DISEASES
CHT MO
A 57643 7
EAR.
STERLING
H6173
584
གས
ལ་
ལྟ་༢༠
નામના સ્થા
પણ બાપા અય્યા હોવા
અન્ય કાર
འ་
حمود
اد الشوربا
ཅཅན་
ན་ཡོདས ་འཐགགས
༨ ནས་

ARTES
1837
SCIENTIA
VERITAS
LIBRARY
OF THE
UNIVERSITY OF MICHIGAN
E-PLURIBUS UNUM
SI-QUAERIS PENINSULAM AMOENAM
CIRCUMSPICE
t
མལ་ནད་
874
The Diseases of the Ear
AND THEIR
52615
HOMEOPATHIC TREATMENT,
WITH A BRIEF OUTLINE OF THE
Anatomy, Physiology and Pathology.
DESIGNED AS A MANUAL
FOR THE
Student and General Practitioner,
BY
CHARLES FREDERICK STERLING, M. D.-O. et A. Chir.
Assistant Surgeon to the New York Ophthalmic Hospital; Lecturer
in the College of the New York Ophthalmic Hospital; Assis-
tant to the chair of Clinical Otology in the New
York Homoeopathic Medical College; At-
tending Physician to the Five
Points House of Industry,
etc., etc.
NEW YORK:
A. L. CHATTERTON PUBLISHING COMPANY.
1885.
COPYRIGHT:
A. L. CHATTERTON PUBLISHING CO. ·
1885.
DEDICATΙΘΝ.
TO THE
NEW YORK OPHTHALMIC HOSPITAL,
AND TO MY
ASSOCIATES ON ITS STAFF,
THIS MANUAL IS
DEDICATED
In recognition of the opportunities afforded for experi-
ence in special work, and in memory of pleasant
intercourse with my co-workers.
PREFACE.
This little work is the outgrowth of a want felt by
myself when first commencing the practice of medicine.
for a small handy treatise on the examination and diag-
nosis of the more common diseases of the ear, and their
homoeopathic treatment. None such was at hand. The
classical works of Roosa, Von Troltsch, and Politzer
were to be had, but they were expensive. more elaborate
than I then cared for, and they contained no help for me
as a homœopathist. Dr. Winslow's book has since made
its appearance, but while excellent, it is also elaborate
and expensive, so that it seemed to me a little aid might
perhaps be given to those who were similarly situated
to myself, and possibly to another class; i. e.: those
physicians, who in practice before otology had reached
its present development, wished for practical directions,
and conscise statement, without theory. This aim I have
kept carefully in view. Sufficient of anatomy has been
given to render the physiology plain and make intelligi-
ble the effect of lesions; more has been purposely with-
held, as tending to confuse. This is not designed to
take the place of the larger works in any respect.
In regard to treatment, I am firmly convinced that
we are not yet in a position to dispense with local meas-
ures; our therapeutics are still too meagre in this
department. The indications given for remedies, are
14
PREFACE.
the results of the experience of Homoeopathic aurists in
this city and elsewhere, gathered from various sources
in our literature, as they have made their appearance.
They have not been compiled from the materia medica
on theoretical grounds. The authority for their use and
results can be given in nearly every instance. Every
statement made in regard to treatment, unless other-
wise qualified, has been verified time and time again by
my colleagues and myself, both in private practice and
the clinics of the New York Ophthalmic Hospital.
I take pleasure in expressing my thanks to those
who have kindly assisted me in the preparation of this
work by their advice and suggestions: Drs. Liebold,
Geo. S. Norton, Leal and Mac Bride. To Dr. Houghton
I am under many obligations for valuable information,
and practical points in treatment, given during several
years.
In conclusion let me say, I do not doubt that there
are many who could have done this work better than
myself, but they did not do it. It is my humble effort
towards bringing about a better appreciation of the
importance of diseases of the organ of hearing.
152 West 34th St., NEw York.
Feb. 28, 1885.
C. F. STERLING, M. D.
CONTENTS.
CHAPTER I.
ANATOMY OF THE EXTERNAL EAR
•
CHAPTER II.
PAGE.
17
ANATOMY OF THE MIDDLE EAR...
26
CHAPTER III.
ANATOMY OF THE INTERNAL EAR..
33
CHAPTER IV.
INSTRUMENTS AND METHODS OF EXAMINATION.
36
DISEASES OF THE EXTERNAL EAR..
CHAPTER V.
Circumscribed inflammation..
Homœopathic remedies
·
Diffuse inflammation
Local treatment.....
Homoeopathic remedies.
42
43
44
45
47
49
CHAPTER VI.
OTHER DISEASES OF THE EXTERNAL EAR.
Impacted cerumen and method of removal.
52
53
Foreign bodies..
57
Parasitic growths
58
•
CHAPTER VII.
CATARRHAL DISEASES OF THE MIDDLE EAR.
60
Hyperemia.
61
Acute catarrhal inflammation.
62
Local treatment..
68
•
Homœopathic remedies..
73
77
Earache from carious teeth..
CHAPTER VIII.
CHRONIC CATARRHAL INFLAMMATION OF THE MIDDLE EAr. 79
16
CONTENTS.
CHAPTER IX.
PAGE.
90
91
93
94
• •
•
100
TREATMENT OF CHRONIC CATARRHAL INFLAMMATION.
Eustachian catheter, method of introduction..
Applications through Eustachian catheter.
Applications to throat and naso-pharynx
Homœopathic remedies. . .
CHAPTER X.
SUPPURATIVE INFLAMMATION OF THE MIDDLE EAR...
•
Differentiation between acute catarrh and acute
Acute suppuration
Etiology.
suppuration .
Local measures.
Chronic suppuration
Appearances and conditions
108
109
113
114
115
117
118
CHAPTER XI.
COURSE AND CONSEQUENCES OF SUPPURATIVE INFLAMMA-
TION OF THE MIDDLE EAR...
Results of chronic suppuration.
Mastoid disease.
Symptoms of mastoid disease.
CHAPTER XII.
Brain complications.
124
128
129
131
134
TREATMENT OF SUPPURATION OF THE MIDDLE EAR .... 138
Local measures.
Local treatment of mastoid disease.
Homœopathic remedies.
CHAPTER XIII.
139
145
147
•
DISEASES OF THE INTERNAL EAR.
Homœopathic remedies.
CHAPTER XIV.
154
160
•
ADDITIONAL MEANS FOR THE RELIEF OF DEAF PERSONS... 164
CHAPTER I.
ANATOMY OF THE EXTERNAL EAR
AND
MEMBRANA TYMPANI.
An intelligent treatment of the diseases of the
ear, must be based upon an intelligent knowledge
of its anatomy and physiology.
The ear is technically divided into three parts,
known respectively as the external, middle, and
internal ear. The external portion comprises the
auricle, and the canal, known as the meatus; the
middle includes the air chamber, or drum, with
its adjacent portions of mastoid cells and eustach-
ian tube, while the internal ear or labyrinth
includes the vestibule, the semicircular canals,
and the cochlea, within which portion is the ulti-
mate distribution of the auditory nerve.
It may be definitely accepted that the auricle
has a certain function in the collection and
direction of sound waves. This is accomplished
both by its outline, and the numerous foldings
and irregularities of its surface, each of which
has its appropriate name. These are maintained
18
ANATOMY OF THE EXTERNAL EAR
in shape by the material of which the auricle is
formed, which is cartilage of the reticular variety.
This is absent in the lobe, which is made up skin
and cellular tissue, but forms about one-third of
the canal. The names of the various eminences
and depressions are unimportant, and can be
readily learned from Gray.
The skin of the auricle is a continuation of that
of the face, and differs from it in no important
particular. The inner two-thirds of the canal is
bony, but at birth this is entirely membranous,
the only bone in the canal being a small incom-
plete ring at its inner end, and known variously
as the tympanic bone, the auditory process, or
annulus tympanicus. This small bone, in shape
somewhat like a diminutive hyoid bone, com-
mences its ossification at about the third month
of fœtal life, and it is from this developing out-
wards after birth, that the anterior and inferior,
and a part of the posterior wall of the osseous
meatus is formed. This bone at birth exists en-
tirely independent of the other portions of the
temporal bone, to which it becomes united during
the first year of life.
The superior wall is formed from the squamous
portion of the temporal bone, growing outwards in
the same manner as the other walls do from the
tympanic ring, to which it in due time becomes
united, thus giving the perfect bony meatus.
AND MEMBRANA TYMPANI.
19
>
Sometimes there is a failure of bony development
in this wall, leaving gaps or fissures, the impor-
tance of which will be referred to later on. The
posterior wall as before said, is developed partly
from the tympanic ring, and partly from the
mastoid portion of the temporal bone.
This completed meatus is not perfectly straight,
but slightly twisted and bent, the most constant
feature of which is an elevation near the middle,
pointing upwards and backwards, so that on the
introduction of the speculum, the auricle must be
drawn upward and backward to straighten the
canal and obtain a view of the membrane. At
about the central portion of the canal, there is a
slight constriction, making it narrower at this
point than at either extremity. In the inferior
wall are slight depressions filled with fibrous
tissue, and called the incisuræ Santorini. There
is a difference in the length of these various
walls, of which the superior and posterior are
the shortest, and the inferior and anterior the
longest.
The canal is lined with a continuation of the
skin of the auricle, in which are found hair
follicles, sebaceous and ceruminous glands. The
skin grows outward from the membrana tympani
as the nails grow outward from the matrix, and
in this manner assists in the removal of the wax
and other material in the canal. Attached to
20
ANATOMY OF THE EXTERNAL EAR
the auricle and within it, are various small
muscles, which are the rudimentary analogues of
muscles in various animals, but as they have no
function in man, they will not be discussed.
The relations which the external auditory
canal bears to certain structures, are so important
that they must be briefly described.
The superior wall growing outwards from the
squamous portion of the temporal, is formed of
two plates of exceedingly thin bone. The upper
one is a portion of the floor of the middle fossa
of the skull, while the lower one is the roof of
the canal. Between these two thin plates are
cellular spaces varying in size and number.
Thus it is seen that this slight osseous lamina is
the only division between the canal and a portion
of the brain, and in cases where a failure of bony
development has occurred, the only separation is
the soft tissue of the canal lining, and the brain
membranes. The posterior wall is the only di-
vision between the meatus and the transverse
sinus and it is also in close relation to the mas-
toid cells. The anterior and inferior walls are in
relation to the parotid gland. The importance of
these statements as well as similar ones concern-
ing the middle ear, will be seen when discussing
suppuration.
THE MEMBRANA TYMPANI.
This membrane is the boundary between the
AND MEMBRANA TYMPANI.
21
external and middle ear, and possesses relations
to both. Preceding its description, must be given
that of the annulus tympanicus in which it is
set. This small bone forming the junction be-
tween the temporal bone and osseous meatus is
U shaped. It is grooved for the reception of the
membrane. Its anterior and posterior extremities
are important topographical points, and have
received the names respectively, of the major and
minor spines. A line drawn from one to the
other represents the superior boundary of the true
membrane. The groove in which the membrane
is received, is lined with cartilage, and known as
the sulcus tympanicus; the deficiency in the
superior portion is called the segment of Rivinius.
The membrana tympani or drum head, is the
vibrating membrane at the botton of the the audi-
tory canal, which receives the impressions of the
sound waves, and passes them on toward the in-
ternal ear. It is a delicate structure, of an ellip-
soidal shape, the long diameter of which is on
the average from 9 to 10 m. m. Its transverse
diameter is a little less, the proportion between
the two being about 4. 3./// to 4. 0./// Its boun.
dary lines are those of the canal, at the bottom
of which it stands, except at the superior border,
which corresponds with a line drawn from the
major to the minor spine. Above this line there
is still a certain space, occupied by a membrane
22
ANATOMY OF THE EXTERNAL EAR
of different texture, filling up and completing the
elliptical area at the end of the meatus. This
membrane is known as Shrapnell's, or from its
looseness, as the membrana flaccida.
The true membrane, or that portion lying
below the line between the two spines, is the part
principally eoncerned in the transmission of
sound. This is made up of three separate and
distinct layers, yet its total thickness is but 1-250
of an inch. Its outer layer is a continuation of
the skin of the canal, which is here modified in
its structure, possessing neither hair follicles nor
glands. Its inner layer is mucous membrane, con-
tinuous with that lining the middle ear, but so
intimately adherent to it that it cannot be sepa
rated from it, as can the outer layer. The middle
layer is the one upon which the function of the
membrane depends, hence it must be firm, capable
of being made tense without stretching, and also
possessed of a certain degree of toughness.
These qualities are given to it, both by the ma-
terial out of which it is formed and the manner
in which this material is used. This material is
fibrous tissue, arranged in lamellae, so that in its
composition the fibres run in different directions.
There are two principal sets of these fibres, an
outer one next the epidermal side, of radiating
fibres, and an inner one next the mucous membrane
side, of circular or concentric fibres, so that the
AND MEMBRANA TYMPANI.
23
two together bear some resemblance to the web of
the geometric spider. By this arrangement,
strength, firmness and inextensibility are given
to the membrane. This fibrous layer is called
the membrana propria, and when a portion has
been destroyed by suppuration is never replaced
by the same substance, but by cicatricial tissue.
At the periphery all these various fibrous lamel-
lae becomes closely united and reinforced, and
form what is called the annulus tendinosus,
which is attached by periosteum to the groove in
the annulus tympanicus. Shrapnell's membrane,
or that portion above the line of the two spines,
is destitute of this middle layer, which gives it a
much looser character.
It will be remembered that mention was made
of the varying lengths of the walls of the canal.
From this it follows that the membrane closing
up the end, does not stand in a vertical plane,
but must possess a certain obliquity. The su-
perior and posterior wall being the shortest, the
upper and posterior portion of the membrane
must be nearer the orifice, hence nearer the eye
of the observer, while its lower and anterior por-
tion, to meet the longer inferior and anterior
wall, must be farther away, which fact must be
borne in mind when examining an ear. The
angles which the membrane makes with the su
perior and inferior walls respectively, are 140 and
24
ANATOMY OF THE EXTERNAL EAR
50 degrees. As every ear is subject to individual
variations, the measurements given here are only
an approximation to an average.
Not only does the membrane possess the ob-
liquity above described, but there are certain
peculiarities of its surface with which we must
become familiar. Passing downward and back-
ward through the membrane to its centre, is seen
an elevated ridge terminating in a whitish or
yellowish spot. This ridge is the handle of the
malleus, the manubrium, and its yellowish ex-
tremity, the umbo. At its upper extremity is
seen a more marked projection like a pimple,
which is the short process of the malleus. From
the tip of the manubrium, extending downward
and forward to the periphery of the membrane, is
a triangular white spot, its apex at the umbo and
its base at the periphery. This is the light spot,
or triangle of light, produced by reflection from
the surface of the membrane. These three
features in the normal ear must be well studied,
as it is upon their variations in pathological con-
ditions, that much of diagnosis and prognosis de-
pends.
Besides the obliquity and the three points just
mentioned, the membrane has another pecu-
liarity. It is depressed at the umbo, as if slightly
drawn in at that point, which is the case, while
the radii from the umbo to the periphery are
AND MEMBRANA TYMPANI.
2.5
arched, with the convexity outward. This is
because of the resisting influence of the circular
fibres, to the indrawing influence at the tip of
the manubrium. This degree of depression
should also be made familiar, as in the chronic
catarrhal process it is much increased with con-
The
sequent distortion of the other features.
general color of this membrane is a grayish lus-
trous opacity, very similar to the false Roman
pearls, except at the light spot, which is a bril-
liant white. It varies within certain limits in
different individuals. The blood supply will be
given in discussing congestions.
CHAPTER II.
ANATOMY OF THE MIDDLE EAR.
The middle ear demands close consideration,
not only because much the larger proportion of
aural diseases are found here, but because an in-
telligent comprehension of its character, which is
not difficult, will enable the general practitioner
to successfully care for many of its troubles,
which too often are neglected, either through ig-
norance or carelessness.
