CHAPTER XIII. CHRONIC NON-SUPPURATIVE INFLAMMATION OF THE MIDDL2 (Part 2)

Dr. Swift and myself, and to-day two openings were made in the foot, one near the internal, and one near the external malleolus. Pus was evacuated. The dorsal region of the foot was very much swollen, but no fluctuation was detected. The patient's general condition is now better ; his countenance less anxious ; the respiration is not so hurried. The urine was several times carefully examined during the treat- ment. No abnormal condition was found, beyond an acid reaction early in the course of the disease. The heart was also examined, and no organic changes were found. Several openings were made in the foot from time to time ; but the patient slowly improved from this time until March 16th, when he was able to sit up. The membrana tympani healed, and the hearing dis- tance became about one foot on the right side, and four to six inches on the. left. Conversation is heard with ease. Politzer's method has been practised NASAL DOUCHE. 295 every two days. Quinine and iron have been taken in addition to the stimu- lants. The foot is still swelled, but all the openings but two have healed. April 4. The patient has been going about the house for a week. Hearing power is still further improved. A little erysipelatous soreness of the foot occurred lasc night. The naso-pharyngeal catarrh is completely gone. April 7. Patient rode out to-day, and gets about the house, employing himself in intel- lectual labor. Tissues of the foot still swelled and rigid ; motions of the ankle- joint unimpaired. 1873. I am in the habit of seeing this patient quite often. He is now in excellent health, but a very little lame from the inflammation of the foot. My friend, Professor Elsberg, of this city, published a paper* in which he claimed that an analysis of the cases that had been published, of harm to the ear from the use of the douche, showed that the cause was uncertain. Dr. Elsberg has had a large expe- rience in treating diseases of the pharynx, and although he has prescribed and employed the douche in more than 1600 cases, he has seen none of the results that I have observed. I can only explain this by the presumption, that when an accident to the ear occurs, the patients1 are more apt to consult a person who is in the constant habit of treating aural disease than to go on with the treatment of the nasal catarrh. Besides, as it is believed by many otologists, it is possible that the douche sets up a chronic inflammation of the tympanic cavity, without any acute stage, and thus the true cause of an insidious chronic catarrh is passed over and supposed to be an advance of the naso-pha- ryngeal inflammation. Of course it is not believed by the author that the use of the nasal douche will necessarily cause aural disease, but that it is a dangerous means of treatment, which should be carefully watched by the practitioner. I append, from a paper previously published, an analysis of cases in which serious results have occurred. t Were it expe- dient to further extend the discussion of this subject, I could add several more, for I am constantly hearing of them from my professional friends, and seeing them in my own practice. While preparing this chapter for the press, I am treating daily a patient suffering from suppuration of the middle ear, that was caused by the use of the douche.J * Archives of Ophthalmology and Otology, vol. ii., p. 77. •f L. c, vol. iii., No. 1. \ The famous Cheseldeu mentions the fact, that syringing the nose when the Eustachian tube is open, sometimes causes deafness. 296 NASAL DOUCHE. ANALYSIS OF REPORTED CASES OF INJURY TO THE EAR FROM THE USE OF THE NASAL DOUCHE. Patient. Instructor* in Use of Douche. Fluid Used. Ear Disease Pro- duced. Casel. Rev. Dr. C. A physician. A warm solution of carbolic acid. Acuta otitis media suppurativa. Pyie- niia. Recovery. " 2. Dr. Frank, t Dr. Frank. Cold water, which he advises in all cases. Acute otitis media. Recovery. " 3. Mr. D. Dr. Eoosa. Warm solution of salt and water. Perforation of both mentbranae tympa- ni. Recovery. " 4. First of Dr. C. I. Pardee's}: cases. A physician. Warm solution of salt and water. Otitis media suppura- tiva. Necrosis of middle ear. Per- manent deafness. " 5. Second of Par- dee'sj cases. Medical student. A physician. Salt and water. Acute otitis media. Recovery. " 6. A Physician. A physician. Unstated. Otitis media suppura- tiva chronica. " 7. Patient at Man- hattan Eye and Ear Hospital. Unknown. Unknown. Otitis media acuta. Recovered. " 8. Mrs. C. Dr. Mathewson's case. A physician. Warm fluids. Otitis media acuta. Recovered. " 9. Dr. Hackley'sf case. Unknown. Warm salt water. Otitis media suppura- tiva chronica, su- pervening on old perforations. " 10. Dr. Piffard's§ case. Unknown. Warm fluids. Otitis media acuta. Recovery. " 11. Judge . A physician. Unknown. " Deafness." Recov- ery. " 12. Dr. Loring'sll case. A physician. Warm fluid. Otitis media suppura- tiva chronica. " 13. Physicianf Dr. Mathewson's second case. A physician. Unstated. Otitis media acuta. Recovery. " 14. Physician.^ Dr. Mathewson's third case. A physician. Unstated. Otitis media subacuta. " 15. Physician. A physician. Warm salt water. Fainting and otitis media catarrhalis. " 16. Dr. 0. D.Pome- roy's case.! Dr. Pomeroy. Warm salt water. Otitis media suppura- tiva. * The instructor is given in order to meet the point made by the advocates of the douche, that no harm occurs when it is properly employed. t Archivfur Ohrenheilkundc, Brl. V., p. 202. t The Medical Gazette, vol. vi., No. 23. Medical Record, Feb. 1, 1S70. § Reported by Dr. Pardee, 1. c. || Verbal report to writer. 