Valsalvian method in the treatment of aural disease, and as a means of diagnosis it BOUGIES. . 101 is, in most cases, vastly inferior to the use of the catheter or Politzer's method. I may add a word about the last-named means of examining the Eustachian tube, namely, bougies. Filiform catgut bougies may sometimes be employed with advantage in determining if the non-entrance of air by the catheter or Politzer's method be due to a stricture ; but the need for their employment occurs only in a very limited number of cases, and when they are used great care and judgment are necessary. This subject will be fully discussed in the chapter on Chronic Non-suppu- rative Inflammation of the Middle Ear. It will be understood by the reader that very many cases of aural disease — for example, those of the external auditory canal — will not require the exhaustive examination that has just been detailed, yet many cases will require a systematic and complete observation, such as I have attempted to delineate, in order to a diagnosis which shall be exact and consequently valuable. The time thus consumed is sometimes considerable, but not as great in amount as those who simply read these descriptions will perhaps imagine. The details occupy more in description than in execution ; and their strict performance will of themselves in time make those who carry them out good observers of the phenomena of disease,.