The primary function of the middle ear is not
to confuse students, as I was once told by one of
mine, but that of a protection to the internal ear.
Interposed between the external and internal
ears, it must have a special adaptability to fa-
cilitate the transmission of sound waves, while
performing its office as a guard. Let us see how
this is accomplished. It is a cavity hollowed
out in the temporal bone, containing air fur-
nished by way of the eustachian tube. It is
wedge shaped, the thick part at the top, narrow
ing to a mere chink at the floor. Its lateral edges
are known respectively as the anterior and pos-
ANATOMY OF THE MIDDLE EAR
27
terior walls, its top as the roof or tegmen tym-
pani, the surface covered by the membrane as the
outer wall, while that next the internal ear, as
the inner or labyrinthine wall.
In this cavity hang three little bones, the ossi-
cles, the outer one of which is attached to the
membrane, while the inner one communicates
directly with the internal ear. Vibrations of the
membrane are communicated to and through
these bones, making ultimately an impression on
the fluid in the internal ear, in which float the
receptive filaments of the auditory nerve. The
first one, known as the malleus, has a rounded
upper extremity called the head, and a long
tapering inferior extremity, the manubrium. Be-
tween the two is a constriction called the neck.
This is suspended from the roof by a short round
ligament, while the lower extremity is received
into a sort of sac in the membrane between the
two fibre layers, the tip only being firmly adhe-
rent. From the neck ligamentous fibres spring
forward and backward towards the two spines,
known as the anterior and posterior ligaments,
and serve as guys. Between these two the mal-
leus swings, and these guys are together called
the axial ligament. It has other attachments
which serve merely to limit its motion.
Suspended in the middle of the cavity is the
second ossicle, the incus or anvil. On the side
28
ANATOMY OF THE MIDDLE EAR
toward the malleus is a depression in the body
of the bone into which fits the side of the malleus
head. This is furnished with articulating carti.
lage and a capsular ligament. This joint has a
peculiar modification, by which in the act of
hearing, the malleus and incus become firmly
locked at this joint, and motion communicated to
the malleus by vibrations of the membrane is
partaken in by the incus, which also has limiting
and suspensory ligaments. On the side of the
incus opposite the malleus is a long curved de-
scending process, which unites at its tip with the
third ossicle, the stapes or stirrup. This is ex-
actly like a very diminutive stirrup of a riding
saddle. Its broad base lies against the inner
wall of the cavity over an oval foramen, covered
by a thin membrane, which prevents the fluid of
the internal ear, lying upon the other side of this
membrane, from pouring out into the middle ear.
This base is fastened over this oval window by a
species of capsular ligament, allowing a certain
degree of motion. The small head of this stirrup
is articulated with the descending process of the
incus.
Thus we find natures method of establishing
communication between the external and internal
ear, through the protecting middle ear. Vibra-
tions of the membrana tympani move the malleus,
which in turn moves the chain, and the various
ANATOMY OF THE MIDDLE EAR
29
degrees of movement are impressed upon the
fluid containing the sensitive nerve filaments,
which receive and differentiate these impressions
into intelligible sound-from the wooed maidens
whispered 'yes'-to the crash of the liberated
lightning. Conduction then is the second func-
tion of the middle ear.
That this may be perfectly accomplished cer-
tain adjuvants are necessary. These are found
in sundry muscles, the eustachian tubes, and the
mastoid cells. The most important of the mus-
cles is the tensor tympani. On the anterior wall
in its upper portion is seen the orifice of a small
canal, from which emerges a tendon. This passes
across the cavity to the malleus, being inserted
near the neck, on the inner and anterior side of
the manubrium. Its muscular portion is confined
within its canal from which it arises. Just below
the point where this tendon emerges is a large
opening, the mouth of the eustachian tube, which
runs from the middle ear downward, forward and
inward, to the lateral wall of the nasopharynx.
It is about one inch in length. The third towards
the tympanum, is hollowed out of the petrous
portion of the temporal bone. The two-thirds
towards the pharynx is of cartilage and soft
tissue, the walls of which are flattened and ap-
proach each other very closely. This is lined
with mucous membrane. The function of the
30
ANATOMY OF THE MIDDLE EAR
eustachian tube is to convey air to the middle
ear, and serve as a drainage tube into the throat
for its secretions.
On the posterior wall, directly opposite the
eustachian tube, are the openings of the mastoid
cells. These are all situated in the mastoid pro-
cess, and are supposed to serve both as a safety
chamber to modify dangerously loud sound
shocks, and also as a reverberating or resonance
chamber to intensify weak sounds.
The mastoid cells and the cavity of the tympa-
num are lined with a continuous mucous mem-
brane which has certain peculiarities. That portion
of it lying next the bone performs the function
of periosteum, while the more superficial layers
possess the properties of both mucous and serous
membranes. Upon the outer wall, this forms the
inner layer of the membrana tympani.
At the upper portion corresponding to Shrap-
nell's membrane, this lining reaches to the roof,
and returning upon itself forms a fold or pouch.
This is divided by the malleus into the anterior
and posterior, of which the latter is the most dis-
tinctly defined. These are known as the pockets
of Troltsch.
On this same outer wall, one in front of, and
the other behind the membrane, are two openings
in the bone, from the posterior one of which
emerges the chorda tympani nerve, which passes
ANATOMY OF THE MIDDLE EAR
31
forwards just beneath the malleo-incudal joint,
and makes its exit through the anterior one.
These two openings are known as the iter chordae
anterius and posterius. This nerve, a branch of
the facial, has nothing to do with the ear, merely
passing through it, as a short cut through a
neighbor's yard.
These are the principal points in the anatomy
of the middle ear. There is very much more
detail that is purposely omitted as it would only
tend to confuse. Therefore after a brief consider-
ation of the size of this little cavity which con-
tains many wonderful things, and its relations,
we will pass to the next division. It was com-
pared to a wedge standing vertically. Its width
is about half an inch; its height varies from half
to three-fifths of an inch in different portions.
From the membrane to the inner wall it is only
about one-twelfth of an inch. Later on will be
seen what an important factor this is in certain
pathological conditions, in interfering with the
free vibrations of the drum head.
The relations which various parts of this cavity
bear to important structures must not be forgot-
ten. The roof is directly under the middle fossa
of the skull. When the bone fails to be com-
pletely developed, there are often gaps or fissures
here, and the only barriers between this and the
cranial cavity are the respective linings of each.
32
ANATOMY OF THE MIDDLE EAR
The anterior wall lies close to the carotid canal,
and is also occasionally deficient. The inferior
wall lies directly above the jugular fossa and so
in close relation to the bulb or sinus of the
jugular vein. The posterior wall and mastoid
are in a correspondingly close relation to the
transverse sinus; so we see in how close proximi-
ty to important structures is this little cavity,
and how serious the consequences may become
if a purulent process passing to necrosis remains
uncared for.
CHAPTER III.
ANATOMY OF THE INTERNAL EAR.
It is not in accordance with the plan of this
work to discuss the internal ear and its diseases
at length, but a few remarks upon it are appro-
priate.
It is the seat of the ultimate distribution of the
auditory nerve, situated in the most protected
portion of the petrous part of the temporal bone.
It has three general divisions, known as the ves-
tibule, the semicircular canals, and the coch-
lea. The three together are called the labyrinth.
Various filaments of the auditory nerve are dis-
tributed to these different parts, for the perform-
ance of special functions. Those in the vestibule
and semicircular canals are supposed to represent
sound as such, not its particular character or
quality. The semicircular canals are thought to
have the added function of aiding in maintaining
the equilibrium of the body, or as it is termed, the
function of orientation. The cochlea is the most
highly specialized portion, and to it is referred
the differentiation of sound into articular speech,
34
ANATOMY OF THE INTERNAL EAR
different tones in the scale, chords of music, and
the like.
The anatomy of the internal ear is most minute
and complex. The vestibule, as its name implies,
is the entrance chamber to the semicircular can-
als on the one side, and to the cochlea on the
other. This, as well as the canals and cochlea, is
filled with a serous fluid called the perilymph,
in which float the nerve filaments. This peri-
lymph is supposed to be in communication by a
minute opening with the arachnoid fluid of the
brain. Within the vestibule are two little mem-
branous bags, known as the saccule and utricle,
distended by a fluid called the endolymph. These
serve as a support to certain portions of the vestib-
ular branch of the auditory nerve. The com-
munication of the vestibule with the middle ear,
as before said, is by the fenestra ovalis, which is
closed by a membrane, against which rests the
footplate of the stapes.
The semicircular canals are of bone. Inside of
them is a membranous expansion, taking the
same shape as the bony canals, and known as the
membranous semicircular canals. These also are
distended by endolymph, and like the saccule and
utricle, afford support to another portion of the
ultimate nerve filaments. The utricle, saccule
and membranous canals, are together known as
the membranous labyrinth, along with certain
ANATOMY OF THE INTERNAL EAR
35
membranes in the cochlea serving a similar pur-
pose.
The cochlea is a tube, wound two and one-half
times about a central pillar. This tube is sub-
divided into two by a partly bony, partly mem-
branous division, reaching from the central pillar
across the middle of the tube. One of these small-
er tubes starts from the vestibule, winds around
the central pillar to the top, and winds down
again on the other side of the bony and membra-
nous division, ending at what is called the round
window, on the inner wall of the middle ear.
This round window is tightly closed by a fibrous
membrane, which serves as in the fenestra ovalis,
to prevent the perilymph from running out into
the middle ear. The central pillar is perforated
at its base, and receives the cochlear branch of the
auditory nerve. The trunk of this branch ascends
the pillar which is hollow. The walls of this hol-
low center are perforated by numerous foramina,
through which emerge the terminal filaments of
this cochlear branch, resting upon the bony and
membranous division of the cochlear tube. Upon
this division is built a wonderfully intricate little
structure called the organ of Corti. It is upon
this little organ of Corti that the ultimate recep-
tive nerve filaments finally rest, and the duty de-
volves of differentiating impressions received by
the fluid into the various tones which we perceive.
CHAPTER IV.
INSTRUMENTS AND METHODS OF EXAMINATION.
In an examination of the ear we are obliged to
use certain specially adapted instruments. Goethe
says:
"He who some results intends, must use
the tools that best are fitting."
It is not necessary in such examinations and
treatment of the ear, as this little book is de-
signed to aid, that the practitioner should possess
a complete specialists outfit. All that is neces-
sary can be purchased for twenty or twenty-five
dollars. The following list is sufficient for all
ordinary purposes of diagnosis and treatment.
Aural mirror with head band.
A set of three specula.
A cotton holder.
One or two looped probes, known as Buck's
curettes.
A small pair of dressing forceps.
A pair of angular forceps.
A Politzer bag, tube and nose piece.
A pneumatic speculum known as Siegle's.
A hard rubber syringe.
INSTRUMENTS AND METHODS
One or two eustachian catheters, hard rubber.
Two rhinoscopic mirrors.
A powder blower.
Tuning fork.
The aural mirror is concave with a metal back-
ing, to which is attached by a universal joint the
head band. This mirror is perforated in the cen-
ter to allow direct vision in the axis of the re-
turning rays. The best average size is three and
a half inches in diameter, which is large enough
to be used also for laryngoscopic examinations.
Ear specula come in sets of three sizes. Metal
ones are the best. These come both in solid sil-
ver, and plated, which are just as good. There
is a most decided choice in the selection of these
specula according to their shape. Those with an
oval extremity are greatly to be preferred as more
nearly fitting a cross section of the meatus, and
thus gaining the greatest available area. Toyn-
bee's modification of Wilde's speculum meets all
the requirements.
The cotton holder is a slender steel shaft, made
tapering from the handle to a very delicate
roughened extremity, upon which a tuft of cot-
ton is twisted. This should be quite stiff for two-
thirds of its distance from the end of the handle,
but quite malleable and flexible in its other third.
A cotton holder that is slender and springy near
the handle is a nuisance.
38
OF EXAMINATION.
The Buck's curette is similar to the cotton hold-
er but has a looped end. Two sizes are desirable.
These are frequently made too thick and clumsy.
They are also made perfectly straight. I prefer
one in which the extremity is made quite delicate,
and anneal it for about one inch from the end.
This permits of a very slight bending of the
looped end, not more than 5º or 8° from the axis
of the shaft, but it is of great assistance in remov-
ing foreign bodies, etc.
The dressing forceps will be of great assistance
in removing soiled cotton from the holder, etc.
The angular forceps commonly on sale will an-
swer most of the purposes for which they are
needed, but a much better form though a trifle
more costly, is the scissor jointed and handled
angular forceps. There is less spring in the
blades, and a firmer grasp. A pair bent on the
flat and opening horizontally is preferable to
those bent on the edge and opening vertically.
The politzer bag needs a short description.
This is made of soft rubber, in the shape of a
balloon, with a valve opening inward at the large
end, and a hard rubber or ivory nozzle at the
other, to which may be attached a long gum
tube with a nose piece. This is used to force air
through the nostril and eustachian tube into the
middle ear.
The pneumatic speculum is an important in-
INSTRUMENTS AND METHODS
39
strument. This consists of a small hard rubber
cylinder with a glass end. To the other end is
screwed a hard rubber speculum. From the side
is a small opening to which is attached a piece of
gum tubing ending in a mouth piece. The spec-
ulum being inserted in the canal, and suction
made on the mouth piece, the membrane can be
seen to move under the exhaustion. The degree
of mobility is an important factor in diagnosis.
and prognosis. The instrument also has a direct
value in treatment.
The rubber syringe may be of most any size; one
or two ounces is the most convenient. It should
be a one hand syringe. I have found the most
convenient form of nozzle to be a tapering cone,
over which I slide the large end of a eustachian
catheter. The reasons will be shown when
speaking of the use of the syringe. A couple of
eustachian catheters, two rhinoscopic mirrors of
different sizes, a powder blower and tuning fork
complete the list.
Now having our instruments we will proceed
to examine a patient. The first requisite is a
good light. I have made satisfactory examina-
tions with a candle, but a good argand gas burner
is the best. Where gas is available, no more con-
venient and simple arrangement can be found
than what is known as the "parallel bracket."
This is made by Mitchell, Vance & Co., of this
40
OF EXAMINATION.
city, and is a bracket attached to the gas pipe in
the wall, possessing a universal motion. Its cost
is between five and six dollars. Next to this
comes the drop light. Where gas is not in use
the ordinary student lamp gives an excellent illu-
mination. The patient should take his seat with
the light behind him, and a piano or other revolv-
ing stool much facilitates his turning. Suppose we
desire to examine the right ear; let him turn his
right side to you, the light being an inch or two
above the level of his head, and a little in front
of it. This allows the rays to fall on the mirror
placed on your head without obstruction, which
reflects it on the ear. Taking a suitable sized.
speculum you gently introduce it into the meatus.
Take the ear between the first and second fingers
of the left hand and draw it upward and back-
ward. This straightens the canal, and with the
free thumb, gently press the speculum in as far
as necessary. Learn to do all this with one hand,
and in this way. If awkward at first, it will soon
be very easy, and you will have enough to occu-
py the other hand. Then directing the light into
the speculum, study the canal and the membrane
at your leisure. Then turn your patient about
and study the other.
As most patients consult you for deafness, it is
well to have a standard for testing. There are
various ones in use by specialists, but the watch
INSTRUMENTS AND METHODS
41
is the most useful and handy. A person with
normal hearing can hear an ordinary watch at
about twenty or twenty-four feet. Whatever it
may be, let it represent the denominator of a
fraction. Suppose it twenty feet, and your pa-
tient hears it only at ten feet. The fraction 10-20
represents his hearing power, or one-half of nor-
mal. This expression will be intelligible to au-
rists the world over.
The tuning fork is used to differentiate between
diseases of the conducting apparatus and those
of the nerve; in other words between the middle
and internal ears. Some discussion has been
going on recently as to its actual value, but its
test has generally been regarded satisfactory.
Sounding it, hold it near the patient's ear.
