CHAPTER XL (Part 2)

intensest form of catarrhal inflammation. I have seen almost magical effects from their use. One of the most striking of the cases in my note-book is the following : I was called on a very severe win- ter's day to see a young gentleman in a neighboring city, who had been suffering for two days from acute pain referred to the ear. I found the symptoms of acute aural catarrh, in a reddened but intact drum membrane, congested pharynx, and so forth. When I entered the room he seemed to be in mortal agony. He said that he had not slept for forty-eight hours, and his anxious countenance verified his assertion. I at once seat out for some leeches, and caused one to be applied to each ear, and before they had dropped from the tragus he was asleep, and went rapidly on to perfect recovery. Such cases might be multiplied, for they are of frequent occurrence in hospital and private practice. Leeches are, however, a troublesome remedy, and in coun- try districts they are not always to be had. In their absence I place the use of warm water as next in efficiency. This should be poured continuously into the ear, and not used by means of a syringe, as I have known patients to employ the water when told to pour warm water into the ear. Clarke's aural douche (see illustration on page 124) is the best means of which I know for applying warm water to the ear. Some- times the warm water is unpleasant, instead of grateful, to the patient, and then the vapor of water or the smoke from a cigar or pipe may be conducted into the ear. Children may sometimes be relieved from a commencing attack of acute aural catarrh, by breathing into the affected ear for a very few minutes. If leeches cannot be had, and the use of warm water or of steam does not subdue the pain, cups — wet or dry — applied around the auricle, are sometimes of use, or Hourte- loupe's artificial leech may be applied. Poultices, as I have said, are only to be used as a last resort. Then they should be made small enough to be put in the canal, with only a slight covering of the auricle, but a denser one over the mastoid ; and their use should be given up as soon as the inflammation has abated. 246 PAEACENTESIS IN ACUTE CATARRH. If the patient or his friends are told to apply the leeches, the exact spot upon which they are to be placed should be marked with ink, or they will be put on the lobe, or on the neck, or in some other position where their use will do no good. I have quite often found, that a neglect to state just where the leeches should be applied, has caused all the efforts to relieve pain to be of no value. Eohland's styptic cotton — a preparation of cotton in a solu- tion of alum — prepared by Dr. Eohland of this city, will be found a very efficient means of arresting the hemorrhage from a leech bite. The bleeding should, however, usually be encouraged, by the use of warm compresses, for an hour after the leech has dropped from the ear. Paracentesis of the drum membrane is a very efficient remedy at times, when there is bulging of the drum-head, and we see that perforation is imminent ; or even in cases of pro- longed pain without bulging of the membrane, when the leeches have been used at too late a period, or have proved ineffectual. Schivartze, of Halle, taught us the value of this means of treatment in acute cases, and I have found it of great value. I would even pass a cataract needle through the posterior portion of the membrana tympani, in any case, whether bulg- ing was seen or not, when the use of leeches did not markedly diminish the severe pain within a few hours. I have done so with striking effect in some cases. Yet leeches and warm water, if promptly used, will usually check the progress of even the severest case. Very often, however, we are not called until the disease has advanced so far as to involve every part of the middle ear, when periostitis of the mastoid has occurred, and suppuration seems to be inevitable. Paracentesis of the membrana tympani should be per- formed while the head of the patient is well supported, and a good light is thrown upon the membrane by means of the oto- scope attached to a forehead band. A needle, such as is used in the operation of discision of a soft cataract, is the one I employ. The point of opening should be determined by the seat of the greatest amount of bulging, which I have found to be in Shrapnell's membrane, and in the posterior and inferior quadrant of the membrane. The operation causes so little pain, TREATMENT OE ACUTE CATAEEH. 247 that this element does not enter into the consideration of the surgeon. I have found the light of a candle about the best and most convenient source of illumination, when the opera- tion is to be done in a sick room, and the patient is in bed. An instrument with an angular handle has some advantages when the operation is to be done for chronic inflammation, and we desire to make a larger opening ; but for acute cases a thorough puncture, through which the blood, mucus, or pus can be drawn, is usually an opening large enough to relieve pain. I have more frequently performed the operation in cases where the severity of the pain has passed, and yet I have also performed it with the happiest of immediate results when the patient was at the height of distress. If we find on examination that the mastoid region is red, hot, tender, and swelled, it will be necessary to make an inci- sion through its tissues down to the periosteum ; but it is only very rarely that this is the case in acute aural catarrh. Such a state of things is more apt to be found in subacute