CHAPTER XIII. CHRONIC NON-SUPPURATIVE INFLAMMATION OF THE MIDDL2 (Part 4)

the Eustachian tube did not yield readily to Politzer's bag, the pump, or the catheter, the bougie was of very material assist- ance. In a large experience he had met with two accidents, purulent inflammation of the middle ear, and temporary emphysema of the eyelids, face, and neck. These accidents occurred from neglect of certain rules which he now carries out. Dr. Weir uses catgut bougies on which are marked the length of the catheter, the distance to the isthmus or narrow- est part of the tube, 74 millimetres, then the distance from the point to the tympanic cavity, 11 millimetres, and finally the width of the cavity, 13 millimetres. The bougies ranged from Nos. 2 to 5 of the French Scale. Dr. Weir's directions as to the employment of the bougies are so thorough and careful that I transcribe them. The instrument having been passed through an ordinary Eustachian catheter, and " once engaged in the tube is pushed onward as far as the isthmus, allowed to rest then a few mo- ments and then withdrawn, and air gently blown in through the catheter. If the air did not readily enter the tympanic cavity, all forcible attempts to force it were carefully abstained from and the bougie reintroduced, either then, or preferably at another sitting, and carried only to a very short distance, say one or two millimetres farther on, and the experiment resorted to, to ascertain if the tube were open." Dr. Weir has found the most obstructions in the first portion of the tube, though in several instances he had overcome total obstructions at the tympanic orifice. " The conical French bougies should be discarded as dangerous, from the tapering ends being too long ; but the catgut bougies might be made slightly conical by rubbing them on emery paper." ELECTRICITY. This is an agent whose real value has been much under- estimated in many departments of medicine, but which I am inclined to believe has been overrated in the treatment of aural disease. The effects of electricity on the acoustic nerve DEATH AFTER USE OP THE CATHETER. 313 will be fully discussed in the third part of this volume, while it is only necessary to say at this point, that not much is to be expected from the use of electricity in chronic non- suppurative inflammation of the middle ear. Drs. Beard and Rockwell * think that " the best results are obtained in those cases passing from the sub-acute to the chronic stage, and that then they are brought about by the mechanical action of the Earadic current, on the adhesions within the middle ear." These are just the cases that are amenable to treatment by the catheter, Politzer's method, and applications to the pharynx. Before closing the subject of the employment of the Eustachian catheter in aural disease, an allusion should at least be made to the singular dread of the instrument, now happily dissipated, which obtained in the minds of the pro- fession in England and the United States. This dread seems to have depended upon two cases of death from the use of the catheter which occurred in the practice of a certain Dr. Turn- bull, then of London, but who occasionally visited America, for the purpose of treating aural disease, until his death, which occurred a short time since, as I have been informed. These famous cases were reported in the London Lancet. In the same journal,! there is a letter from a correspondent ac- cusing this Dr. Turnbull of advertising in the " Times " in an unprofessional manner — that is, by stating that he could cure " any case of deafness, not arising from organic disease, by the use of a peculiar remedy." In order that the length and breadth of this matter of the death of patients from the use of the catheter, may be fully presented to the profession and not continue to be darkly hinted at, I quote from the Lancet^: the account of the inquest upon these celebrated cases. " On Monday evening an investigation took place at the Carpenters' Arms, Hoxton, before Mr. Baker, relative to the death of Mr. Wm, Whitbread, * A Practical Treatise on the Medical and Surgical Uses of Electricity, p. 566. f Vol. II., 1839. X Vol. II., p. 558. 314 DEATH AFTER USE OF THE CATHETER. aged 6G, which was supposed to have been occasioned by an operation lately performed on him by Dr. Turnbull of Russell Square. It appeared that the deceased, who was in the enjoyment of good health up to that time, had an operation performed upon him on Thursday week by the above physician, which consisted in injecting air through the nostrils for the relief of excessive deaf- ness, under which he had been for some time laboring. Almost immediately after he was attacked with a violent swelling in the throat, and though the utmost attention had been paid to him, he expired on Thursday last." " Mr. Wickham, a medical gentleman in the neighborhood, deposed, that on making a post-mortem examination of the body, he found that the inflamma- tion in the throat was not sufficient to have occasioned the death of the de- ceased ; death was produced by extensive inflammation of the brain, which, in his opinion, was occasioned by natural causes, and that neither the operation nor the inflammation of the throat had anything to do with it." " The jury, on this evidence, returned a verdict of ' Natural death by the visitation of God.' " "On