Sound it again at the same intensity, and touch
the tip of the handle to the teeth, the forehead or
vextex, or the mastoid process. If he now hears
it better, it is accepted as proof that the lesion is
in the conducting apparatus, because in a normal
ear the conducting power of the bone is less than
that of the middle ear in response to sound waves
on the membraue. This is spoken of as aerial
conduction, and bone conduction.
We have now placed our patient in position,
we have tested his hearing, now what patho-
logical conditions may we find in his ears? These
we will take up in their order from the outside.
CHAPTER V.
DISEASES OF THE EXTERNAL EAR.
(Otitis Externa, Circumscripta et Diffusa.)
In discussing the diseases to which the ear is
subject, it is well to bear in mind one general
fact, that diseases are limited by the character of
the tissue in which they are found. For instance
serous inflammations are not found in muscular
tissue. So in the ear, diseases of its external
portion are those peculiar to the skin, cartilage,
etc. In the middle ear they are those to which
mucous membranes are subject, while in the inter-
nal ear, lesions characteristic of serous cavities.
are found. As beneath all lies bone, so when the
morbid process has become deep enough, perios-
titis, caries and necrosis are always possible.
The two most prominent diseases of the exter-
nal ear are circumscribed and diffuse inflamma-
tions. Both of these are again subdivided into
the acute and chronic forms. Taking up the
acute circumscribed variety first, we find it is
simply a small phlegmonous abscess or furuncle,
which, analagous to styes upon the eyelids, is a
DISEASES OF THE EXTERNAL EAR
43
localized and very painful affection. The most
frequent seat is just within the meatus, on the
anterior and inferior wall, though it is found at
any portion of the canal. Its most prominent
symptom is pain, which often is of an exceeding-
ly acute character. Great tenderness is another
feature, so much so that traction upon the auricle
often causes the patient to cry out. It is accom-
panied by swelling, sometimes confined to its
immediate vicinity, while occasionally the whole
canal partakes. If the furuncle occurs in the bony
portion of the meatus, the pain is usually greater
than when in the cartilaginous portion, on ac-
count of the unyielding character of the tissue.
The swelling often closes the meatus, so that a
view of the drum head cannot be obtained. If
its location happens to be near the membrane, it
also will become congested from proximity.
In the majority of cases the diagnosis is easy.
Careful touching with a probe will usually reveal
a circumscribed area of greater tenderness than
elsewhere. From the swelling of the canal, deaf-
ness is a very frequent accompaniment. Ringing
in the ears (tinnitus) is present when the boil is
near the membrane. When nearer the orifice it
is not so common. Constitutional disturbance,
such as fever, headache, loss of appetite, etc., are
frequently present. These boils, like others, are
prone to successive appearances. Usually they are
44
DISEASES OF THE EXTERNAL EAR
single, though two may be found. Their natural
duration is from eight to ten days-sometimes
longer. Treatment will often abort them and
prevent the recurrence of others.
The most frequent cause is a run down condi-
tion of the system, either from malnutrition, or
excessive waste, such as prolonged anxiety, social
dissipation, etc. They are more common in adults
than children, and most frequent in the spring.
The most common method of treatment in the
old school is free incision. We seldom resort to
it. Certain remedies seem to possess almost a
specific affinity for this affection. They are
Hepar sulphuris, Picric acid, and Calcarea pi-
crata. The pain, the swelling, and the tenderness
are common to the three remedies, but in Hepar
sulphuris the constitutional symptoms are more
pronounced, and the swelling and infiltration
greater. Itching is often felt. Picric acid, when
it is more limited. Calcarea picrata, though as
yet without a proving, seems to combine the qual
ities of both. It was introduced by Dr. Hough-
ton, and since then (some two or three years) I
hardly use anything else. In the great majority
of cases, twenty-four hours relieves most of the
symptoms, and two or three days suffices to bring
back the ear to its normal condition. A little
plug of cotton saturated with glycerine is said to
greatly allay the pain in this affection.
DISEASES OF THE EXTERNAL EAR
45
The chronic form of circumscribed inflammation
is an ulceration. It is so rare and when seen
generally in connection with other troubles,
that the space for its description can be more
profitably employed. This may occur from in-
flammatory action, but is most commonly the re-
sult of syphilis, epithelioma caries or necrosis.
DIFFUSE EXTERNAL INFLAMMATION.
(Otitis Externa diffusa.)
The diffuse form of inflammation is a painful,
sometimes obstinate, offensive disease, trying to
the patient and physician as well. In the acute
variety it commences with itching, followed by
pain, which continues almost uninterruptedly,
though it may be less intense at various times.
There is congestion and swelling of the whole ca-
nal lining, in which even the drumhead partakes.
With this there is fever and constitutional dis-
turbance. Side by side with the swelling appear
deafness and tinnitus. Soon the swollen and in-
filtrated tissue begins to break down, not at one
point as in the circumscribed form, but at many,
so that even the whole canal may become a sup-
purating sore. The discharge is at first of a
serous character, sometimes tinged with blood,
and usually very copious. Soon this becomes a
true purulent discharge. This may gradually
46
DISEASES OF THE EXTERNAL EAR
diminish in quantity, and pass over into a chron-
ic form, or the inflammatory action may go more
deeply, and involving the tissues beneath, set up
a periostitis, caries, necrosis, and even death,
though such a course is not common. It is quite
prone to assume an indolent character, the tissues
becoming boggy and sodden, granulations spring-
ing up, bleeding easily, and discharging an of-
fensive ichorous fluid that excoriates the auricle
for some distance from the meatus.
Accompanying the earlier stages is frequently
a swollen and tender condition of the glands.
about the ear, and pain on moving the jaw.
There are two varieties, known as the primary
and consecutive forms. The latter is most gener-
erally secondary to middle ear suppuration, is
much less painful than the primary form, and
is of a chronic nature from the first.
The primary form may be purely idiopathic in
its origin, but by far the greater proportion of
cases are due to some local irritation. Writers
dwell on, and clinical experience confirms, the
danger arising from the habit of scratching the
meatus with improper things, such as pins, wood-
en and quill toothpicks, and similar articles.
The results which may follow this disease are
various. Complete restoration of course occurs
in many cases. In others, strictures, adhesion of
the walls, fistulæ, etc., may follow. It is much
DISEASES OF THE EXTERNAL EAR
47
more rare than the circumscribed form. The
diagnosis is sometimes easy, sometimes not, that
is as to its primary or consecutive character. If
a view of the drumhead can be obtained, the
question is solved at once, but in the majority of
cases this cannot be seen, and we are forced to
wait until it becomes visible. In such cases the
history of the case must be taken into considera-
tion. It is important, however, to ascertain the
condition of the middle ear, to learn whether an
inflammatory condition there is complicating the
trouble. This is especially the case in children.
The use of the politzer bag and Valsalva's experi-
ment are resorted to, to ascertain this.
This disease sometimes follows an attack of
diphtheria in children, and in extremely rare
cases the ulcerating tissue becomes covered with
a diphtheritic membrane. Sometimes in neglect-
ed cases and poorly nourished children, this may
pass into a gangrenous condition.
TREATMENT.
These cases should receive a certain amount of
local treatment. Cleanliness is very important.
This may be done by gently removing the dis-
* Valsalva's experiment consists in closing the nostrils with the
thumb and finger, and directing the patient to attempt to blow,
the mouth being closed. The air is thus forced into the middle
ear if the eustachian tube is open, and a hiss or whistle is heard
as it escapes through the perforated membrane.
48
DISEASES OF THE EXTERNAL EAR
charges with the cotton holder, or by a gentle
stream of water. Prolonged use of water quite
hot from a sponge or fountain syringe relieves
both pain and congestion, but no forcible stream
should be used. Afterwards the canal should be
thoroughly dried with the cotton holder. Pow-
dered boracic acid may then be dusted in. Fluid
vaseline is an excellent emollient if it is pure.
Occasionally I have seen it produce great aggrava-
tion, but upon changing for another maker's prepa-
ration have found its beneficial qualities. It also
seems to possess some therapeutic value. Animal
and vegetable oils should never be used. To
quiet the great pain, Magendie's solution may be
dropped upon the surface.
*
In the new local anesthetic, hydrochloride of
cocaine, I think we will possess a very valu-
able agent. I recently used it upon a case of
consecutive diffuse otitis, which had resisted
treatment most obstinately and given intense pain
for days. The pain was instantaneously relieved,
and after a day or two's treatment with this, reso-
lution set in with amazing rapidity. Further ex-
perience with it however, is necessary to deter-
mine its exact value. The local use of eucalyptol*
is many times followed by much benefit.
* This name is given in preference to the muriate or hydro-
chlorate upon the advice of Dr, Leal, Prof. of Chemistry in the
N. Y. Homœopathic Medical College.
DISEASES OF THE EXTERNAL EAR
49
In sluggish cases with sodden oozing tissues, the
pneumatic speculum is of great value. It relieves
them of their engorgement, exerts a stimulating
effect, and brings about a much more desirable
condition of things. The treatment should be
directed towards reducing the inflammation and re-
lieving the pain. If seen at the commencement,
the old school recommend the application of
leeches to the tragus, but we rarely have
occasion to use them.
HOMOEOPATHIC REMEDIES.
The homœopathic remedies applicable to this
disease are the following:
Arsenicum album.-There is much burning
and itching; scratching makes it worse; heat
relieves it. The tissues are red and infiltrated.
Sometimes watery vesicles are present. The dis-
charge is thin, clear, watery, and excoriating.
Arsenicum iodatum.-The symptoms for this
drug are very similar to Ars., but more intense.
Cases resisting Ars. when it seems indicated; no
remedy is more frequently used with benefit than
this.
Calcarea carbonica. Suitable in fair, fleshy
children. Scrofulous subjects. The diseased
tissues are firmer than in Ars. The granulations
50
DISEASES OF THE EXTERNAL EAR
are cellular in their structure. The discharge is
thick and cheesy. Cases where there is little
pain.
Calcarea phosphorica. This is useful in the
later stages of the disease, after the system has
become prostrated. The ear still remains hot,
red, sore and swollen. The discharge is rather
excoriating. The pains are worse at night, and
aggravated by heat or cold. In anemic and deli-
cate children, also in cases after the bone has
become affected.
Calcarea picrata.-This remedy I have used in
cases in which there is a great deal of aching
pain, much tenderness to the touch, a scanty dis-
charge, and a general irritability of the tissues.
It seems to work better in cases in which there is
a tendency to confine the morbid process to a
more limited area.
Ferrum phosphoricum.—A very valuable rem-
edy at the beginning, before breaking down has
occurred. Congestion, swelling and pain. Of
less use after the discharge has commenced, but
invaluable during the febrile stage.
Hepar sulphuris.-With the well known symp-
toms of this remedy. Constitutional disturbance,
swelling, tenderness, free discharge of laudable
pus.
Kali muriaticum.- To be used after Ferrum
phos., when exudation has commenced.
DISEASES OF THE EXTERNAL EAR
51
Psorinum.-The discharge is very offensive. The
tissues are raw, red and oozing: "nasty" cases.
Silicea. When the affection is more pro-
nounced at the inner end of the meatus over the
bone. Pus thick and yellow; tendency to close
over on top with extending ulceration beneath.
CHAPTER VI.
OTHER DISEASES OF THE EXTERNAL EAR.
The external ear is subject to many other dis-
eases which affect the skin and cellular tissue
elsewhere, such as erythema, erysipelas, intertri-
go, cancer, etc. These demand no special consid-
eration, being treated upon the same principles
as when occurring in other places.
In intertrigo and the moist forms of eczema, I
have had uniformly good results from prohibit-
ing all washing, and keeping them well dusted
with corn starch, meanwhile giving the proper
constitutional remedy, such as Sulphur,Psorinum,
Graphites, etc.
Perichondritis is very rare; I have seen but
one case. This yielded promptly to Belladonna,
but I was fortunate in seeing the case early.
Othaematoma is a peculiar tumor of the auricle,
most frequently met with in the insane; general-
ly of traumatic origin. In the N. Y. Med. Record,
Vol. xxvi, Dr. Sexton has a series of able articles
upon it.
OTHER DISEASES OF THE EXTERNAL EAR 53
IMPACTED CERUMEN.
Among the most frequent cases of trouble with
the ear, are those in which the cerumen has be-
come packed in the meatus. This is the result
either of some anomaly of the secretion, or to
efforts at excessive cleanliness, by which it has
been firmly wedged there. Sometimes with the
forceps or the curette this may be easily dis-
lodged, but first and foremost as a means of relief
stands the syringe.
In hospital practice I generally give the patient
a small bottle of fluid vaseline, with instructions
to drop in three to five drops every night, and re-
turn in three or four days. This penetrates and
softens the mass better than any other agent, but
in private practice I generally remove it at once.
The appearance of hardened cerumen is unmis-
takable. Upon looking into the ear is seen a
black solid mass often reaching clear up to the
orifice. It is not of the yellow color of ordinary
cerumen, but in the drying and hardening process
it has become very dark. Though it may have
been for some time accumulating, its effects are
often noticed quite suddenly, some accidental
circumstance having forced the mass upon the
drumhead. The patient experiences sudden deaf-
ness, tinnitus, and often dizziness and pain.
Having made your diagnosis, you proceed to
54
OTHER DISEASES OF THE EXTERNAL EAR
remove it. This may seem a simple matter, but
it is really quite a little art. First ascertain if
the plug fills the canal from side to side, or has
a little play. If tight, take your curette and
with great care and gentleness insert its loop be-
tween the plug and the wall of the canal. If you
do not in this manner make a small passage way
for the stream of water beyond the face of the
mass, you may frequently syringe all day, and
simply drive it more tightly upon the membrane.
Having thus made a little chink, take your
syringe and fit upon its end a eustachian catheter.
Directing its point towards the opening made,
throw in one or more streams of warm water. I
usually do it very gently at first, to accustom the
patient to the sensation, then more forcibly. The
stream dissects its way along the opening made
for it, and soon its retroactive force dislodges the
ceruminous mass which appears either at the ori-
fice, or falls into the vessel receiving the dis-
charges held beneath the lobe of the ear. This
should set up snugly to the junction of the auricle
with the face, to prevent the water from trickling
down the neck.
There are various specially contrived basins
and receptacles for the returning water. The
most perfect I have ever seen is a device of Prof.
Liebold's, which he has kindly shown me.
This consists of an open tin spout, one end of
OTHER DISEASES OF THE EXTERNAL EAR 55
which fits in behind the lobe, and the two sides
of which extend perhaps half way up the auricle,
flaring enough to be a little wider than the ear.
The other extremity is a blind end. Attached to
the point behind the ear is a spring wire which
extends over the head and as low on the other
side as the ear, when it returns upon itself and
the other end of the wire is soldered to the point.
of the spout in front of the ear. In other words
this is a wire hook hung upon the head with a
tin spout which comes beneath the ear.
In the floor of this spout near the blind end is
an aperture with a short tin tube, perhaps half
an inch long, pointing directly downwards, and
about two inches from the ear. On one side of
this tube is a short pin which fastens by a
bayonet catch, a rubber bag with a vulcanite
neck to this short tin tube. The apparatus is
hung upon the head, and the spout coming direct-
ly beneath the ear, conveys all the discharges
into the bag suspended below it. This is the
most perfect and cleanly apparatus I have ever
seen.
Two finger bowls, one to contain the warm
water and the other for the patient to hold be-
neath the ear, will answer all purposes however.
Caution should be observed at the first use of
the syringe. Many persons become very dizzy,
and I have seen patients faint when the stream
56
OTHER DISEASES OF THE EXTERNAL EAR
was first applied. A little patience, however, ist
all that is necessary.
As a rule the removal of ceruminous accumula-
tions can be accomplished at one sitting. Now
and then a peculiarly hard case will require more.
I recently was consulted by a gentleman, who
had been so deaf for many years. that conversa-
tion was carried on with great difficulty. He was
supposed incurable. The plug was so hard, and
the canal so sensitive, it took three sittings to re-
move it, but his relief was complete.
