CHAPTER XVI. CHRONIC SUPPURATION OF THE MIDDLE EAR. (Part 3)

very skillful in its employment, f In 1853, Toynbee suggested another artificial membrana tympani, without knowing of the previous invention. Toyn- bee's appliance consists of a thin disk of vulcanized rubber, in Toynbee's Artificial Membrana Tympani. the centre of which is attached a fine wire about an inch long, which terminates in a little ring, to enable the finger to more readily grasp it when its removal is desired. An improvement upon the original method of attachment of the wire, is to insert it spirally into the disk, like a cork-screw in a cork. We can never tell without trial, whether the artificial mem- brana tympani will, or will not improve the hearing. Inas- * Yearsley on Deafness, p. 245. t An artificial membrana tympani was employed more than two hundred years before Yearsley, but not for the purpose of improving the hearing. Marcus Banzer, in 1640, recommended for this purpose a tube of elk's claw, which was covered by a piece of pig's bladder. Leschevin in 1763, Autenreith in 1 815, and Lincke in 1840, continued to employ such an appliance. Lincke used thin silver or gold tubes, somewhat conical in shape, from five to eight lines in length, and of from two to three lines in thickness. The outer end of the tube had a rim to prevent it from slipping too far into the meatus. The inner end was covered by a thin piece of gold-beater's skin, which was varnished. — Lincke's Handbuch, p. 447. del) ARTIFICIAL MEMBEANA TYMPANI. much as I am sometimes asked if an artificial membrana tym- pani will do any good, if the membrane be intact, it ma}' be as well to state, that it is only of service in cases of partial or complete loss of the drum-head. Von Troltsch relates a case of a deaf judge who used to improve his hearing temporarily by pressing upon the membrana tympani with a probe ; but I have never been able to increase the hearing power by any similar procedure upon a membrana tympani that was com- plete. The improvement to the hearing that does sometimes occur when the cotton Wool, or the membrane of Toynbee is used, is probably due to the restoration of the interrupted Fig. 74. Method of Inserting Artificial Jlanbrana Tympani. continuity of the ossicula auditus to the fenestra ovalis and the labyrinth. Toynbee, explained its benefit by stating that it occurred as a result of the closure of the membrane ; but this has been shown to be an erroneous explanation. Cases have been seen where the perforation was not closed by the t artificial membrane, and yet great improvement to the hear- ing resulted from its use. When the patient first begins to wear this membrane, it should be used but for a very short CHRONIC SUPPUEATION — PROGNOSIS. 381 time during the day. It is always a foreign body, and hence it is liable to produce irritation and increase the suppurative pro- cess. Lest any should think, that the artificial membrane is not a practical and valuable means of alleviating some cases, I may state that I have now under observation five patients, for whom I first introduced the membrane, who have worn it for years, with uninterrupted benefit to the hearing power. I have taught several other persons to apply the membrane, and with benefit ; but inasmuch as I have not seen them for a long time, it is not quite certain, although probable, that they are still using the substitute for the natural membrane. I am in the habit of tentatively applying the artificial membrana tympani in all old cases of chronic suppuration in the middle ear, when the loss of hearing is very great. If one ear be sound, so that the hearing for ordinary purposes is very good, as it always is under such circumstances, it is not worth while to use the artificial drum-head for the diseased ear. An ex- cessive inflammatory action in the remains of the drum-head, or in the middle ear, precludes any use of the artificial mem- brane. The patient for whom it is to be employed, should also be an adult, and possessed of a considerable amount of intelligence. It is not of any use in the case of children, or of unusually heedless or stupid adults. The wire to which the disk is attached, sometimes becomes separated in removing the membrane, and the disk of rubber is left behind. This accident, although a very insignificant one — for the disk is readily removed by syringing — is very apt to frighten the patient, unless he has been previously warned not to be dis- turbed if such an accident occur, and not to allow any im- proper attempts to remove such a foreign body. Prognosis. — The prognosis in chronic suppuration of the middle ear depends upon a variety of local and constitutional symptoms. If the consequences of chronic suppuration have occurred, such as exfoliation and death of bone, the formation of polypi, exostoses and so on, the treatment is apt to be pro- longed, and in some cases, may never be entirely or even par- tially successful. Again, when the membrana tympani is entirely removed, and one or more of the ossicula lost, the 382 CHRONIC SUPPURATION — PROGNOSIS. prognosis is grave. Yet the membrana tympani has a regen- erative power second to that of no other membrane of the body. I have repeatedly seen it entirely restored after all but a narrow rim had been entirely swept away. This has occurred at times in cases of long standing. The prompt healing of the drum-head after operative perforation and in acute inflammation, is