1 Reported in Archives for Ophthnlmolo^v and Otoloarv, vol iii.. No. 2. Dr. Pardee, in his paper in the Medical Gazette, claims' that the douche isar. inefficient, as well as dangerous instrument. He does not think that the conformation of the nasal pas- sages allows of their being cleansed by such a flood of water as comes from the douche. GRUBER S METHOD. 297 GRUBER'S METPIOD. Graber adopts a method of cleansing and medicating the nasopharyngeal space, for which he claims superiority over the naso-pharyngeal syringe and the nasal douche. Dr. Gruber also claims that his method of treatment was promulgated a year before the nasal douche was introduced to the profession — that is, in 1863, at a meeting of the medical profession in Vienna. But Gruber spoke of his method only with reference to aural disease, while Weber's nasal douche was recommended as a means of treating the nares. Gruber's method consists in the use of a two-ounce hard rubber aural syringe, the nozzle of which is well rounded off, in the following way : The syringe is filled with the fluid to be injected and placed in one nostril. The fluid is then forced with more or less vigor into the nos- tril, the other being closed with the finger, if the operator desires to inject the Eustachian tubes, but left open if the intention be to simply inject the naso-pharyngeal space. " In the force with which I empty the syringe, in the more or less perfect closure of the other nasal meatus, are found the fac- tors which more or less favor the entrance of fluids through the tubes. The latter effect may also be increased, after the syringe is removed, by causing the patient to perform the Valsalvian experiment." * Gruber believes that it is the root of the tongue, as well as the soft palate, that by instinctive contraction and lifting up- wards shuts off the superior from the inferior pharyngeal space, and prevents fluids injected by the nasal douche or by his method from passing downward. This statement is proved by the fact that when the soft palate is destroyed by ulcera- tion, the fluid may be made to pass out of the other nostril, as well as if the palate were sound. Gruber deprecates much instruction to the patient as to how he shall breathe or hold his palate during the injection of the fluid, but he prefers to leave him to his own instincts. A fluid should be used which will do no harm if some of it pass into the stomach. * Monatssclirift fur Okrenlieilkunde, Jakrgang VI., No. 4. 298 GKUBEIl ON THE NASAL DOUCHE. Dr. Gruber fully corroborates my views that the harmful effects of the nasal douche are due to the entrance of the \luid into the middle ear, and he shows that however proper it may be to intentionally, inject fluid in small quantities into a diseased cavity of the tympanum, it is manifestly incorrect to force it into an ear that was previously healthy, with no restric- tion as to quantity, as is done in the use of the nasal douche. " The current from the nasal douche is continuous, even when the cavity of the tympanum is already full ; the fluid in the pharynx attempts more and more to enter into the middle ear, and when the pressure is very great, rupture of the mem- brana tympani may occur. I have often seen ecchymoses on the membrana tympani, that were caused by the nasal douche." * Nebulizer for Plmrynx. I am very glad to have the views which I first brought before the profession, thus endorsed by so high authority as Professor Gruber. It is to be hoped that the method of anterior syringing, and the use of the posterior nares syringe, may finally supplant the nasal douche. The solutions that may be used with benefit as gargles are, of course, very numerous. The gargle that I most frequently prescribe is a saturated solution of chlorate of potash. Where there is much granular pharyngitis, a gargle containing iodine, will probably be more efficacious. I am in the habit of ad- vising patients suffering from chronic disease of the middle ear, suppurative or non-suppurative, to use a gargle of cold * Gruber, 1. c, No. 8. CAUTEEIZATION OF MOUTH OF EUSTACHIAN TUBE. 299 water, by Von Trdltsch's method, as long as they live. The gymnastic exercise of the muscles of the Eustachian tube, is by no means an unimportant means of treatment. Gargling is a very efficient means of cleansing the pharynx, if it be performed in the manner advised by Von Troltsch. The fluid is held in the back part of the mouth, the head being thrown well back, the nostrils closed by the fingers, and then the motion of swallowing is performed. With a little practice, the patient will become very proficient in this method. Those who are skeptical as to the virtue of gargling, and who claim that the process does not cause the fluid to wash the pharynx, will be convinced of the contrary by the following simple experiment : Let the posterior wall of the pharynx be painted with the tincture of iodine, and then a gargle of starch-water be used in the manner described, and the charac- teristic reaction will be found in the ejected fluid. Pomeroifs Faucial Catheter. Cauterization of the mouths of the Eustachian tubes, and of the posterior pharyngeal wall, is of great value in the treat- ment of catarrh of the middle ear. Nitrate of silver in solutions of from 20 to 100 grains to the ounce of wrater, is the agent chiefly to be employed. It should always be used by a nebu- lizing apparatus, in preference to a probang, although where the granulations are well defined, the individual elevations may be pencilled with the solutions. These applications are not very unpleasant, and they are 300 FAUCLYL CATHETERS. certainly very efficient in diminishing secretion, and in chang- ing the character of tissue. The use of the solid stick is very unpleasant to the patient, and is, I think, to be avoided. Dr. O. D. Poineroy, of this city, who has done much to intro- duce the nitrate of silver treatment of the pharynx in aural disease, usea a peculiar instrument for making applications to the mouth of the tube, and for inflating the cavity of the tym- panum.