One word as to why I recommend the cath-
ether on the end of the syringe. In the first
place not to obstruct the illumination and view,
on the principle that angular instead of straight
forceps are used in ear work. In the second
place you can direct the stream with greater
accuracy to the precise point you desire, and the
beak being at right angles, your hand and person
are out of the way of the returning stream, which
sometimes manifests a disposition to seek your
face and shirt bosom, instead of the receptacle
prepared for it. Many times I have been deluged
in this way, when using the straight, short nozzled
catheter. Burnett in his work objects to a sharp
or slender elongated nozzle, as liable to do injury.
Care and common sense must be used. If a man
will not exercise them he had better burn his
diploma, certainly not attempt to meddle with
OTHER DISEASES OF THE EXTERNAL EAR 57
the ear, which is too delicate an organ to permit
of careless handling.
It is well to mention another form of obstruct-
ive plug which forms in the ear, simulating cer-
umen. It is made up of modified epithelium,
derived from the skin of the canal, gradually
filling the meatus. Its character is horny and
hard, nor unlike the corns upon ones toes. It is
very obstinate and difficult to remove. Syring-
ing alone has no effect. It has to be removed by
careful and patient picking, several days being
often necessary. It is called keratosis obturans.
Fortunately it is quite rare.
FOREIGN BODIES.
Analogous to collections of altered secretions
in the ear, is the preseuce of foreign bodies, which
from some cause or another have made the canal
their resting place. These are so various, I some-
times think I can tell a man's occupation by the
articles I may find there. Grains of barley, wheat,
and corn, shoe and shirt buttons, pieces of slate
pencil, cherrry pits, coffee beans, beads, bits of
coal, and insects, are among the commonest things
the surgeon is called on to remove. The length
of time which these have been there may be
very great. Cases are recorded of over sixty years
having elapsed between the impaction and remov-
-al. Children often put these things in their own
58
OTHER DISEASES OF THE EXTERNAL EAR
or playmates' ears, from sport, ignorance, or mal-
ice. The syringe is the means for their removal.
Of course there are special cases where it is not
practicable, as in the case of a small cork wedged
in the ear by a child. In such instances, the
physician is called upon to exercise his ingenuity,
but the great majority are easily and safely re-
moved by syringing. Proceed exactly as in the
case of wax plugs. Sometimes the meatus is swol-
len and sore. A little fluid vaseline used for some
days lubricates the canal, reduces the congestion,
and permits its easy removal. As a rule avoid all
attempts at extraction by the forceps, or other in-
struments, as nine times in ten it drives it further
into the canal. Sometimes in the case of insects,
they retain their life for some time, and by their
mandibles seize the tissues and hold on. A
preparation of one part of sulphuric ether to two
parts of fluid vaseline, will soon deprive them of
life and allow of their dislodgement.
PARASITIC GROWTHS.
When the conditions of heat and moisture are
present, the canal may become the site of para-
sitic growths. The most frequent are vegetable or
fungi. The general term given to this condition is
Otomycosis. The heat and moisture essential to
their development are found in suppurations, either
OTHER DISEASES OF THE EXTERNAL EAR 59
in diffuse external otitis, or chronic of the middle
ear. The symptoms are pain, heat, fullness, itch-
ing, dizziness and deafness. The growth usually
commences at the fundus of the canal, upon the
membrane, and gradually grows outwards, form-
ing a complete cast of the meatus. There are a
number of varieties, each having their specific
technical designation, which does not concern us.
The appearance is varied, according to the spe-
cies, a blackish brown, yellowish, greenish, gray-
ish black, etc., similar to the mould growing
upon a piece of bread left in a damp place.
They multiply with great rapidity. They cannot
be removed with the syringe, forceps, or cotton
holder until they have been killed. Various
parasiticides are in use, but none is superior
to alcohol. This instilled several times a day
will destroy them, after which the syringe easily
removes the debris.
With this brief reference to the growth of para-
sites in the meatus, we will dismiss the subject of
the external ear, and pass to the consideration of
lesions of the conducting chamber or middle
ear.
CHAPTER VII.
CATARRIAL DISEASES OF THE MIDDLE EAR.
(Otitis Media Catarrhalis.)
ACUTE CATARRHAL INFLAMMATION.
(Otitis Media Catarrhalis Acuta)
The diseases to which the middle ear is liable
are divided into two grand classes, catarrhal and
suppurative. Perhaps a word of explanation in
regard to the use of the terms catarrhal and sup-
purative may not be out of place. It was the
custom among the older English writers, and to
some extent among the German, to class all affec-
tions of the ear as catarrhal, thus using the terms
mucous catarrh, purulent catarrh, etc. By com-
mon consent, the later writers, Roosa, Burnett,
Politzer, etc., have limited the term to specific
forms of disease, the word otitis being used to
designate a lesion of the ear, in whatever portion
it may occur. Following this custom, the use of
the term catarrh is limited to those affections of
the middle ear, not characterized by the forma-
tion of pus, while the word suppuration is con-
CATARRHAL DISEASES OF
61
fined to that process where the affection has
passed the catarrhal stage, and a genuine puru-
lent secretion has become established.
HYPEREMIA.
Preceding acute inflammations of the middle
ear, and not infrequently accompanying lesions of
the canal, is a hyperemia of the drumhead. As
the blood supply was omitted in the anatomical
description it will be given here. On its outer
surface there is a vascular ring about the periph-
ery, derived from the auricular arteries. On the
inner or mucous surface there is a similar one,
formed by the anastomosis of a branch of the
stylo mastoid artery, and the tympanic branch of
the internal maxillary. These two rings are
united by capillaries. From the internal ring
one larger branch reaches the manubrium, and
descends along that process. Projecting from
the peripheral ring towards the center of the
membrane, and from the manubrial vessel to-
wards the periphery, are minute capillaries. None
of these vessels are visible under normal condi-
tions, bnt as soon as any exciting cause tends to
produce a hyperemia, such as touching the mem-
brane with a tuft of cotton, syringing, etc., these
vessels spring into view as a red ring about the
periphery, and a red line descending the handle of
62
CATARRHAL DISEASES OF
the malleus. A certain portion of the membrane
between the two is free from redness at first, but
if the congestion continues for any length of
time, the whole surface becomes of a uniform red
color. I had the pleasure of showing the class in
the New York Homœopathic Medical College
this winter a beautiful instance of such a partial
congestion, produced by a violent effort of blow-
ing the nose.
ACUTE CATARRHAL INFLAMMATION.
Acute catarrh of the middle ear is accompanied
by pain, tinnitus, a sense of fulness, deafness,
fever, and occasionally delirium. At first the
hearing may be even more acutely sensitive
than normal, so that ordinary sounds seem pain-
fully loud, but this soon passes over into a dulled
condition, and sounds ordinarily distinct become
only a confused murmur.
If seen at the very commencement, inspection
may show the membrane with only the peripheral
and manubrial congestion, but this lasts but a
short time, the vascular engorgement filling the
capillaries to their greatest capacity, and the
membrane becoming a uniform red throughout
its whole extent. The pain is usually quite se-
vere. If a child old enough to talk, he continu-
ally moans," my ear, my ear." If too young to
THE MIDDLE EAR.
63
talk, it will roll its head about, and bore it into
the pillow, every now and then giving vent to a
scream, as an unusually sharp twinge of pain is
felt. Sometimes even in grown persons this pain
is so acute, that they show evidence of ex-
treme suffering. Such a condition in children is
often mistaken for an affection of the brain, and .
treatment directed with reference to such a diag-
nosis, and to ward off an attack of supposed on-
coming convulsions. The attacks are sometimes.
sudden, sometimes giving premonitions of their
occurrence by a certain uneasiness, and slight
pains now and then felt in the ear, which gradu-
ally increase in frequency and severity. It is not
an uncommon thing for a child to go to bed per-
fectly well, and be awakened from sleep by the
pain of an attack. Many cases are without febrile
movement, but it often is present.
As in every disease there are mild and severe
cases, so in this, they not infrequently occur (per-
haps are the most frequent) with much less inten-
sity than above described, last a day or two, and
pass off, coming on again in a week or month.
These cases, which often do not consult a physi-
cian, are important in their after effects, as we shall
see when discussing the chronic catarrhal forms.
The causes which underlie these attacks are
various. Most frequently it is exposure to cold
or wet. I have been able to trace it in children
64
THE MIDDLE EAR.
in many cases, to sitting while at play upon a
cold stone step. Riding in the cars with a win-
dow open and the air striking the ear will pro-
duce it. Bathing is a very common cause.. Not
a summer passes, but that after the water becomes
warm enough to permit of bathing at the various
beaches near New York, case after case makes its
appearance with the statement that the attack
came on after bathing at Manhattan Beach or
some other place. Some persons are peculiarly
sensitive to the air striking their ears when riding,
and even in mild weather, if they do not take the
precaution to protect them, are sure to suffer from
earache. The sport of children washing each
others' ears and face with snow sometimes causes
it. It often accompanies a catarrhal cold.
Whooping cough and scarlet fever are very prone
to produce it, though in these instances it is but
too often a stage in the onward march to suppu-
ration.
The pathology of the condition is as follows:
From whatever cause it may spring, as a rule the
affection commences at the pharyngeal mouth of
the eustachian tube. Following the congestion
comes a swelling of the walls, which it will be
remembered are in quite close apposition. From
the swelling a closure of the tubes occurs, and
their function of ventilation and drainage is tem-
porarily impaired. The tympanic cavity thus
THE MIDDLE EAR.
65
becomes deprived of its supply of air (that already
there being rapidly absorbed by the tissues), and
the natural secretions of the cavity are retained.
On account of the vacuum thus caused in the
tympanum, there is a rush of blood through the
tympanic vessels to supply the deficiency, and the
first step of congestion is established. This in
itself, with the atmospheric pressure on the mem-
brane, is enough to produce an earache, and these
cases are known among specialists as tubal ca-
tarrh, when the process goes no further. But we
have other factors. It will be remembered that
the lining of the tube and tympanum is continu-
ous, and it is well known how rapidly inflamma-
tory action spreads over mucous surfaces. Here
we have direct continuity of tissue, and the in-
flammation passes directly on to the tympanic
lining. Here the normal secretion of mucous is
very largely increased, from the activity induced
in the tissues by the greater blood supply and
inflammatory irritation. The tubes being swollen
so that they are not readily pervious, this in-
creased secretion is also retained and added to
the natural secretion of the parts. This soon fills
the little cavity, and we recognize on looking
through the speculum that the membrane appears
pushed out or bulging into the canal. This bul-
ging is much more prominent in the superior por-
tion of the drumhead, which we called Shrapnell's
66
CATARRHAL DISEASES OF
membrane, for from the looser character of its
texture, it more readily yields under the pressure.
In this highly organized little cavity, richly en-
dowed with sentient nerves, is it any wonder that
we get pain with such a state of things?
In the cases of tubal catarrh spoken of a mo-
ment ago, it is often the case that the pain remits
during the day and comes on again at night.
This is readily understood. Following the rule
which obtains in most acute diseases, during the
day the inflammatory action is less, there is a
subsidence of the tubal swelling, and both air
may enter and secretions drain out, thus relieving
the pressure. But at night, added to the common
exacerbation, the prone position changes the di-
rection of the tube to a more nearly horizontal
plane, thus retarding the ease of drainage. More.
over, lying down increases the determination of
blood to the part, with a consequent increase of
congestion, and the tube becoming more tightly
closed, all the factors of pressure are at work
again.
Now having learned what the conditions act-
ually are, what appearances do they present by
which we may recognize them; in other words
what do we see?
As before said, if examined through the specu-
lum at an early stage, we will see the congestion
about the periphery and along the manubrium.
THE MIDDLE EAR.
67
The general color and outline of the membrane
will not be changed, though some of its lustre
may be absent and the light spot deprived of its
brilliancy. In a short time however, the con-
gestion spreads over the entire surface, and it
becomes a uniform red. Its outlines are lost so
that we are not able to detect its junction with
the walls, from lack of the distinctive color. Next,
from the absorption of air within the cavity, the
atmospheric pressure from without bears in upon
its surface, driving it towards the inner wall, and
showing a much increased concavity or depress-
ion. This, as is readily seen, produces pressure
on the stapes, which bearing upon the labyrinthine
fluid, gives the patient a sensation of noise, i. e.
tinnitus.
Meanwhile secretion has commenced to accumu-
late, and sometimes through the membrane can
be seen the exact line indicating its height.
While this atmospheric pressure is the greatest,
the manubrium stands out more prominently on
account of the depression of the membrane on
either side. As, however, the secretion continues
to accumulate, the pressure, from its confinement,
commences to be exerted from within outwards,
and overcoming the atmospheric pressure, the
membrane commences to bulge outward. This
is first noticed at Shrapnell's membrane, in the
region of the pockets of Troltsch, as before said
68
CATARRHAL DISEASES OF
and explained. From this point the course of the
disease is in one of three ways. Either resolution
sets in, the congestion and swelling lessens, the
tympanic cavity becomes cleared of its accumula-
tions, and things resume their normal state; or the
inflammatory process proceeds to a still greater
height, the products assume a purulent form, and
the membrane breaking down, the discharge is
poured out through the meatus; or, and this is
the most frequent result, a partial resolution sets
in, the congestion and swelling diminish to a
certain extent, and a subacute form takes its place,
ultimately passing into that most obstinate of
troubles, a chronic catarrhal otitis media.
Now in these acute forms of tubal and tympan-
ic catarrh, it is possible for the process to be cut
short at any stage by judicious treatment. This is
both local and constitutional. The local will be
first discussed, and the remedies with their indi-
cations be given later.
TREATMENT.
One of the first indications is to relieve the
tympanum of pressure. This is done by the
forcing of air into the middle ear by way of the
eustachian tube. The politzer bag is the readiest
means of accomplishing this. In its absence
there are certain substitutes. The method of
using it is as follows. The patient is directed to
THE MIDDLE EAR.
69
hold a sip of water in his mouth. The nose piece
is inserted into one nostril so that it fills the
orifice, the other nostril being closed by pressure
of the thumb and finger, while the other hand
holds the bag. At a given signal the patient
swallows the water. At the same moment press-
ure is made upon the air bag, forcing an air
current through the nostril. The act of swallow.
ing shuts off the lower from the upper pharynx,
and the air finding no escape downwards, and
being prevented from returning through the other
nostril, is forced to seek a vent through the
eustachian tube. When this is accomplished, it
has entered the tympanum, the equilibrium is
restored, the pressure removed, and the contents
have an opportunity to drain off through the
temporarily dilated tube. Sometimes several at-
tempts are necessary to accomplish this. The
tubes may be partially glued together and do not
open readily, or pressure may not be made at the
right moment. A little patience overcomes all
this. Whistling, blowing, or crying on the pa-
tient's part brings about the same result of shut-
ting off the lower pharynx. In case you have no
air bag, a common soft gum tube inserted into
the nostril (the other being closed), the free end
of the tube being in your own mouth, and a for-
cible blow being given through the tubing, will
accomplish the same result. Very often relief
70
CATARRHAL DISEASES OF
will be felt at once, but of course it is but tempo-
rary, and this will have to be frequently repeated.
Moreover it has a therapeutic value, for with the
relief of the vacuum and pressure, one factor in
congestion is removed.
Sometimes the adhesion of the tubal walls is
so close, air cannot be forced through it. In such
case the pressure must be relieved from the out-
side. This is done by puncturing the membrane
and allowing air to enter from, and the contents
escape into the meatus. The relief is immediate
and great. Fortunately, we comparatively rarely
have to resort to this. Occasionally after punc
ture, there is no discharge but a little blood,
though the same relief is experienced.
The point chosen by preference for the punc-
ture is the posterior portion of Shrapnell's mem-
brane, though some recommend the posterior
inferior quadrant of the drumhead. The advan-
tage of this last point is its lower elevation,
allowing more complete drainage. The operation
should be done with a paracentesis knife or
needle, which is a small lance shaped point, on
the end of a slender malleable shaft, attached to
a handle. The flexible shank allows it to be
bent at an angle, so that the hand does not ob-
struct the view. A mere prick is all that is
necessary. It is a perfectly simple and safe
operation.
THE MIDDLE EAR.