a matter of common experience. The state of the general system will also at times influence the prognosis to a marked degree. Patients with phthisis pulmonalis seldom recover from a spontaneous rupture of the membrana tympani. The physician will find ample material for general advice in some cases, and yet there are many in which local treatment only is required ; while it is essential in all. We may say, on the whole, that the prognosis can never be decidedly given, so long as the membrana tympani is open, for this membrane is essential to the safety of the ear from renewed attacks of acute suppuration. All our efforts should be directed, therefore, to closing up this opening. There can be no danger from closing it too soon. Our chief difficulty will be in closing it at all. If regular and careful treatment by a physician, continued for months, fails to close the opening, or to cause the discharge of pus to cease, the patient may perhaps be given up, as one for whom there is no hope of cure. The family and friends should be taught to cleanse the ear thoroughly, as long as any purulent forma- tion occurs, and they should know that the chief danger to the ear, and the general system, lies in an accumulation and retention of pus. CASES. Case I. — Chronic Suppuration of twelve years standing — Exostosis of Tym- panic Cavity — Patient under treatment for more than three years — Both Membrana} Tympani healed — Hearing distance remains the same. W. P. H., aet. 33. June 1869. History — Ten or twelve years ago, from some cause to patient unknown, the right ear began to discharge, and then the left. They have discharged at intervals ever since. Occasionally there is pain in the ear. The hearing distance is — R, ft ; L., ^g-. The right membrana tympani is in a state of ulceration ; about one-third is gone. The lower and posterior CHRONIC SUPPURATION — CASES. 383 quadrant remains. Considerable pus lies in the cavity of the tympanum. The left membrane is nearly gone. There is a small granulation springing from the cavity of the tympanum. The pharynx is tolerably healthy. The patient was ordered to use the warm douche daily. He visited me three times a week, when the ears were cleansed by the syringe and warm water, and Politzer's method, and, an astringent, usually the sulphate of zinc, was instilled, In November, in about four months from the time of my fiist seeing him, the left membrana tympani had healed. The granulation disap- peared with no other treatment than the cleansing and the use of an astringent. March 17, 1870 — The right membrana tympani now exhibits a clearly cut opening in the posterior and inferior quadrant. A small amount of pus oozes from it. A minute but positive elevation of bone comes out to the opening. The hearing is at times very poor, on account of the blocking of the tympanic cavity by pus. The patient has been under my observation ever since first note, often coming to the office every day. Nitrate of silver, nitric acid, various astringents, with the continuance of the douche and syringe, have been employed in vain. March 17, 1871 — The patient has just passed' through an attack of acute catarrh, induced by taking cold. The hearing distance became -4% during this attack. Leeches were used, and subsequently the catheter, steam being passed through it. After the subsidence of the inflam- mation, the opening in the membrana tympani was found to be very much smaller. It was then cauterized with the mitigated stick of nitrate of silver, melted upon a probe, and in a few weeks it healed entirely ; so that in October, 1872, he was dismissed, with H. D. R, ft ; L., -/«-, and both drum membranes healed. I have not attempted to give the full notes of this interest- ing but tedious case. I have inserted it to show what perse- verance on the part of the patient will finally accomplish in some cases of chronic suppuration. There were no peculiar means of treatment adopted during the three years the patient was under my care ; but he was informed that it might require years to heal the drum-heads. He realized the danger from a continued suppuration, as well as the inconvenience and dis- comfort, and he determined never to give up the attempt to cure it. Very few patients will submit to such a prolonged observation or treatment without faltering in their allegiance to their medical adviser. Case II. — Suppuration in loth Tympanic Cavities for fifteen years, a result of the Pharyngeal Inflammation of Scarlet Fever— No treatment since first attack— Healing of one Drum-head, with great improvement to Juaring power — Other Membrane still open. Mr. A., set. 26. Nov. 1870— Since patient was 11 years old, when he had 384 CHRONIC SUPPURATION— CASES. scarlet fever, he has had a discharge from Loth ears, with great impairment of hearing. Hearing distance, right ear, ^V ; left, -4V. The membrau paid on each side are removed 1))' ulceration. There is a large amount of pus in each canal, with granulations which bleed readily. The ears were treated by the warm douche, the syringe, and Politzer's method of inflation. The latter at once improved the hearing, so that the watch was heard at 4 inches, ■£$, on the left side. Some inflammatory reaction was caused in a few days by the cleansing process, and the douche only, could be employed. The patient was seen from once to twice a week, and used the douche and an astringent at home. One year after, his hearing distance