CHAPTER VI. PARASITIC INFLAMMATION OF THE EXTERNAL AUDITORY CANAL. (Part 2)

of the state of things in the canal was delayed. Portions of the lardaceous, flaky substance removed from the canal were placed in glycerine. He was ordered to iise injections of warm water, by means of Clarke's aural douche, several times daily, and to drop in a solution of zinc, sulph., gr. ij ad aqua 3 j, twice a day. The Eustachian catheter was used, and air injected through it into the cavity of the tympanum. It was some days before the entire collection was fully removed, and in spots where it had been separated and taken out, it was renewed very rapidly, and each time reproduced the symptoms of pain and fulness. A -weak solution of carbolic acid was then used ; but it caused very great irritation, and inflam- mation was set up, which lasted many days. This was treated by the use of warm water, through the douche. When it had subsided, the lardaceous masses were removed by the forceps, and in some instances casts of the mem- brana tympani came away, although the walls of the canal showed the most disposition to a reproduction of the growth. July 27, the opening in the membrana tympani had healed, and the hear- ing so much improved that the watch was heard six inches, and the symptoms completely relieved. There was still a slight tendency to the growth of the fungus, as it proved to be, on the posterior wall of the canal. The membrana tympani was lustreless and rigid, the handle of the malleus distinct, but there was no light spot. From the 1st of August I did not again see my patient until October 18th. Meanwhile he had used the aural douche daily, and the growth had not returned ; but the catarrhal inflammation of the middle ear had not been materially benefited, as shown by the rigidity of the membrana tympani and the impairment of hearing. The membrane is now (November 19) somewhat translucent, and the patient is being treated, with benefit, by means of the injection of air, the use of a gargle, etc., for the middle ear affection. The flakes, preserved in glycerine, were examined by my friend Dr. C. E. Hackley and myself under the microscope, and Dr. Hackley believed them to exhibit specimens of Aspergillus nigricans. At a later date, Dr. "Win. B. Lewis very kindly made a thorough examination, and confirmed Dr. Hackley's opin- CASES OF ASPERGILLUS. 143 ion. In this case it is clearly evident that the growth of the fungus was secondary to the inflammation of the middle ear, for the patient never fully recovered his hearing power. Case II. — Sept. 28, 1869, 1 was consulted by Mr. S., set. 51, on account of impaired hearing, vertigo, pain in the ears, and tinnitus aurium. Vertigo was the symptom upon which the patient laid the most stress, and of which he was most anxious to be relieved. He said that he was so dizzy whenever he attempted to walk about, as to be unable to attend to his ordinary business. His condition in other respects was excellent. The patient also stated he had heard perfectly well until two months since, when he was attacked with the aural symptoms narrated above, which had been aggravated since their inception. He had been treated by the instillation of oils, and so on. He could hear my watch about one inch on the right side, and not at all on the other. Both auditory canals were found filled with a tenaceous material, which could only be removed by the forceps. It was several days before I could completely remove the firmly adherent coating of the canal and membrana tympani. The morbid product was immediately examined by Dr. Lewis, and found to be a specimen of the Aspergillus flavescens. Its removal gave the patient great relief; but on the reappearance of the growth, which was in two or three days after its thorough removal, the vertigo and tinnitus returned. The mem- brana tympani was intact, but lustreless and rigid. The Eustachian tubes opened sluggishly, and there was all the evidence of aural catarrh, beside the affection of the canal and of the outer layer of the membrane of the tympanum. The free use of warm water, with an astringent, finally subdued the morbid process in the canal, so that the patient was able to make a journey to the South. When he left my care, Oct. 18, the auditory canals were entirely free from abnormal secretion, the hearing was improved, so that the watch was heard from five to six inches on the right side, and from one to two on the left. The dizziness was entirely gone, and the tinnitus ceased to be annoying. The catarrh of the inside ear, as shown by rigidity of the membrana tympani, sluggish action of the tubes, and impairment of hearing, still continued. I saw this patient about a year afterward, and he was entirely well, his ears having returned to a normal condition. Case III— Lt. L., set. 80, U. S. N.— Dec. 2, 1872.— Since a child, has been more or less deaf in right ear, owing to a series of abscesses. This impairment of hearing was increased by his service near the frequent explosion of cannon. About a year ago he had an abscess in left ear (probably in auditory canal), with considerable purulent discharge having an offensive odor. For about two weeks he has had a series of abscesses in the left ear, with considerable discharge of black material. Hearing distance, R. -&-, L. -4%. The tuning-fork was heard more distinctly in the right ear when the han- dle was placed on the forehead or teeth. The pharynx is granular. The right membrana tympani is very much sunken and is opaque. The auditory canal of that side contains numerous scales of epidermis strewn with black spots. 144 SYPHILITIC ULCERS AND CONDYLOMATA. The left canal is full of pus, and the membrana tympani is perforated. The microscopic examination showed the presence of the aspergillus nigri- cans in both auditory canals. The patient's general condition was excellent, except, as is the case with most aural patients, he was somewhat despondent on account of the loss of hearing. The diagnosis of chronic suppurative inflammation of the middle ear, with aspergillus growth, was made as regards the left ear. In the right, there was chronic non-suppurative inflammation with the same fungus growth in the auditory canal. The patient was seen nearly every day until December 24, and treated by the use of leeches, the syringe and warm water, with the subsequent applica- tion of nitrate of silver, gr. 40 ad 3 j, brushed over the canal and drum-head. The patient also caused his ears to be syringed at home, and instilled a solu- tion of sulphate of zinc, two grains to the ounce, into the ears. The Eusta- chian catheter and Politzer's method were used to force air into the middle ears, and the patient used a gargle of chlorate of potash. The aspergillus fungus disappeared in a few days, but the affection of the middle ear and canal lasted much longer. On the 24th of December, however, just' 22 days after he came under 8- 1 S treatment, Lt. L. was discharged, with hearing distance for watch, R. j|, L. — . At 16 feet distance he could hear and carry on a conversation in the ordinary tone, with his face away from the speaker. The left canal still continued to swell, and the epidermis to scale off. The patient had eczema of the scalp and auricle. Some weeks after he was said to be still improved. SYPHILITIC ULCERS. CONDYLOMATA. I have not seen affections of the auditory canal which could be said to be the result of the poison of syphilis ; but trustworthy authors* speak of secondary syphilitic ulcerations of the auditory canal, and of condylomata f occurring in the same part. Schwartze believes that polypoid growths in the canal are sometimes a local manifestation of syphilis. Inas- much, however, as granulations exactly like those occurring in syphilitic cases are also found in the auditory canals of persons not affected with syphilis, it becomes very difficult to say that such growths are ever pathognomonic of the disease. This much is certain, syphilitic affections of the auditory canal are extremely rare, while it cannot be denied that the poison of syphilis once in the system will modify any affection that may occur in any of the organs of the body. * Schwartze, Archiv fur Ohrenheilkunde, Ed. IV, p. 262. f Steudener, 1. c, Bd. IV, p. 20. SYPHILITIC ULCEES AND CONDYLOMATA. 145 I will, however, reserve the discussion of the effects of syphilis upon the ear, for a fuller treatment in a later chapter. I need only further say, at this point, that whether ulcera- tions or growths in the auditory canal be or be not caused or modified by syphilis, the necessity for local treatment — at the basis of which is local cleanliness — remains as urgent as if there were no constitutional disease. The most appropriate constitutional treatment can never do away with the necessity for local care.