71
There are many local applications which are
of great value, but perhaps I am justified in say-
ing that all which have a domestic reputation are
uniformly harmful or useless, except heat. Avoid
all fats and oils except fluid vaseline. Heat may
be applied either dry, or by irrigation with quite
warm water. An excellent plan, and one I al-
ways use, is to cover the whole head with a large
night cap, lined with cotton wool at least one
inch thick. Over the affected side I place an.
other loose layer of cotton directly against the
ear and face, moderately saturated with fluid
vaseline. This is worn night and day. Of course
the patient is to be confined to the house, and
great care taken against exposure, for in this
affection there is unusual susceptibility. In the
way of local applications, the fluid extract of
Plantago major, either pure or diluted half with
water, warmed and dropped into the ear, many
times exerts a wonderfully soothing effect.
very frequently use the following, which scarcely
ever fails to give relief.
B
Fl. Ext. Plant. Maj.,
I
Tinct. Bellad,
Tinct. Acon. Rad.,
Magendie's Sol. Morphia,
Aqua Dest., q. s. to make
Misce.
3 iv.
gtt. xv.
gtt. x.
gtt. xx.
j.
72
CATARRHAL DISEASES OF
Of this, I apply by a dropping tube four or five
drops warmed, in the ear, at intervals varying
from five or ten minutes, to once in two or three
hours. I also, between the applications, put in
the ear a small pledget of cotton saturated with
the solution. The case is a rare one in which
relief is not obtained after three or four applica-
tions, and not infrequently after the first. The
hydrochloride of cocaine before spoken of, has
relieved the pain in a marvellous manner, but the
cases of course have been very few upon which
I have had any opportunity to try it. Magendie's
solution alone, is recommended by old school
authorities, but I prefer to use it in the above
formula, for the relief is as prompt, and the
therapeutic action greater. As a rule avoid all
poultices. In rare cases they may be called for,
but their tendency is to break down the mem-
brane, and bring about the very condition you
are striving to avert, viz., the passing over into a
suppuration.
The introduction of steam into the ear is an
excellent method of applying heat. In those
houses where steam is used for heating purposes
by means of radiators, this can be very easily
done, by attaching a piece of india rubber tubing
to the check valve on the radiator, and holding
it near the ear, let a jet of steam pass into it.
Of course care must be taken that too hot steam
THE MIDDLE EAR.
73
be not used, but in the ordinary house warming
apparatus, the pressure is not more than three
or four pounds, and there is little danger.
In regard to remedies, they must be selected
from the whole materia medica, as in other dis-
eases, each one being of more importance than all
the rest when specially indicated, as was said by
Prof. T. P. Wilson, when writing on this subject
for the World's Convention in 1876.
Nevertheless we have a few which deserve
especial mention, as being most commonly called
for, and rarely disappointing us.
HOMEOPATHIC REMEDIES.
Aconite. In the earliest stage of the complaint,
when the hyperemia is first visible. The pains are
sharp and tearing especially in the left ear. Fever
runs high; much nervous excitement; excessive
sensitiveness of hearing and intolerance of every
noise. Dryness and scraping in the throat; skin
dry and hot; cheeks red. When traceable to ex-
posure from direct cold. In the practice of the
surgeons at the New York Ophthalmic Hospital,
Ferr. phos. has largely taken the place of Aconite,
but there are cases now and then in which Acon-
ite is the remedy beyond all question, if given at a
sufficiently early stage. Ferr. phos. is applicable
74
CATARRHAL DISEASES OF
to an acute inflammatory condition, lasting a
little longer than a typical Aconite case.
Bryonia. From the relation of Bryonia to in-
flammations of serous membranes, this remedy
would seem to be called for in cases in which the
serous character of the secretion in the tympanum
predominates. The sharp sticking or stitchlike
pains characteristic of this remedy, with painful
sensitiveness of the ear, are cases in which it
should be useful. I have had little occasion to
use it, but there are most certainly cases occur-
ring in which its use would seem to be emphati-
cally indicated.
Belladonna.-In those cases in which the throat
is sore, red and swollen; the tonsils are infiltrated
and swollen; pulsation of the carotids; headache;
face flushed, with heat in head; cold hands and
feet; throbbing pain in ears, worse towards night
and when stooping; pains shoot through and de-
part suddenly.
Chamomilla." Pains very severe, causing hot
perspiration about the head, patient cannot en-
dure it; is very restless and screams; cold aggra-
vates." (W. P. Fowler).
Ferrum phosphoricum.-Fever more marked at
evening or earlier part of the night; general heat;
apathetic; depression and anxiety; head dull,
heavy, full, with flashes of heat; dull beating
headache; pulse felt in brain; beating in the ears
THE MIDDLE EAR.
75
with a dull roar, or humming sound; face flushed,
feels swollen; respiration labored. Heart's action
increased, later diminished, and volume of pulse
increased.
Redness of meatus, and hyperemia of drum-
head. Marked congestion of membrane. Pain
steady and aching; rushing sounds, as if could
hear the blood coursing through the vessels.
Pages and pages would fail to relate all the won-
derful things which this drug has accomplished
in cases of acute inflammatory earache in my ex-
perience and that of my colleagues. If used in
time, before much secretion has caused the mem-
brane to bulge, it will rarely disappoint. I gen-
erally use it in the 6× trituration.
Gelsemium.—In the cases of so-called serous
catarrh. Occasionally a case is met with in which
the exudation is nearly pure serum, and under
the inflation of air through the eustachian tubes,
this bubbles or effervesces, which can be plainly
seen through the membrane. In such cases Gel-
semium must not be forgotten.
Hepar sulphuris.—Darting pains in the ears;
worse at night, and not relieved during the day.
Warmth, either by application of heat, or wrap-
ping head, relieves. Later in the case when sup-
puration threatens.
Kali muriaticum.-The remedy to finish up
your case with. No matter what medicines you
76
CATARRHAL DISEASES OF
have given through the acute stage, after the pain
has subsided and resolution has set in, no remedy
finishes up the work, clears out the tissues, pre-
vents the adhesions and general consequences
equal to Kali muriaticum.
Magnesia phosphorica. This remedy is often
valuable in cases in which there seems to be a
neuralgic element present, in addition to the pain
in the ear. The pain shoots in flashes into the
head and around the face. In such cases a few
doses of Magnesia phosphorica given in connec-
tion with the other remedies will generally allay
this feature. Schussler says it has a more sooth-
ing effect if taken in hot liquids.
Mercurius.-Tearing pains, worse at night in
bed; perspiration which does not relieve. The
various forms of Mercurius are all valuable in
certain conditions. The solub. is highly recom-
mended by Dr. Fowler of Rochester. The dulcis
or vivus is more frequently used by myself.
Pulsatilla.—This remedy is particularly called
for in children rather than adults. The cases are
not of the severest type, though the pain may be
acute and lancinating during the night, the
child playing through the day. Febrile symp-
toms slight.
I cannot consider this subject as finished, with-
out calling especial attention to the necessity of
closely watching the ears in cases of scarlet fever
THE MIDDLE EAR.
77
and diphtheria. All the exanthemata are liable
to ear complications, but in none are they so
common, and the results so distressing if neglect-
ed, as in these two. One other thing. After
your case is relieved of pain and fever, and you
have discharged your patient from daily attend-
ance, your work is not finished. These acute
catarrhs leave results. What these results are
will be seen under chronic catarrh, but your duty
is to prevent them. How? By using the politzer
bag and the pneumatic speculum, two or three
times a week for a fortnight or more. This pre-
vents the organization of bands of dried mucus,
etc., closing the tubal aperture and limiting the
freedom of the drum membrane, and mobility of
the ossicula.
Many times you will be consulted for an ear-
ache, but upon examination you will see no con-
gestion, no bulging, no apparent cause for the
pain. Look at the teeth. Nine times in ten you
will find a carious tooth, the seat of the trouble,
though the patient may deny ever having had the
toothache. The relation of the dental nerves
through the otic ganglion, to the sentient nerves
of the ear, is the cause of the pain being referred
there-i. e. reflex. Rubbing the gums with plan-
tago extract and water, and plantago internally
will generally temporarily relieve it, but the den-
tist is the best remedy.
CHAPTER VIII.
CHRONIC CATARRHAL INFLAMMATION OF THE
MIDDLE EAR.
(Otitis Media Catarrhalis Chronica.)
Chronic catarrhal inflammation of the middle
ear is an insidious, protracted, obstinate disease.
Its treatment is often unsatisfactory, disappoint-
ing to the patient, and discouraging to the phys-
ician. Nevertheless, it is very important to
understand what it is and how it is caused, for if
it is generally known what are its primary stages,
and the importance of attending to those condi-
tions which lay the foundation for it, very much
may be done in the way of preventive treatment,
and thus in the end, reducing the frequency of
this affection, which now seems to be the lot of a
very large proportion of those who arrive at mid-
dle life.
The symptoms of chronic catarrh are many and
varied, but there are two which stand out promi-
nently before all others, and are common to al-
most every case, viz. deafness, and a noise in the
ear or head. This latter symptom in many cases
OF THE MIDDLE EAR.
79
is so distressing, that those suffering from it have
been driven to insanity, and even in some instan-
ces sought refuge in suicide to escape the intoler-
able annoyance.
This is often the growth of years before patients
are forced to seek the physician's advice, and
then it is found, that either it is too late to help
them, or not realizing the condition present, he
gives them a few powders or pellets, which are
worth absolutely nothing.
Now let us see with what we have to deal, and
how we are to meet it. This is the outgrowth of
several things. Either cases of earache have been
neglected, or a naso-pharyngeal catarrh having
existed for some time, the eustachian tube first,
and the cavity of the tympanum in due time,
from direct continuity of tissue, participate in the
process.
When speaking of acute catarrhal inflammation
two things were referred to; the frequently re-
peated mild attacks of earache, passing off in a
day or two, and receiving no attention, and the
dismissal of other cases more severe in their
character, with no after treatment.
In these milder attacks there is usually a pre-
disposition to catarrhal affections of the mucous
membranes. The least exposure to cold brings
on a certain amount of congestion and increased
secretion. Before the tissues have fairly recov-
80
CHRONIC CATARRHAL INFLAMMATION
ered, though all acute symptoms may have dis-
appeared, another attack occurs, going through
the same process. I have known repeated in-
stances where persons commenced with catarrhal
colds early in the fall, and were free from them
at no time till well into the following summer, to
go through with the same history the next sea-
son. At various intervals there may have been
slight pains in the ears, or there may have been.
none. These repeated attacks finally leave their
traces in a hypertrophied condition of the mucous
membranes in the whole region of the naso-
pharynx, or rhinoscopic space, as that portion
above the plane of the palatal arch is called.
The pharyngeal mouth of the eustachian tube
necessarily takes part in this process, and so on
up, towards the tympanum.
Of a similar character in their results, but more
pronounced, are the chronic naso-pharyngeal
catarrhs, from which so many in this country
suffer. This will be spoken of more fully.
The severer cases of acute tympanic catarrh are
another fruitful source of chronic middle ear
disease, from the habitual neglect of after treat-
ment. It was shown in discussing these cases,
how the tympanic cavity became the seat of very
much increased secretion. It was mentioned
when speaking of the anatomy of the middle ear,
that the lining membrane possessed both mucous
OF THE MIDDLE EAR.
81
and serous properties. Now the secretion thrown
out from this structure varies in its composition.
Schwartze divides the catarrhs which do not
eventuate in pus, into mucous and serous. That
such well defined cases do exist, most every
aurist can testify to. My colleague Dr. Houghton
has shown me very interesting cases of undoubt-
edly nearly pure serous exudations in the tym-
panic cavity. These fine clinical distinctions do
not come within the scope of this work to discuss,
but I wish to refer to the fact of their existence,
and again refer to Schwartze as authority for the
statement that most cases are of a mixed charac-
ter. Now the mixed character of this secretion is
one of the important factors in producing the re-
sult known as chronic catarrhal otitis media.
Schwartze says in speaking of these acute cases,
"the very highest degrees of catarrhal swelling
of the tympanic mucous membrane, are capable of
complete retrogression. The cellular infiltration
of the subepithelial connective tissue, disappears
by fatty degeneration and decay, and possibly in
part by absorption into the lymph vessels. For
this process weeks are necessary. In many cases
however, retrogression remains incomplete, and
there remain projections and duplicatures of the
mucous membrane, in the form of pseudo-mem-
branes, or synechiae, by which different parts of
the ear (middle) are abnormally adherent, or the
82
CHRONIC CATARRHAL INFLAMMATION
*
tympanic cavity is permanently affected in size
and form. *
X- The cavity is partially or
wholly filled with thick adhesive mucus, mingled
with a few cell elements, epithelium, etc. X * X
The consistence of the mucus may be such as to
require a regular dissection with forceps and
knife, in order to free the walls and ossicles."
These are the conditions present at the time a
case of acute tympanic catarrh is ordinarily dis-
missed. Is it any wonder that persons can trace
their deafness to a severe attack of earache, when
such a state of things is left to complete its work
in the delicate structure of the middle ear? What
this work is I will soon proceed to show.
The naso-pharyngeal catarrhs recently referred
to, are a third cause at work in the production of
the abnormal condition we are studying. I do
not propose to describe this disease, but simply
remark that the swollen and hypertrophied mu-
cous surfaces in the pharyngeal space, necessarily
include the faucial extremity of the eustachian
tube. This either becomes closed by swelling of
the tissues at its mouth, or by becoming plugged
with tough mucus, or the the hyperplastic pro-
cess includes the tubal walls themselves, and
passes to the tympanum. Most usually all these
features are present in greater or less degree.
Heredity undoubtedly has an influence.
There is one form of this middle ear trouble in
OF THE MIDDLE EAR.
83
which these causes above detailed do not seem
to have a share; at least we meet cases where we
cannot find sufficient evidence of their existence
to warrant us in assigning them the predomina-
ting influence. These cases are the so called 'dry
catarrhs' or 'proliferous' forms. This form is
more insidious in its march than the other. The
patients gradually grow deaf, but so quietly is
the process conducted, that when they really
awaken to the fact, it is quite late in the disease.
The process seems to be one of atrophy, or drying
up, rather than of hyperplasia and increased
secretion. In practice however, they are classed
under the chronic catarrhal forms.
Now let us see what is the actual condition of
the tissues, that the causes we have been relating
bring about. There is thickening of the mucous
membrane from the prolonged inflammatory ac-
tion. The small joints in the chain of bones be-
come covered with an adhesive mucus which
clogs their free movement. The secretions which
have been poured out, finding no exit by way of
the eustachian tube, become deprived of their
moisture by absorption, and the dried remains
cover more or less of the cavity. Sometimes there
are enough cell elements in this mass to produce
organization, and a low grade of connective tissue
is formed, both lessening the space, and obstructing
by its presence the function of that remaining.
84
CHRONIC CATARRHAL INFLAMMATION
Again, it may be found in the shape of small
bands or fibres running from one point to an-
other, and binding the various points to each
other more or less firmly. There are two or three
where this is very apt to be the case, and especi-
ally injurious. These are attachments of the
membrana tympani to various points, limiting its
motion; the same attachments to the stapes, and
the joint between the malleus and incus, and ad-
hesions of the bones to the walls of the cavity.
Contraction takes place in these various false
connections, which makes them tense, and still
further impairs the motility of the conducting
apparatus, as well as forcing them into abnormal
positions. The eustachian tubes are either tightly
closed by swelling, or their calibre filled with
obstructive plugs of tenacious mucus.
In the dry or proliferous form there is a slightly
different state of things. Here, doubtless in many
cases, there is a deficency of secretion from the
start. The mucous surfaces become covered with
a dense fibrous tissue; the stapes becomes firmly
fastened in the fenestra ovalis; the malleus and
incus are anchylosed at their articulation, and
there are various degrees of bony enlargement,
both in the walls of the cavity, and the ossicular
chain. The tendon of the tensor tympani often
becomes contracted or atrophied. The changes
which occur in the drumhead are also character-
OF THE MIDDLE EAR.