suppura- tion, or as a result of chronic suppuration, under which heads the subject will be fully discussed. The condition of the pharjTigeal mucous membrane should at the same time be attended to, by means of gargles and external applications. A saturated solution of chlorate of pot- ash forms one of the best of applications to the pharynx, while the neck may be enveloped in a warm-water poultice. The Eustachian catheter, and Politzer's method of inflat- ing the middle ear, should be used as soon as the acute symp- toms have subsided, say in twenty-four hours. If employed with gentleness, there need be no fear of aggravating the sub- dued inflammation into a relapse. The hearing should be accurately tested by means of the watch and tuning-fork, in order to see, after the pain has sub- sided, if any impairment has occurred. If only one ear be affected, careless patients will believe that the hearing is per- fectly good, after the pain and fulness have passed away ; but the physician should be sure of this for himself. In half- treated acute catarrh are laid the foundations for that insidi- ous and obstinate disease, chronic non-suppurative inflam- mation of the middle ear. 248 TEEATMENT OF ACUTE AURAL CATARRH. While this energetic local treatment is carried on, the attention of the physician should be turned to the genera] system. It will often be necessary to give a full dose of opium or morphine at bed-time. It is somewhat remarkable, how- ever, that opium has very little effect, when used without local depletion, to quiet the pain from aural inflammation. Very large doses will be taken in vain, unless the local means that have been described are also employed. The patient should be kept in the house, and in a well- warmed room, during the stage of pain and fever. Pediluvia and diaphoretics are hardly necessary in case the pain is once subdued. 7.?he diet should be nourishing. The patient should be enjoined to keep his skin in good order by means of fre- quent bathing, in order to prevent relapses. The improper habits of life, or the exposures to cold, that have induced this attack, should be carefully sought out, in order that future ones may be avoided. The practitioner who, while treating a grave constitutional disease, finds this local inflammation breaking out, should by no means allow the severity or clanger of the constitutional symptoms to prevent him from the proper treatment of the acute aural catarrh. The local and constitutional treatment can well go on together ; while the neglect of the ear at the proper time may lead to irreparable damage not only to the health and prosperity of the patient, but it may destroy his life. "We cannot be too much impressed with the fact that a neglected acute aural inflammation may lead, through suppu- ration of the middle ear, with all its consequences of caries, polypi, meningitis, cerebral abscess, pyaemia, to the most deplorable results. Better would it be for a child suffering from scarlet fever or measles to die from the disease, than to recover from the constitutional affection only to succumb, with great misery, to the effects of the neglected inflammation of the middle ear. It is to be hoped that the neglect of treatment of the ear will not prevail in the next generation to the extent that it does in ours. The practitioner who looks through the generally excellent SUB-ACUTE CATARRH. 249 works on the diseases of children, will be painfully impressed with the fact, that very little attention is given to the common complications of infantile diseases with acute catarrh and sup- puration in the ear. The course of a case of acute aural catarrh, promptly treated in the manner that has been outlined, usually ends in complete recovery, with integrity of the structure and func- tions of the ear. In less favorable cases suppuration occurs ; but this is usually tractable, and even then the organ may be restored to complete usefulness. My published cases show that fifty of the fifty-nine cases that were recorded recovered ; while it is probable that some of the remaining nine did also, although I have no notes to show this. Two died. In one of the cases there were constihitional symptoms, as I was informed, of fever, and the acute aural catarrh may be said to have been incidental to typhoid fever. The other case of death was a case of mastoid disease, and the patient died of disease of the brain. It will be referred to in the chapter on the affections of the mastoid. SUB-ACUTE CATAERH OF THE MIDDLE EAR. There is a variety of catarrh of the middle ear which is very common in young persons and in children, that hardly demands a separate chapter for its proper consideration, but which differs in so many respects from the ordinary type of acute catarrh, that it seems to require a more extended notice than the references that have been made to it in discussing the latter-named affectioo. I have ventured to term this affection sub-acute catarrh of the middle ear. It has many of the symp- toms of the truly acute form. The absence of pain is the chief distinguishing mark by which it is separated from the latter form. Some authors, judging from their statistics, have clas- sified it under the head of chronic aural catarrh. While this view may not be strictly incorrect — for the affection that I am about to describe, may last for months, and run into the strictly chronic form — it has, in my opinion, more of the characteristics of acute catarrh in its nature, and in its readi- ness to yield to treatment, than of chronic inflammation. 