Friday morning, at eight o'clock, an investigation, which occupied the greater portion of the day, was entered into before Mr. Wakeley, M. P. , and a highly respectable jnry of tradesmen, at the Plough Tavern, Museum Street, to prosecute the inquiry into the circumstances connected with the death of Joseph Hall, aged 18, who died whilst undergoing an operation for the cure of deafness, at the house of Dr. Turnbull, Russell Square, on the morning of Saturday last. The circumstances connected with the case had created an intense interest, and during the proceedings the inquest room was attended by many of the leading members of the medical profession." " George Kimber merely stated that he and deceased were in the employ of Mr. Jackson, ornamental composition maker, of Rathbone place. He saw him last alive on Saturday morning, about seven o'clock, at which time he was getting ready to go to Dr. Turnbull's to be operated upon for deafness, to which he was subject ; he was in all other respects quite well and healthy." " Charles Spadbron, of Gravesend, deposed that he saw the deceased about ten o'clock on Saturday morning at Russell Square. He appeared in good health. There were other patients present at the time. Mr. Lynn, the gen- tleman who assists Dr. Turnbull, was pressed to operate. The deceased filled the instrument himself, and discharged the air by turning the cock. (The instrument was here produced, and the witness showed liow it was filled. The bottom of the cylinder was held fast, between the feet and the piston, worked up and down by the handle until the pump became filled with air.) The operation was repeated four times on deceased, but the tube through which the air passed was removed by Mr. Lynn from the right to the left nostril. On the tube being taken from deceased's nostril the fourth time, he fell back in the chair, apparently lifeless, and never spoke afterward." " In answer to the coroner, the witness stated that he had had the operation performed on himself four times at a sitting ; it produced a swimming in the head, and a portion of the air appeared to escape by the mouth, and the rest down the throat." " Mr. James Reid of Bloomsbury Square, surgeon, deposed to having, by order CAUSES OF INJURIOUS EFFECT OF CATHETER. 315 of the coroner, made a post-mortem examination of the body in presence of Messrs. Liston, Quain, Savage, and Lyon. Mr. Reid went into a long general anatomical statement, but the only points strictly bearing on the case were the following : That he found a thin layer of blood on the left side of the mem- brane, and globules of air under it, and in the small veins of the brain. Tbat the left tympanum, or internal ear, bad its lining membrane swollen, of red appearance, and there was a slight effusion of blood in it. From the known plethoric habit of the deceased, and from the fact of his having exerted him- self at filling the air-pump before he was operated upon, he should say the cause of his death was apoplexy." " Mr. Savage, lecturer on anatomy at Westminster Hospital, was next exam- ined, and differed from the last witness, and stated that there was extravasated blood on both sides of the membrane, and that the tympanum of the right ear was affected as well as the left. He did not consider that deceased died of apoplexy, but that the injection of cold air, through the Eustachian tubes, was the primary cause of deceased's death." " Mr. Liston, surgeon to University College Hospital, stated that he was present at the post-mortem examination, at the request of the coroner, and the probability was, that deceased died in a continued fainting fit. He could not easily disconnect the forcible injection of cold air into the tympanum from the effect that followed it. In the region of the tympanum were a number of small nerves, connected with the most important one in the body, which, receiving an impression, would cause spasms, or other fatal affections of the heart. Nothing precisely satisfactory could be come to on account of the decomposed state of the body." " The coroner complained that though the subject of the inquiry had died on Saturday morning, no notice of his death had been sent by Dr. Turnbull or Mr. Lyon to the summoning officer of the district. He wished those gentlemen to give some explanation of their conduct." " Dr. Turnbull and Mr. Lyon severally entered into an explanation." " The coroner then addressed the jury at considerable length. And in accordance with the spirit of his observations, the jury returned a verdict of ■ Accidental death,' with a caution to Dr. Turnbull never again to intrust the instrument of operation in unprofessional hands." — {Times) There are numerous explanations for these cases ; but the account of the post-mortem is not exact enough to allow us to say which of them are correct. The first -named patient may have died from the emphysema produced by a wounding of the tissue by the point of the instrument. An examination of the tissues of the throat, immediately after the accident, would have determined this point ; but there is no account of such an examination having been made. The experiments of Voltolini* show that all traces of an emphy- * Monatsschrift fur Ohrenheilkunde, Jahrgang VII., No. 1. 