* Although Dr. Pomeroy names his apparatus a fau- cial catheter, I am inclined to think that its chief value is as a means of making applications to the mouth of the tube, and not of inflating the middle car. The instrument consists of a hard rubber tube, seven and a half inches in length. Its breadth at its proximal extremity is one-fourth of an inch, but it lessens towards the beak, which is a little more than one-eighth of an inch in thickness. The proximal extremity has a lip for the adjustment of a rubber tube. At about an inch and a half from this is a perpendicu- lar guide, placed in an opposite direction to the beak of the instrument. This guide serves to show the direction of the beak of the instrument when in position. The curved portion of the tube is one inch and three-sixteenths in length. At a line or a line and a half from the end of the beak, is an aper- ture of the caliber of a No. 1 Bowman's probe, for the injec- tion of air or fluids. This aperture is so placed, as seen in the cut on the previous page, as to cause the air or fluid to be thrown from the operator, or in the axis of the Eustachian tube. Air is injected into the mouth of the tube by simply compressing the air-bag, when the catheter is in position. Fluids, of which a drop or two are sucked up at each applica- tion into the beak of the instrument, are forced into the tube, in the form of a fine spray. Dr. Pomeroy thinks that the use of this instrument is ordi- narily simpler than the employment of Politzer's method ; but in this view I cannot coincide — and as a catheter, I hardly think it will take the place of an instrument introduced through the nose. The verdict of the profession has hitherto been for the method of Cleland, as against that of Guyot, and none of the * Transactions of American Otological Society, 1872. TREATMENT OF EUSTACHIAN TUBE. 301 faucial instruments have, as yet, reversed this judgment. The faucial catheter of Dr. Cutter," ingenious as it is, will hardly supersede the catheter in ordinary use, which is, as has been demonstrated, an efficient instrument, and one that in ninety- nine cases out of a hundred is readily introduced, and with no " guess-work," as has been said, but with an exact knowledge of its position. Solutions of sulphate of zinc, of alum, sesquichloride of iron, and so on, in weak solutions, may be used with advan- tage by the patient himself during the treatment of naso- pharyngeal inflammation. They are most efficient when used in one of the nebulizers that are now so largely employed in the treatment of the throat.— (See Fig. 63.) THE TREATMENT OP THE EUSTACHIAN TUBE. Among the means employed in the treatment of the Eus- tachian tube, the use of the Eustachian catheter stands pre- eminent. It is difficult to say whether we treat the tube or the cavity to which it leads by the means of this in- strument. We may often very much improve the hearing power of a patient by the introduction of the instrument be- tween the lips of the tube, even when no air, vapor, or fluid, is passed through it. After such a procedure it is much more easy to inflate the ear by Politzer's method. Some have rather hastily, as it seems to me, concluded that all, or the greater part of the effect produced by the catheter, might be had by applications to the mouth of the tube, and have dis- carded the catheter ; but I become more and more convinced after ten years of pretty steady experience in its use, that the Eustachian catheter is essential in the treatment of chronic non-suppurative inflammation of the middle ear. The agents to be introduced through it are : Atmospheric air, Yapors, Fluids, Bougies* Electricity. * American Journal of the Medical Sciences, April.. 1872. 302 ATMOSPHERIC AIE — VAPORS. I have placed common atmospheric air first, because I re- gard it as the most important of the agents to be employed. It is, however, not so efficient in chronic as in sub-acute or acute aural catarrh, where its effects are almost magical. In fact, it may be claimed, that there are no idiopathic affections for which relief is so immediately obtained as acute catarrhal inflammation of the middle ear, where inflations of the tympanic cavity with simple air are often sufficient to cause a patient, for whom the world of sound is again open, to shed tears of joy. Among the vapors employed, I attach most importance to the vapor of water — steam — an old remedy, but one which had most undeservedly fallen into disuse in this country, until it was again employed by myself. Br 0. I. Pardee* has published a paper, in which he has carefully noted the results of six cases of the most obdurate variety of non-suppurative disease of the middle-ear, and in all of these there was marked improvement, both in the hearing distance and in respect to the tinnitus aurium, by the use of steam through the catheter. Dr. Pardee deduced from his cases the practical lesson, that in the treatment of the disease of the tympanic cavity, its condition of moisture or dryness should be considered, and that when dryness exists, our thera- peutic efforts should tend to re-establish the normal secretion. I am in full accord with Dr. Pardee's proposition, and I do not therefore use the vapor of water in the strictly catarrhal cases, but