250 SUB-ACUTE CATARRH. Symptoms. — The subjective symptoms of sub-acute catarrh of the middle ear may be stated as follows : It is observed ?that the patient, without suffering from pain in the ear, or if so, from pain that is not long-continued, is very often so hard of hearing as not to hear ordinary conversation. Very little is thought of this by the friends of the patient, or per- haps by the medical adviser ; but the trouble recurs, the attacks become more frequent, and the period of impairment of hearing more prolonged, so that school-life is seriously interrupted. The general health may, and may not, be im- paired. I have seen many such cases in boys and girls in excellent general health, as well as in the delicate and strumous. The objective symptoms are as follows : The pharynx is usually in a thickened or granular condition, the normal secre- tion is excessive, and it may be changed in quality, and be decidedly muco-purulent. The tonsils may or may not be hypertrophied. The membrana tympani has lost its normal neutral gray color, and is of a pinkish hue. The vessels are not usually to be traced upon any part of it. It may be exceed- ingly brilliant. The light spot is usually absent, or is smaller than usual ; a fact which shows that the drum-head is sunken in- ward. The experiments of Magnus, which have been described in the tenth chapter, show that any excessive pressure which pushes the drum-head inwards lessens, or if the pressure be great enough, obliterates, the light spot. The hearing as tested by the watch is found to be very much impaired, and only such conversation as is addressed to the patient, with his face towards the speaker, is heard. This impairment of hearing is very often attributed to "absent mindedness " by parents, and to "stupidity" by teachers. Children are not usually absent-minded, and when they are stupid, there is always a cause, which should be traced out, and the poor child not treated as if it were respon- sible for the disease that has rendered it so. Again and again will the practitioner find that he is obliged to correct the false ideas of parents and teachers, who believe that chil- dren do not always prefer to hear, if they can. Malingering as to deafness, is a deception which children rarely understand, SUB-ACUTE CATAEEH. 251 and which thej can never successfully maintain. A child that does not habitually answer readily when addressed, should be at once carefully examined as to its hearing power, and not scolded for absent-mindedness. Treatment— -It is apt to be the case, that proper hygienic rules have not been observed in the management of such young patients. They have been allowed to eat and drink food impro- per for growing persons ; for example, tea and coffee, pastry and so forth, to the greater or less exclusion of simpler and more nutritious substances, and thus a capricious state of the appe- tite has been induced. In the case of boys, frequent and pro- longed bathing or swimming, of which ducking the head under water forms the chief part, is sometimes found to cause or increase the impairment of hearing. The regulation of the diet of such patients, the wearing of flannel next the skin, the abstaining from any habits which may be recognized as pre- disposing to inflammation of delicate structures, building up of the system by a proper therapeutic course, such as the exhibition of cod-liver oil and iron, with proper attention by the use of gargles to the mucous membrane of the pharynx, will perhaps in time allow Nature to relieve these cases ; but the impairment of hearing, which is the most striking and most troublesome symptom, will be the last one relieved, and it may not be relieved at all, and the patient grow up to be permanently hard of hearing. We have at our hands, however, in Politzer's mode of inflating the ears— a method of treatment that has been fully described on page 98 — a means of instantly improving the hearing, and thus of removing the most embarrassing symptom in an instant. The wonder and joy depicted on a little patient's face when the world of sound opens to him again, after the air has once entered the Eustachian tubes and tympanic cavities, is some- thing very pleasant to see. In the absence of the air-bag, a bit of india-rubber tubing inserted in one nostril, the other being closed, through which air is blown from the lungs of the surgeon, will do very well. Indeed, where the subjects are very young I prefer this method; which is Mr. James Hin- ton's adaptation of Politzer's principle. 252 SUB-ACUTE CATARRH. The pathological changes in these cases, which cause the impairment of hearing, are probably in some cases simply plugging of the faucial orifice of the Eustachian tube, in others of the caliber of the tube and the tympanic cavity by mucus. Structural changes, such as thickening of the mucous membrane, bands of adhesions, have not occurred. Hence I would not class these cases among those of chronic catarrhal inflammation. I append three cases, two of which have been before pub- lished ;* but I have been able to follow them up, and note that the recovery was perfect. I again publish them, with an additional one of the same character. The cases are very common, and it is not therefore for their rarity that they are inserted, but that they may perhaps teach how much may be done to instantly relieve this form of disease. The practitioner who ignores the ear will certainly pass by, among these cases, many which, if properly examined and treated, would add very much to his reputation, and increase his power of doing good. CASES. Case I.— F. S. B., aged 16, N. Y., Sept. 1, 1865. Has been deaf at times