316 DURATION OF TREATMENT. sema would pass off within ten hours after death, so that the post-mortem examination would give no information on this point. The surgeon who determined that death was produced by inflammation of the brain, unfortunately gives no account of the evidences which led to the formation of this opinion. The second patient may have died in a fainting fit, or from em- physema. The air-pump, is now scarcely used in the profession as a means of injecting air into the Eustachian tubes, because the air-bag is quite as efficacious, and because it is a much sim- pler apparatus. The management of an air-press should cer- tainly never be left to the patient. Yoltolini, in the experiments to which allusion has been made, killed a rabbit in a few minutes by wounding the tissue of the pharynx, by a wire passed through a catheter, and then blowing forcibly into the opening. He thus produced great emphysema of the neck and chest. Yoltolini believes that the cause of death of the rabbit, was a pressure upon the larynx by the emphysematous tissue, and not the pressure upon the lungs. Turnbull's patients may have both died from the same cause ; but as we do not know the instrument used, or, in fact, any of the details, we can only surmise the real cause. I need hardly say that the Eustachian catheter has never been even suspected of being the cause of death, since the time of these cases, although it is in daily use by physicians in all parts of the civilized world. Before passing on to a consideration of the operative treat- ment for this class of aural affections, a word or two should be said as to the length of time a case should be treated. In- asmuch as we cannot hope, in many of the cases, to do more than arrest the progress of disease, and perhaps improve the condition, since we cannot dismiss them as cured — that is to say, with the hearing perfectly restored, the tinnitus aurium gone — we desire to know how long we shall treat the ears locally. The general hygienic treatment, such as the frequent employment of baths, of a gargle, the exercise of great care to keep the extremities warm, to avoid taking cold, and so on, DURATION OF TREATMENT. 317 should be kept up during a patient's life, and he should be told at the first consultation that he has a life-long warfare to engage in, unless he desires to end his days with the use of an ear-trumpet. But we cannot keep up a local treatment of the Eusta- chian tubes and pharynx indefinitely. Those who believe that a catarrhal pharynx and nares can be thoroughly cured in our climate, that a disposition to colds in the head, can be effectively subdued by the use of the spray of nitrate of silver, or the spray of any other agent used by means of the most perfect apparatus, will continue to use these means of local treatment until the end is accomplished. But those who have been less successful in such attempts, must fix some limit to the time of treatment. If it be proposed to get the confidence of a patient suffering from chronic non-suppurative middle-ear disease, which is progressive in its character, it is proper to tell the whole truth at the first consultation and say that we have no hope of making him hear very well again. It is only a question of arresting the progress of the disease, and perhaps of increasing the hearing power. To this end, about twice a year, they should receive a course of local treat- ment until the disease has ceased to progress, for a period of time varying from three to eight weeks, while the general treat- ment is to be a life-long course. The only reason that these limits of time are fixed is, that I have seldom seen anything accomplished in less than the shorter time, or after the longer term has expired. Yery many patients leave us, at the outset, never to return. Some of them cannot leave their families to stay in a large city while their ears are being treated. This difficulty is being rapidly met. In every considerable town reputable and educated men, who have found that there is something more in aural practice than in syringing out the wax and then dropping in glycerine to restore it, are giving attention to otology, and the laity are beginning to reap the fruits of this cultivation of a hitherto barren field. There is another class, however, whom such advice never influences. One of their family, has been a victim of chronic aural disease for a period varying from two to twenty years, and they have at last, at the request of tire family physician, 318 DURATION OF TREATMENT. screwed themselves up to the courage of consulting a special- ist. They come in town for a day's shopping, and call upon the doctor, meanwhile always being in a great hurry, and sending word to the consulting-room, that they have come fifty miles to see him. When such advice as I have delineated is given, and the almost bewildered physician sits down to lay out a plan of treatment and correct the improper habits of life that have induced and maintained the disease, he finds that he is dealing with persons who expect magic ear-drops, vibrators, or some mysterious and quickly-acting agent that will restore the hearing in the interim of rest of a New York shopping excursion. Of course, such patients figure in the statistical tables under the head of "seen but once, result unknown" although in the mind's eye we can set them down as going on slowly but surely to the ear-trumpet, and banishment from social intercourse.