85
istic. It becomes dense and thickened, even to
five times its normal dimensions. Its shape is
materially altered, being forced out of position,
both by the traction of adhesive bands, and the
atmospheric pressure on the outside.
Now let us see what changes these morbid
processes produce in the appearance. Some we
distinctly see, others are inferred. On looking at
the drumhead, we notice that its position is
altered, being very much cupped or retracted.
The light spot is either distorted, or absent alto-
gether. This distortion differs in different indi-
viduals. Sometimes the angle at which it stands
is changed, and its base is thrown upward.
Sometimes there is a mere white line in the place
of the triangle. Again, all there is to be seen
is a mere speck at the apex, as if its lower two-
thirds had been wiped out. Occasionally it is
divided into two portions. Now and then in the
proliferous variety, there are irregular patches of
dull white upon its surface. These are of various
shapes, and may be either single or multiple; I
have seen the whole of one side so changed. One
form now and then met with, is a crescent round-
ing the end of the manubrium These white
spots are called opacities, and are due to the
deposition of limy material in the substance of
the membrane. Of course its lustre and polish
are wanting. The short process of the malleus is
86
CHRONIC CATARRHAL INFLAMMATION
unusually prominent, while the manubrium stands
out like the ilium in a cadaver dead of phthisis.
There are various other irregularities on its sur-
face. On applying the pneumatic speculum, it
may be so firmly bound down by adhesions on its
inner side, that no motion is perceptible, or certain
parts may spring forward under the suction, while
others remain stationary. It is not infrequently
the case that the canal in these cases is very
large and straight, so that the membrane can be
distinctly seen without the speculum, even at
some distance. Whether this is due in any way
to the morbid process, I am not prepared to state,
but that there is a connection in some way, I have
little doubt, for such a canal is rare in a healthy
ear.
On examination of the throat, characteristic
changes will be seen there. The posterior wall
of the pharynx is often studded with minute
granular elevations, either dry, or secreting a
gummy fluid. Sometimes the wall has a dry,
glistening appearance. In some cases it is of a
deep red; in others, so pale as to appear anemic.
Frequently a thick mass of greenish yellow mu-
cus hangs down from the posterior nares, cover-
ing more or less of the posterior pharyngeal wall.
On introducing the small mirror and examining
the reflection of the superior space, the tissues
will be found thickened and hypertrophied. The
OF THE MIDDLE EAR.
87
adenoid development may be such, as to entirely
occlude and prevent a view of the mouth of the
eustachian tube. If visible, frequently a plug of
tenacious mucus will be seen hanging from it.
Now and then cases will be met in which large
polypoid growths are present in this space, and
pass up through the posterior nares. In these
instances the breathing space being largely di-
minished, air is taken through the mouth. Many
cases of naso-pharyngeal catarrh also contract this
habit, which is a very bad one, rapidly evaporating
the moisture from the mucous surfaces, leaving
them dry and parched, and still further compli-
cating the difficulty.
Such is a brief picture of what you can see.
Now of what does the patient complain?
The first symptoms are usually tinnitus, and
gradually increasing deafness. Of these the first
is complained of the most. "I don't care so much
about the deafness, Doctor, if you can only stop
this everlasting ringing in my ears," is a frequent
statement. This seems to vary at different times,
occasionally almost dying away, then coming
on louder than ever. It is particularly noticeable
at night, when everything is quiet. I have one
patient now under treatment however, who says
that when everything is quiet, and she herself
calm and tranquil, the noise subsides, to appear
with renewed violence when she is active or ex-
88.
CHRONIC CATARRHAL INFLAMMATION
cited. There are doubtless, nervous elements in
this case.
The character of this noise varies
greatly. Patients are apt to liken it to sounds
with which they are familiar, the humming of
bees, the escape of steam, the distant roar of the
sea, the rumbling of a railroad train, etc. Wilde's
description has become classical; "as if all the
teakettles in Ireland were boiling in their ears."
Frequently a cracking or snapping noise is heard.
This occasionally is audible to the physician.
Now and then is seen a a case in which in
spite of deafness, there is hyperesthesia in re-
gard to noise. Even ordinary sounds produce
pain. A sense of plugging or fulness in the ears
is often felt, similar to that experienced when
swallowing with the mouth and nose closed. Not
only this fulness in the ears is complained of, but
a fulness in the throat or sensation as of a foreign
body there. This is most frequent in those
cases with exudative naso-pharyngeal catarrh.
Vertigo is occasionally felt. This is not constant
but comes on at irregular times. A not infre-
quent symptom is the hearing better in a noise.
These patients may be so deaf that ordinary con-
versation is carried on with difficulty, yet in a
street car or stage they hear with surprising
case.
Almost all of these symptoms have an explan-
ation, too long to be given here, but in general
OF THE MIDDLE EAR.
89
terms depending on the altered conditions result-
ing in increased labyrinthine pressure, or stiffness
of the conducting apparatus.
There is one objective symptom which should
have been mentioned, viz., the altered secretion
of cerumen in the external meatus. In very many
of these cases, the ceruminous glands seem to
cease their action and the canal becomes entirely
deprived of its wax. In other cases there seems
to be an increased amount, resulting in the wax
plugs spoken of. Though I have not made an
exhaustive study of this, my observation would
lead me to differentiate these cases in this way;
that the obstructive plugs are formed in the
earlier stages of the true catarrhal process which
is characterized by increased secretion, while
those cases of diminished secretion are found in
the dry or proliferous forms, and the later stages
of the other. What we can do for these cases
will be discussed in the next chapter.
CHAPTER IX.
TREATMENT OF CHRONIC CATARRHAL
INFLAMMATION.
In many cases of chronic catarrh unfortunately
little aid can be rendered. But again there are
many cases where undoubted benefit can be given.
From what has been said, it is clearly seen how
important it is that treatment should be continued
in acute cases for some time after the suffering is
relieved. By the use of remedies the retrograde
process is materially assisted, and by the frequent
use of the air bag, the tube is kept open, and the
tympanic cavity supplied with air. The use of
the pneumatic speculum also serves to assist, by
exercising the membrana tympani, and the
chain of bones, preventing the formation of con-
tractile false bands, and pseudo anchylosis of the
ossicular joints.
Most
The use of these two instruments is also impor-
tant in the treatment of the chronic forms.
of these are progressive, and the persistent infla-
CHRONIC CATARRHAL INFLAMMATION
91
tion of the drum, and the exercise of the mem-
brane serves to retard its progress, and at least
prevent the case from becoming worse. In some
cases it is of very decided benefit.
Applications to the eustachian tube and cavity
of the tympanum are quite generally used by the
old school, and by some of the Homoeopathic
school. Dr. Winslow expresses himself emphati-
cally in their favor. For myself I rarely use
them, and they are not commonly applied by my
colleagues either in hospital or private practice.
I believe, with rare exceptions, we can accomplish
by internal medication wonderful changes in the
pathological conditions of the middle ear. For
the benefit of those who fully believe such things
must be done, I give a few formulæ, which are
highly recommended by those who use them.
They are applied through the eustachian catheter.
The method of introducing this instrument is as
follows:
After the nose has been thoroughly cleansed,
take the catheter in the right hand by the ring
end, and insert its beak into the nostril, on the
side you desire to treat, the shaft of the instru-
ment standing vertically. The upper lip should
be drawn down slightly by gentle pressure
against it with a finger of the other hand. Gradu-
ally raising the right hand, the beak slides along
the floor of the nasal fossa, enters the post nasal
92
TREATMENT OF
space, and finally strikes the posterior pharyngeal
wall. The instrument now is horizontal, and but
a small portion of it visible. Now elevate the
right hand slightly, turn the instrument so that
the ring points directly towards the desired side,
and gently withdraw it a short distance. The
beak then slips by the fossa of Rosenmuller, over
the posterior lip of the tube (which projects
slightly into the pharyngeal space), and enters
the mouth of the tube. It then remains quietly
in position without being held. It should be re-
membered that the ring is always the index of
the beak, and whichever way the ring points the
beak does the same. All manipulations should
be made with the utmost gentleness, no force
being used. When in position it should give
neither pain nor discomfort. Its introduction is
disagreeable to some, though it should never be
painful. Sometimes it may be necessary to use
the inflation bag through the catheter, as the lips
of the tube may be so glued together that the air
current through the nostril will not force it open.
Its frequent use however, is to be deprecated, as I
am positive it excites more or less irritability of
the tissues, and in some cases has produced ex-
tensive laceration.
For various conditions, the following formulæ
are given by Dr. Winslow in his book, and recom-
mended by him.
CHRONIC CATARRHAL INFLAMMATION
93
For dislodging and clearing away inspissated
mucus in and at the mouth of the tube,
Ꭱ
Potassii hydras,
gr. j.
Aqua dest.,
f. 3j.
or,
Be
Sodii bicarb,
gr. v.
Aqua dest.,
f. 3j.
Warm a few drops of either in a dropping tube,
empty it into the catheter when in place, and
drive it through the catheter by the air bag.
For congestion and swelling of the mucous
lining of the tube,
Ꭱ
Sodii biboras,
Aqua dest.,
gr. v.
f. 3 j.
Use in the same way.
For a stimulating injection after the last,
Ꭱ
Tr. Picis liq.,
Aqua dest.,
For an astringent injection,
B
Zinci sulph.,
Aqua dest.,
M. xx.
f. 3 j.
gr. ij
f. 3 j.
He recommends the use of this in obstinate
cases once every day.
94
TREATMENT OF
The use of electricity in this disease has its
advocates and opponents. Dr. Roosa doubts its
utility. I make very little use of it. On the
contrary some of my colleagues use it frequently
and claim excellent results from it. I believe it
to be of more value in some of the lesions of the
internal ear, than those affecting the middle
ear.
In those cases affected with naso-pharyngeal
catarrh, this condition should receive attention.
The use of the posterior nasal syringe is excel-
lent for cleaning out this cavity. I frequently
make use of the following: to about one-half
pint of warm water, add two tablespoonfuls of
a saturated solution of sea salt, and ten or twenty
drops of the fluid extract of Hydrast. Can. This
thoroughly cleans the space, the mouth of the
eustachian tubes as well, and seems to exert a
directly beneficial effect.
Sometimes it is desirable to apply astringent or
stimulating lotions to the pharyngeal surfaces.
The following preparations will be of service.
Ꭱ
Potasii iod.,
Iod..
Glycerine,
Misce.
gr. x.
gr. v.
3 j.
M
Use a very hot mortar, mixing first the iodine
CHRONIC CATARRHAL INFLAMMATION
95
with a little glycerine, then adding the iodide of
potassium.
R
R
.$
Ꭱ
R
Tannic acid,
Glycerine,
Alum pulv.,
Glycerine,
Fl. Ext. Hydrast. Can.,
Glycerine,
Pinus Canad.,
Glycerine,
1
3 ss.
3 j.
3 ss.
3 j.
UN
3 j.
M NM
3 j.
3 j.
5].
These are to be applied with a brush after a
cleansing of the surfaces. The tannin and alum
preparations will be found useful in acute aggra-
vations of the throat with tendency to ulcerations.
The iodide glycerate in old stagers, with glandular
enlargements.
The use of dry powders to the throat is many
times of great benefit. Dr. MacBride kindly in-
forms me that he has had excellent results from
the following. In subacute, or mild cases, verg-
ing toward a more deeply seated and chronic
condition, the use of one part of iodoform in one-
96
TREATMENT OF
hundred of sugar of milk. In real bad cases,
exuding an offensive discharge,
Ꭱ
Iodoform,
Tannic acid,
Sach. lac.
gr. x.
gr. j.
3 jss.
These can be applied by means of an atomizer,
fitted with a rubber tip like a posterior nasal
syringe. Those who can afford it will find the
application of sprays and powders to the naso-
pharynx rendered very much easier and pleasant
by the use of Dr. Sass' apparatus, which
consists of a metal receiver, and air pump, by
which air is forced into the receiver to any de-
sired pressure. From the receiver issues a rubber
tube fitted with stopcock, etc. To this is attached
the vessel containing the preparation you desire
to use. The confined air forces the preparation
through the application tube, on the principle of
the hand atomizer. With the apparatus come a
number of vessels and tips arranged to throw any
variety of spray in any direction.
Of course in these cases personal hygiene is to
be attended to. The avoidance of undue exposures
the wearing of flannels, etc., is to be advised. One
very frequent cause of the continuance and per-
sistency in these cases, especially among men and
boys, is the habit of dampening the hair every
CHRONIC CATARRHAL INFLAMMATION
97
time it is brushed. This keeps the head continu-
ally moist, and materially aids the catarrhal pro-
cess. Many have been very greatly benefited
after stopping this habit, who had resisted treat-
ment before. For this practical fact I am indebt-
ed to Dr. Houghton.
Another thing I learned from him which has
been of great benefit in many cases, and that is
the local application to the naso-pharynx of the
same remedy in a lower trituration, that you may
prescribe internally. For instance if you are
using Kali mur. in the sixth or twelfth internal-
ly, liberally dust it on the naso-pharynx in the
third.
In regard to the use of local applications to the
membrane, there is not much to be said. In dry
cases, fluid vaseline seems to lubricate and soften
a little. A little plantago in some glycerine
sometimes seems to stir up the tissues in some
instances, and relieve both tinnitus and deafness.
We have been using this in a good many cases
recently at the New York Ophthalmic Hospital,
but are not as yet positive as to its action. One
thing I must speak of as a reprehensible habit in
patients. No matter from what the ear may be
suffering, they crowd the meatus full of cotton.
Now in painful cases, or when there is a dis-
charge, it is all very well to protect the sensitive
portion from exposure, but in the old chronic dry
Uor M
98
TREATMENT OF
forms it is a positive injury to habitually wear
cotton plugs in the ears, except when great sensi-
tiveness to atmospheric influences is present.
The local treatment which I have been describ-
ing is all excellent as far as it goes, but he makes
as great an error who thinks it all that is neces-
sary, as he who thinks all suppurative cases can
be cured by internal medication alone. Remedies
are our main reliance in this disease, and the
rest, though very important, must be looked upon
merely as adjuvants. In none of these lists do I
claim the indications to be complete, or the lists
full, but they are a few of the more prominent,
which clinical experience has served to verify.
Before dismissing this part of the subject, I
must call attention to one thing of importance in
these cases. Many of these conditions occur in
persons who wear false teeth. It has been a
favorite practice with dentists to make these false
teeth on red gum plates, in which there is a large
amount of mercury. In persons who are sensitive
to the action of this drug, the parts of the mouth
covered with the plate will frequently be found
extensively ulcerated. When such a condition
exists, it is absolutely imperative that these mercu-
ry plates be removed, and one substituted that
does not possess such noxious properties. Treat-
ment is useless until this is done. Case after case
has been seen resisting all therapeutic measures,
Maou
CHRONIC CATARRHAL INFLAMMATION
99
the reason for which has then been found to be
the wearing of these cheap false teeth, and upon
their removal improvement was at once manifest.
A few words are proper to be added with refer-
ence to various operative procedures which have
been practiced upon these catarrhal cases, to over-
come the mechanical difficulties which interfere
with conduction. These are not given as instruc-
tions, for such work strictly belongs to the spec-
ialist, but for information.
Paracentesis of the membrane has been often
done, but it is almost impossible to make the
opening permanent. The removal of a small
portion is followed by the same result. Eyelets
have been inserted in the opening made, with but
temporary results. Excision of the malleus
handle, and removal of the whole or various
portions of the ossicles, have been resorted to
without success. Tenotomy of the tensor tym-
pani tendon when it has become contracted, has
been performed many times with a partial dimin-
ution of the tinnitus. Division by a small, spec-
ially constructed knife, of the various adhesions
in the tympanic cavity, has been resorted to, but
unsuccessfully.
The object of most of these has been to relieve
the pressure on the labyrinthine fluid exerted by
the stapes, whether atmospheric or mechanical.
When a device shall have been formed which will
Uor M
100
TREATMENT OF
serve to maintain a permanent opening in the
membrane, then these various procedures will be
of use. In these old thickened cases, there is less
objections to the entrance of outside air through
the meatus and membrane, as they resist much
more energetically the atmospheric influences,
which in a normal or suppurative ear would be
followed by more or less inflammatory action.