was, E., -4% ; L., f£. The left membrana tympani has just healed. April 16, 1872, or nearly a year later, having been seen at longer or shorter intervals ever since, and having kept up the treatment at his home, the hear- ing distance of left ear is ff. The patient has still occasional attacks of sub- acute suppuration from right ear. His hearing power for conversation is excellent, and no true pus is found in right tympanic cavity, but some stringy mucus is forced out by Politzer's method. January, 1873 — The patient is stdl seen at long intervals. The condition of the ears remains about the same. Case III. — Suppuration of both- Middle Ears, occurring icithout pain — Half of each Membrana Tympani gone — Moderate amount of pus secreted — Treatment did not avail to improve the Hearing Power — Artificial Mem- brana Tympani used with benefit. E. R. T., set. 28. Nov. 1872— Three months since, patient found, on awaking in the morning, that both ears were discharging. There was no pain experienced in them. He had had naso-pharyngeal catarrh for some time, which had been treated regularly by the use of the nasal douche and the posterior nares syringe. The patient is not in very good general health. He has had a pulmonary hemorrhage, and evidently has phthisis pulmo- nalis. He hears the watch six inches on the right side, two inches on the left. Hearing distance, R., -4%- ; L., 4%. The pharynx is granular. The anterior and inferior quadrant of the membrane is gone. The remainder of the membrane is white, and does not reflect light. The left membrane also has a large perforation, the anterior half being absent, and the remain- der of the membrane looking like the right. There is a moderate amount of pus secreted in the tympanic cavity. The auditory canals are red and sen sitive. The patient has already had more or less systematic treatment, and he cleanses Ms ears daily by syringing. There are great variations in the hearing power. The patient was seen daily for some six weeks, and efforts made to heal the membrana tympani by the use of sulphate of zinc, alum, sulphate of copper, nitrate of silver, in solution and in solid form. Cod-liver oil was given, and the general condition improved, but the membrana? tympani did not heal in the slightest, although the discharge was lessened, and the condition of the audi- tory canals was improved. February 15, 1873. — The patient's hearing power continued to grow worse, when the artificial membranse tympani were inserted, with immediate benefit CHRONIC SUPPURATION— CASES. 385 to the hearing power, so that he could transact his business, which was thai of a commercial traveller. Hearing distance, E., -/g- ; L., -/„-. April 15. — The patient is still wearing the membranes with the same benefit. The ears are daily cleansed by syringing, and an astringent is dropped upon them. Mr. T. says that he cannot hear " at all " without the artificial membranes. It has been a common observation with the patients who use an artificial membrana tympani, that they cannot hear as well after removing the artificial drum-heads, as they did before wearing them. Yet in some cases, the improvement continues for hours after they are removed. The latter effect is probably due to the fact that the restored continuity of the ossicula and the fenestra ovalis is kept up, even after the agent that caused the restoration is removed. Case IV. — Chronic Suppuration of ten year? duration stopped in three days, by the removal of a small granulation through the Drum-head, and the application of nitrate of site r — Rearing power improved. E. E., Nov. 8, 1872, sent to me by Dr. H. C. Eno. When the patient was 16 years old he "got cold in the right ear;" the ear was very painful ; it dis- charged and has continued to do so ever since. It has been under careful treat- ment for some months, and does not discharge as much as it did. The hear- ing: distance is -A 48 On examination, a slight amount of pus is found upon the membrana tym- pani. On removing this, a small granulation is seen to come through the membrane in the anterior and inferior quadrant. November 9. — The granulation was removed by means of a pair of angular forceps. A solution of nitrate of silver, gr. 40 ad 3 j, was applied in the open- ing, after a thorough cleansing of the ear by syringing and Politzer's method. November 10. — The opening in the membrane has closed.. The patient remained under observation until Nov. 22, and suppuration did not again occur. The hearing distance became -4A8-. It may be thought that these cases illustrate the bright side of the treatment of chronic suppuration ; but I do not 'think they are any more than average specimens of cases of simple ulceration, that is, ulcerations unattended by death of bone. "When caries or necrosis of any part of the walls of the cavity has occurred, the prognosis is very unfavorable for a perfect arrest of the morbid process. I have not found so much difficulty in relieving uncomplicated cases of chronic suppuration, as in finding patients who were patient enough 386 CHRONIC SUPPURATION — CASES. to submit to the tedious treatment necessary to a cure. Dis- trust of the advice of the profession is nowhere more common than in cases of chronic suppuration, in regard to which the laity have been taught two erroneous and contradictory doc- trines, first, that a discharge from the ear is seldom checked ; second, that it is dangerous to arrest it, if we can.