The difficulty in maintaining the permanent
opening lies in the fact, that the thickened mucous
lining has a much stronger tendency to the
development of connective tissue or hyperplasia,
for closing the orifice, than in any other con-
dition.
HOMEOPATHIC REMEDIES.
Arsenicum.-Dr. J. H. Buffum gives several
cases in the N. Y. State Trans. for 1882, in which
he has successfully used this remedy. The con-
ditions seem to be those with much naso-pharyn-
geal catarrh. His most marked case has sensi-
tiveness on right side of nose; tissues in nostrils.
much swollen, and dark red color; middle tur-
binated bone tumefied, to occlusion of the nostril;
burning pain in nose. Discharge from nostrils,
slight, watery and acrid; hypertrophy of tissues
in pharyngeal vault, and at openings of eustach-
ian tubes.
Maou
CHRONIC CATARRHAL INFLAMMATION
101
Argentum nitricum.-A distant ringing in the
ears. The ears "open and shut;" whizzing
sounds; feels as if a splinter in the throat;
(Hepar). The fauces and uvula are dark red.
Tenacious mucus in the throat and posterior
nares. The distant ringing in the ears with the
sticking as of a splinter, are the marked features
in Arg. nit.
Aurum muriaticum. The chronic cases of
naso-pharyngeal catarrh ; offensive odor from the
mouth; ozona.
The nasal bones have become
affected from the catarrhal process. Cases with
specific history after much mercury. Depressed
anxious, melancholy state of mind.
Baryta muriatica.-With severe buzzing; bub-
bling or cracking in one or both ears when
swallowing, sneezing, etc.; reverberation in the
ear on blowing the nose violently. In children
with intermitting deafness, and in damp weather,
with occasional earaches and deafness following.
The characteristic features of Bar. mur. cases are
the crackling and buzzing, and aggravation from
damp weather. Its especial sphere of action is on
the eustachian tubes. (Rounds).
Belladonna.-Useful in both acute and chronic
cases. The tinnitus in chronic cases is of a ring-
ing character. The throat has a dry glazed look,
as if coated with varnish, and is of a brighter red
than normal. In catarrhs and colds brought on
102
TREATMENT OF
by wetting the hair or after cutting it. Its pro-
longed use is rarely called for.
Calcarea carbonica.- In the usual calcarea
cases. Deafness following wetting the feet, expo-
sure to slight drafts; pain in the ear on blowing
the nose. Head is cold; perspiration on head
evenings. The noise in the ears is of a knocking,
roaring, buzzing character. If pains are present,
they are of the pressing, pulsating type, often
one-sided. A cracking in the ears on moving the
jaws. Pains may extend from throat to ears.
Calcarea phosphorica.—In the chronic catarrhs
of children.
Causticum.-Ears stuffed; whole side of head
feels dull and numb; reverberations of voice to
the patient; seems as if talking in a barrel, or
out through the ears. Itching along tube to ears
as if an insect were crawling.
China. The tinnitus in the ears is pitched upon
a high key. A "quinine buzzing." After the use
of quinine in quantities, china in high potencies
has many times relieved the symptoms.
Ferrum phosphoricum.-In the acute earaches
which sometimes occur in the chronic cases from
unusual exposure, Ferr. phos. will nearly always
give relief. Sometimes Merc. will relieve when
this fails.
Ignatia.-Hering gives the symptom, "hard
hearing for everything but speech." It has also
CHRONIC CATARRHAL INFLAMMATION
103
been used where everything was heard well but
speech. (Phos.) The contradictory character of
Ignatia symptoms in general, would indicate
either of these symptoms. Personally I have
used it very little.
Graphites. Dry cases; hearing improved in a
noise.
Hepar sulphuris. This is a remedy which
perhaps thoughtlessness prevents our using as
frequently as it might be done with benefit, from
the habit of associating it with pus formation.
Dr. Park Lewis gave at the O. and O. meeting in
Milwaukee, 1880, the following indications.
Especially children. Drumhead looks dull,
like glass breathed upon; cracking sounds on
moving the jaw; congestion in throat, but with-
out granular pharyngitis; nasal catarrh and se-
cretions from posterior nares; feels as if splinter
in throat. When we consider the readiness with
which we think of Hepar in catarrhal troubles.
outside of the ear, it is but consistent to expect
its beneficial action on the mucous lining of the
tubes and tympanic cavity.
Hydrastis Canadensis.-Thick tenacious mucus
in the posterior nares; ropy secretion; with the
dull, heavy frontal headache from the catarrhal
process in the frontal sinuses. Excellent inter-
nally, when used locally on the throat.
Kali iodatum.-Used in old tough cases; in
104
TREATMENT OF
chronic proliferous forms; burning, scraping,
roughness of the throat; expectoration is green-
ish, stringy, and salty. Also in specific cases
with throat symptoms after mercury. A very
important remedy in old intractable cases, and
the main reliance of many colleagues in this class
of cases.
Kali muriaticum.-No remedy in the materia
medica meets so many cases as Kali mur. It is
useful in recent cases and in old cases. Its espec-
ial sphere of action seems to be in the catarrhal
cases without pain, in which there has been se-
cretion, hypertrophy, and accumulations. In the
true proliferous cases it is of less use. It seems
to lessen the secretion, clear out the accumulated
mucus, and reduce the chronic swelling of the
mucous membrane in the throat, tubes and tym-
panum.
The particular indications for its use are a
palish anemic throat, more or less thickened con-
ditions of the mucous membranes, and membrana
tympani. Closure and stoppage of the eustachian
tubes, and adhesions of the drumhead. In many
cases in which I could neither force air into the
tympanum, nor find free movement under the
Siegle speculum, after two or three weeks use of
this remedy, the tubes became open, the drumhead
became more mobile, the tinnitus lessened or
ceased, and even the retraction of the membrane
CHRONIC CATARRHAL INFLAMMATION
105
was less pronounced. Following this has come at
marked improvement in the hearing. Many
times its use must be persisted in for weeks or
months, but in hundreds of cases I can testify to
its excellent effects. I prefer to use it in the 6×,
but many times it works better even lower.
Kali phosphoricum.-This remedy finds its
special affinity in cases accompained by many
nervous symptoms, tendency to hypochondria,
etc. Always a new story to tell, or a new symp-
tom discovered. In elderly people. The noises
are constantly changing their character; now a
roaring, next a hissing, then a buzzing, etc.
Mercurius dulcis.—A remedy of almost equal
value to Kali mur. The particular indication for
its use is the character of the throat. Where
this is red and congested, with swelling of the
tubes, it will remove the hyperemia and its ac-
companiments. The deafness and noise in the
ears increase at every cold. A sense of fulness.
The tinnitus is often a pulsating roaring. There
is a sore, raw feeling in throat, extending up the
tube, and the patient feels as if he were about to
have an earache. Useful in a moist throat more
frequently than in a dry one, though often a
sense of dryness. The pharynx and uvula look
thick, flabby and infiltrated. Often this remedy
used in similar cases to the above, and followed
by Kali mur. when the redness disappears, works
106
TREATMENT OF
wonders. A benumbed, dull feeling between the
throat and ear; a pressure in the ear from with-
out. Also in cases when an acute condition with
pain worse at night, is added to the chronic pro-
cess.
Phosphorus.—In nervous women. Often after
the use of Merc. dulc. in acute catarrhs. Voice
sounds unnatural, as though a veil were before
the ear.
Tinnitus worse when lying down, as well
as the deafness. The deafness is accompanied
with a rush of blood to the head, and all sounds.
are heard better than the human voice. Some-
times when Phos. fails, Phos. acid will benefit
with similar symptoms.
Muriatic acid.-Dryness of the mucous linings
in the head, and dryness of the ear. Rawness,
dryness, and emptiness in the throat.
Nitric acid.-Similar to muriatic acid. The
differentation between the two is in the general
system; muriatic acid having especial relations
to the digestive tract, while "nitric acid deserves
preference if there are also complaints in the
respiratory tract." The relations of muriatic and
nitric acid to the chronic catarrhal process, and
their indications, were given by Dr. Liebold, at
the Am. Inst., 1882. These two remedies are of
great value and importance in many cases.
Mercurius vivus.-This remedy, like Ferrum
phos., is frequently valuable both in chronic
CHRONIC CATARRHAL INFLAMMATION
107
catarrhal and suppurative cases, when an acute
exacerbation is present, with intense pain, worse
at night. Sometimes as said before, the Merc.
dulc. relieves this condition, but there are cases
of considerable intensity which the dulcis fails to
relieve, that the vivus meets the condition and
gives the sought for relief.
CHAPTER X.
SUPPURATIVE INFLAMMATION OF THE
MIDDLE EAR.
(Otitis Media Suppurativa, Acuta et Chronica).
Suppurations of the middle ear are among the
most important lesions of this organ that you
will meet. I consider them by far the most
important, for the following reasons. They are
among the most common. They are the most
neglected. They are the most offensive. They
impair the function of the ear equally with other
forms, and even more. There are wide spread
errors among profession and laity in regard to
them, and they are a constant menace to life.
This latter assertion may seem a strong state-
ment, but any aurist of experience can relate
cases by the score almost, where a neglected sup-
puration, “something that would cure itself," has
ended in death, or a very near approach to it.
Last year I had the honor to present to the
N. Y. State Homœo. Soc., a paper* on the re-
lation of certain diseases of the ear to the brain.
* Published in Hahnemannian Monthly, Oct., 1884.
OF THE MIDDLE EAR
109
Those who took the trouble to read it, will, I
think, acknowledge that a suppurating ear is
always a source of danger, even to the extent of
the above remark. Those who have the patience
to follow this, will, I am sure, admit that it is not
a trifling thing.
Suppurative disease, like most others, has an
acute and a chronic form, each with their charac-
teristic features. Where the acute ends and the
chronic begins, it is not always easy to decide,
but for convenience sake, and in deference to the
usual custom, they will be thus separately con-
sidered.
ACUTE SUPPURATION.
The earlier symptoms of an acute suppuration,
are those of an acute catarrhal otitis media, but
more intensified. There is the same fulness and
itching in the throat and ears, the same hyper-
sensitiveness to sound, deafness, tinnitus and
pain. But these symptoms succeed each other
much more rapidly, and appear with greater se-
verity. The pain steadily increases from a slight
twinge to unendurable agony. It remits neither
night nor day. The countenance gives evidence
of the excessive pain endured, looking haggard
and worn. Fever is generally present, and the
patient often seems in a condition of profound
prostration. Severe as the pain is in the day
110
SUPPURATIVE INFLAMMATION
time, it is much worse at night. The sufferer is
deprived of sleep, his appetite fails, his tongue is
coated, and he bears every mark of a severe ill-
ness. This continues till the membrane becomes
ruptured, and the evacuation of the pus gives ease
and comfort. Undoubtedly many of these cases
are of a purely catarrhal form at first, and pro-
ceed to the formation of pus, either through neg-
lect or added exposure. Others without question,
are of a suppurative type from the beginning.
These latter are apt to experience the intense
pain at an earlier period than the former. In
children this may be a very serious disease.
Burnett says, "upon its timely recognition may
depend the life of the little patient. Certainly
much suffering would be avoided, perhaps many
lives saved, if the ear were even once thought of
as the possible cause of an apparently obscure
disease, in those too young to tell where the seat
of their pain is. Not only in children, but in
adults, this disease is one of the most important
the physician meets. The importance of treating
it properly in its acute stage cannot be too fully
appreciated. Yet, it is lamentable to state, that it
is usually entirely disregarded."
From every
author of treatises on the ear, the same views
could be quoted. General practitioners do not
realize how much of the future happiness and
prosperity of an individual may depend upon
OF THE MIDDLE EAR
111
the results of an acute suppuration of the ear.
In no case of a child taken suddenly ill, with
pains apparently in the head, should an examin-
ation of the ear be neglected.
The objective symptoms are also similar to
those in a severe case of acute catarrh. The red-
ness however, is of a duskier hue. The bulging
of the membrane is more pronounced, and from
the soaking in the pus behind it, often seems
sodden and boggy. These attacks seem to occur
more frequently in a healthy ear, than in one in
which the chronic catarrhal process has been
present, as the thickened and hypertrophied lining
resists the tendency to purulent inflammation.
Its course and results are in one of three di-
rections. After rupture of the drumhead, the
inflammation may rapidly subside, the discharge
cease, the membrane repair itself, and things
seem as before, but in these cases as in the acute
catarrhal cases, there are products and changes
left in the tympanic cavity which need subse-
quent treatment, for if neglected, they lay the
foundation for after troubles.
The second and most common course, is for the
more acute symptoms to disappear, but the dis-
charge continues, finally passing over into a
chronic form, and becoming that most unpleasant
object, a "running ear," with all its unfortunate
consequences.
112
SUPPURATIVE INFLAMMATION
The third way in which this may end is in
death. Fortunately this is not common. The
wonder is that it is not more so, when we consider
the anatomy of the part, and the near relations of
vital organs. As the manner in which this can
occur will be referred to when speaking of the
dangers arising from chronic suppuration, it will
not be dwelt upon here.
Like other forms of suppurative inflammation
in different parts of the body, its tendency is to
the destruction of tissue. This is first manifested
in the breaking down of the membrana tympani.
In the great majority of cases, this gives great
relief to the patient, and the acute symptoms
rapidly subsiding, the physician too commonly
deems his duty ended. In a recent discussion on
this subject, a gentleman of great experience in
general practice, mentioned a case of intense ear-
ache in a little patient of his, finally ending in
suppuration, with the great relief following, and
implying in his remarks that the serious part of
the malady had been overcome by the remedies
bringing about a discharge, and not much more
attention was needed. I took emphatic issue with
him, claiming that from my standpoint, that
then was the most urgent time for treatment. As
a rule, in cases of acute suppuration, the ruptur-
ing of the membrane is the end of the destructive
process in the acute stage, but sometimes much
OF THE MIDDLE EAR
113
more damage is done. The destruction conse-
quent upon the chronic form, I am not now re-
ferring to. This further involvement may be
a carious and necrotic process of the bony walls.
of the cavity, passing directly to the brain, set-
ting up a meningitis, and sometimes abscess of that
organ. The mastoid may become involved and
more or less destruction of that portion occur.
Sometimes the inflammatory process passes to the
sinuses in the immediate vicinity, and a fatal
phlebitis follows. The possibility of such an un-
fortunate ending should always be borne in
mind.
The causes which produce this disease are the
same as those given for acute catarrh, but there
is a difference in the frequency of the propor-
tions. Cold and exposure as in the other, bring
it about, but by far the most frequent source is
scarlet fever. Following in its wake come
diphtheria, measles, whooping cough, typhoid
fever, and the varions exanthemata.
Cold sea
bathing brings about the purulent as well as the
catarrhal variety. Direct violence of course may
produce it, if a sharp instrument, like a tooth-
pick, for instance, be accidently driven through
the membrane, while scratching the meatus, but
blows upon the ear, and loud explosions near it
may also induce it. The manner of their action
is two-fold. By the sudden impact the column
114
SUPPURATIVE INFLAMMATION
of air in the canal may be driven against the
drumhead with such force that it bursts, or if it
does not break, the shock of the concussion may
be so great upon the delicate tissues within the
drum, that the reaction may bring about an in-
flammatory condition with the formation of pus.
The introduction of fluids through the eustachian
tube may also induce a suppuration. This may
occur either accidently, as in an irresistible desire
to cough at the moment of swallowing, thus
forcing the fluid from the mouth and nostrils,
and at the same time into the tube, or deliberately
at the hands of the surgeon when using the
eustachian catheter. This is another reason why
I object to its habitual use as a method of treat-
ment.
Now how are we to differentiate an acute suppur-
ation from an acute catarrh, before the rupture of
the membrane and discharge makes the diagnosis
for us? Frequently this is impossible, but there
are some characteristic differences which will
usually aid us. In the suppurative form as said
before, the symptoms succeed each other much
more rapidly, and with greater intensity. The
pain, which many times is severe enough in the
catarrhal variety, becomes unendurable in the
purulent. In the latter it continues through the
day as well. The cause also is to be considered.
A history of a blow, the presence of a severe con-
OF THE MIDDLE EAR
115
stitutional disorder (scarlet fever, etc.), is to be
taken into account. The apparent effect on the
patient's general system, the fever, prostration,
haggard look, etc., all aid in the differentiation.
The membrane seems more generally involved.
Its congestion is more intense, and in my expe-
rience seems of a duskier red. The bulging is
more pronounced. With an equal amount of
pus or mucus behind the membrane, the bulging
will be greater in the former case. This bulging
also is most always in the posterior half of the
membrane.
Bearing in mind what has been said about the
possibility of farther complications, the prognosis
should be more guarded than in the catarrhal
form. An indication of deeper lesions is to be
found in the fact, that after rupture of the mem-
brane and evacuation of pus, the pain still con-
tinues. These should be carefully sought for, as
materially modifying the result.
There are certain local measures which it is
important to adopt in the care of this affection.
The old school unhesitatingly recommend the
withdrawal of blood in the earlier stages, prefer-
ably by leeches. These, if used, are to be applied
either at the tragus, or if the mastoid region is
painful and tender, directly over it, or in the hol-
low behind the ear. There are few cases however,
in which our remedies will not avail to do away
116
SUPPURATIVE INFLAMMATION
with blood letting, if judiciously selected. The
membrane should be carefully watched, and if
any bulging appears in spite of treatment, it
should be punctured at once. This often arrests
the disease at this stage. This incision is to be
made in the posterior inferior quadrant, for the
reasons given when speaking of paracentesis in
the acute catarrhal form. The cotton night cap
as also there recommended is to be used. The
patient should be confined to the house, and in a
warm room, care been taken to prevent drafts or
changes of temperature. The solution of Acon.
Bell. Plantago and Magendie's solution, the for-
mula for which was given on page 71, is an excel-
lent local application for relieving pain. The
use of hot water irrigation is also of great com-
fort in many cases. One thing must be borne in
mind, viz., that the use of poultices will tend very
strongly to bring about the exact condition we
are striving to avoid, viz., the breaking down of
the membrane, and suppuration. To prevent this,
is the aim of all our treatment in the earlier
stages. Moreover, the continued heat and moist-
ure produced by a poultice, macerates the tissues,
and favors the springing up of granulations,
which become a complication of great annoyance.
If in spite of all your endeavors, the inflammatory
action continues, and the membrane breaks, you
have then the first stage of the chronic suppura-
OF THE MIDDLE EAR
117
tion, which will now be considered as next in
order. The remedies for the acute form and
their indications, will be given with those appli-
cable to the chronic condition.
CHRONIC SUPPURATION.
With chronic suppuration of the middle ear, we
enter upon a phase of aural troubles, that is at one
and the same time the bete noir of the physician,
and one of the most important, while one of the
most common and neglected diseases that come
under his professional observation. I make no
1
apology for the frequent references to its gravity.
The error is so widely spread among both physi-
cans and laymen, that too much stress cannot be
laid upon it, and if in the smallest degree, the
perusal of these pages will lead to the recognition
of the place it should occupy in the minds of the
profession, they will not have been written use-
lessly. If anyone who doubts this fact, will take
the time to visit the aural clinics of the New
York Ophthalmic Hospital, or any of the larger
special hospitals in this city, for a few days or
weeks, I think he will be convinced of his error.
Otitis media suppurativa chronica is usually
the sequel of the acute condition we have just
been studying. Its causes are the same, requir
ing no recapitulation. But there are some cases
118
SUPPURATIVE INFLAMMATION
I
in which the tendency to assume a chronic type
seems present from the beginning. Noticeable
among these, are those originating from scarlet
fever and diphtheria. In the latter disease, the
pus forms and the membrane breaks down fre-
quently, with very few of the acute symptoms as
recently detailed. The ear seems to simply com-
mence discharging, and continue discharging.
have very little question that the impaired nu-
trition of the tissues, from the low quality of the
blood in this affection, is one prime reason. In
both scarlet fever and diphtheria, the constitu-
tional symptoms are so severe, that the ear trouble
may be entirely overlooked, until it is brought to
notice by the presence of the discharge. How
these affections induce ear disease, a moment's
reflection will show. They both, by preference,
produce severe manifestations in the throat, and
the relation of the throat to the ear, we have
already dwelt upon at length.
The symptoms of this disease are as in other
aural troubles, deafness, tinnitus, more or less
pain in different instances, with the added one of
a discharge from the ear. The appearances are
various, but there are two which are very uni-
formly present, the pus, and upon cleansing the
canal, a perforation of the membrana tympani.
The character of the discharge assumes all the
forms of which pus is capable. Frequently it is
OF THE MIDDLE EAR
119
of a creamy yellow, bland, and of the consistence
of laudable pus. In fact it is laudable pus in
every respect. From this it varies to a white,
watery fluid, or a thick, yellowish granular mass,
like soft cheese. It may be, and often is in old
cases, of a dark brown color. Sometimes it is
mixed with blood, sometimes of a decided green-
ish hue. Occasionally it may be so bland that
no irritation of the adjacent tissues is produced,
and again it may be so acrid and excoriating, tha
every spot touched by it becomes red, raw and
sore. Cases are frequent in which this condition is
present, not only in the meatus, but way down on
the auricle. Sometimes it is of a very copious
character, pouring out in profuse quantities, and
dropping from the ear; in other instances it is so
scanty, that there may be but a drop in the mea-
tus. Most frequently, inspection shows the canal
more or less full. Its odors are various and
indescribable. Of course there are cases where
the odor is not perceptible, and in the earlier
stages there is apt to be little or none, but in the
older and neglected cases it "smells to Heaven."
Decaying fish, aged eggs, sulphuretted hydrogen
are perfumes, to some of the cases met. Will a
physician's common intelligence and sense, per-
mit him for a moment to admit that such a con-
dition is trifling," "that the patient will outgrow
it," "that it will cure itself?" Certainly in no
120
SUPPURATIVE INFLAMMATION
other portion of the human system, could such a
state of affairs be present, without receiving the
closest attention.
Upon cleansing the meatus, our attention is
directed to the membrana tympani, to see how
that has fared in consequence of this process.
Unless we have been able to diagnosticate a dif-
fuse external otitis, we shall expect to find this
perforated, but how much of it has been destroy-
ed? Sometimes but one perforation is present,
sometimes two, and rarely, multiple perforations
are seen. The perforation may be small, or it may
involve nearly the whole of the membrane, leaving
but a small falciform border. The shape usually
is round or oval, though it may assume different
ones. Any part of the membrane may be the
site of a perforation, but according to Schwartze,
they are most common in the lower anterior
quadrant. The central portion involving the
manubrium, is usually the last to go. Accompa-
nying this destruction of the drumhead, is not
infrequently a loosening and detachment of some
of the ossicles. The malleus I have seen dis-
charged through the meatus in the process of
cleaning, though one is rarely fortunate enough
to see it in the act. Still, cases where it is absent
are quite commonly met with. Sometimes the
handle alone, of the malleus, is either absorbed or
necrosed. Not infrequently it is twisted out of
OF THE MIDDLE EAR
121
sight from the distortion of the parts. The incus
also may suffer a like fate with the malleus, any
portion of it, from a process to the whole bone,
being destroyed. One portion of the stapes
usually resists the destructive action, viz., the
footplate closing the oval window. Both of its
arms may be lost, but this usually remains
firm.
The condition in the external canal varies from
a mere redness or hyperemia induced by the
moisture, to an extensive ulcerative process.
When this occurs, it is in the state known as con-
secutive diffuse external otitis, and was described
before. There are some constitutions with a
psoric" taint, or diathesis, that seem peculiarly
prone to an involvement of the meatus.
(6
If the external canal be free, and the perforation
large enough, we can see within the cavity of the
tympanum. There are certain specially contrived
little mirrors for examining the roof and walls,
which are introduced through the perforation,
but with these we have nothing to do. They be-
long to the specialists outfit. What we can see
without such aids, is what concerns us. Of course
the only portion visible, is the inner wall directly
opposite the drumhead, and from the condition
in which we find this,we infer as to more or less of
the condition beyond the range of vision. This
is generally quite red and hyperemic, as is to be
122
SUPPURATIVE INFLAMMATION
expected. Sometimes it seems studded with min-
ute glistening points. These are either at the
normal distance from the membrane, or appear
near to, and even projecting through it. They are
granulations, which occasionally become so ex-
uberant, that they project way into the meatus,
and occasionally fill it. These not infrequently
organize into polypoid structures, even projecting
beyond the orifice of the meatus. The portion
seen varies in shape and appearance. Some are
smooth and club-shaped at the end, others have
branching papillae, looking like condylomata.
These polypi are not uncommon. They are most-
ly of the class known as mucoid, being developed
from the mucous lining. Fibrous polyps are
comparatively rare.
Of course the instances are many, where the
perforation is so small that no portion of the
tympanic cavity can be seen through it. There
are numerous instances where it is so minute that
cannot it itself be seen, and yet there is pus in
the canal. To decide this point, we use either the
pneumatic speculum, or request the patient to
"perform Valsalva." In the latter case if the
eustachian tube be open, the air is forced through
the aperture with a combined whistling and
sputtering sound. If the Siegle speculum is
used, we can see the pus oozing from one point in
the membrane, which solves our diagnosis. In
OF THE MIDDLE EAR
123
rare instances the pus may burrow beneath, and
forming a channel for itself, makes its appear-
ance at some point in the meatus wall, usually
through one of the Santorinian fissures. I have
such a case now under observation. It is not a
rare thing to meet cases, in which upon inspection
of the membrane, a drop or two of pus being upon
it, a regular pulsation is observed, synchronous
with the radial pulse. Such a case was shown the
class to-day. There are many other features which
can be seen in suppurating ears, but enough has
been said to indicate the general appearances
they present. We now proceed to describe the
course and possible consequences they may lead
to.
CHAPTER XI.
COURSE AND CONSEQUENCES OF SUPPURATIVE
INFLAMMATION OF THE MIDDLE EAR.
In speaking of the course and consequences of
chronic suppuration, I shall dwell more particu-
larly on the issues which may be fatal, for one
of the prime objects in these pages is to enforce
upon the attention, even at the risk of iteration,
the danger of their neglect, and it is eminently
proper that in any disease which rises to the
gravity of frequently endangering life, the way
and manner of its occurrence should be made
plain.
The duration of this affection is of indefinite
length. I do not know that any statistics are
available which would throw light upon it. I see
cases nearly every day of adults, who say they
have suffered from it since infancy or childhood,
and cases are by no means infrequent, in which
after a discharge of a few weeks, it seems to dis-
appear with no particular treatment. This last
class though not rare, is by no means the com-
mon course. Suppuration running from weeks
SUPPURATIVE INFLAMMATION
125
.into months, and months into years, is by far the
most frequent history. In those cases in which
the disease has not been more than a few weeks
or months duration, and then ceasing, the mem-
brane often repairs itself, and though some im-
pairment of hearing may be the result, the case
may be considered to have a satisfactory termina-
tion. In the shorter cases, viz., a few weeks,
repair is often followed by fairly good hearing.
>
The capacity of the membrane to renew itself,
or make good, inroads in its structure, is a very
remarkable feature. After incision it frequently
heals in a few hours, and even when there has
been extensive destruction, it is astonishing how
large a proportion may be renewed, even upwards
of two-thirds, having been replaced by new tissue
in well authenticated cases. The rapidity with
which this is accomplished sometimes is very in-
teresting. In a case sent me by my friend, Dr.
Cheney of New Haven, Ct., in Oct., 1883, I found a
chronic suppuration of some eight months du-
ration. There was a large mucoid polyp project-
ing from a perforation, and occluding the canal
for one-third from the membrane. In the outer
third was a fibrous polyp hanging from the su-
perior wall of the meatus. It was the second of
November before I could be sure that the ear was
free from discharge, and no traces of the polypoid
growths, or granulations left. The perforation at
126
COURSE AND CONSEQUENCES
that time involved from one-quarter to one-third
of the membrane, in its posterior half. On the
nineteenth of that same month, the membrane.
had entirely healed. This patient visited my
office twice a week, and it was possible to watch
the progress of this repair from visit to visit.
This reparative material is connective tissue,
growing from the edges, and finally meeting,
leaving a well marked cicatrix on the site of the
former perforation. The middle fibrous layer of
the membrane is never renewed. In various por-
tions of the membrane, calcareous deposits are
frequently seen appearing as white spots. Many
of these cases possess remarkably good hearing
during the suppuration, even when a large portion
of the drumhead is gone, and no trace of the
ossicles visible. It is a very common error to
suppose the membrane essential to hearing. This
is not strictly the case. As said before, the mid-
dle ear is primarily a safeguard to protect the
internal ear, and the membrane but a factor in
the mechanical arrangements for carrying sound
vibrations to the labyrinth. When this is rup-
tured or destroyed, the sound waves are still
received by the footplate of the stapes, or by
means of the round window (another foramen
with membranous closure, on the inner wall, con-
necting the middle ear with the cochlea). The
theories as to how this is accomplished are in-
OF SUPPURATIVE INFLAMMATION
127
teresting, but too lengthy for discussion here.
After suppuration has ceased, and the mem-
brane repaired, hearing is often much worse than
during the discharge. This is due to two or three
reasons. In the retrograde process, there is usu
ally more or less cicatricial contraction, affecting
the mobility of the conducting apparatus similar-
ly to that in chronic catarrh. This may affect
the union of the stapes with the labyrinth, where
a very slight anchylosis suffices. How slight
may be necessary is seen, when it is remembered
that the normal excusions of the stapes are only
from the eighteenth to the fourteenth part of a
millimetre. Again, the moisture present in a
suppuration is succeeded by a certain dryness
after its cessation, thus losing a possible lubricat-
ing element. It is a common thing for patients
to say, "Yes, doctor, the child's ears have stopped
running, but he does not hear nearly so well."
This however, is the lesser of two evils. It is in-
finitely better to have an impaired hearing, than
to allow a condition to remain, which at any time
may endanger life, and is quite certain to impair
hearing as well at a later stage.
There are a number of nervous phenomena,
which may accompany or follow middle ear sup-
purations, but they will be merely referred to, as
epileptic seizures, paralysis of the facial nerve,
alterations in the sense of taste, and other pecu-
128
COURSE AND CONSEQUENCES
liar sensations in the tongue, an altered gait,
vertigo, etc. In general terms, these are all due
to nerve irritation in different localities, depend-
ing upon the purulent process going on in the
ear. In the larger works they are dwelt upon
quite at length, to which the reader is referred if
he desires to study them.
One very common accompaniment of this dis-
ease has already been spoken of, the development
of granulations, and subsequent modification in-
to polypoid structures. These must be removed
as one of the first steps in treatment. They have
a very strong tendency to return, and treatment
must continually be directed toward their sup-
pression. The methods in vogue will be spoken
of later.
The consequences of chronic purulent otitis
media have been concisely formulated by Roosa,
as follows:
1. Polypi.
2.
Exostoses.
3. Mastoid disease.
4. Caries and necrosis.
5.
Cerebral abscess.
6. Pyaemia.
7. Paralysis.
POLYPI we have briefly spoken of. Their eti-
ology and histological structure belong to more
elaborate treatises.
OF SUPPURATIVE INFLAMMATION
129
EXOSTOSes are not common. When met with
they are a serious complication, and demand
treatment at the hands of a competent specialist.
Congenital ones do not concern us. These ac-
quired exostoses may appear either in the tym-
panic cavity or external meatus, reducing the
capacity of both. They are removed when
accessible by filing and drilling.
MASTOID DISEASE is a condition giving rise to
serious anxiety, as it is usually the beginning of
those deeper lesions which unless promptly ar-
rested, frequently end in death. I have been at
some little pains to ascertain the relative frequen-
cy of this complication. Out of 44147 cases of ear
diseases of all kinds which have occurred in this
city, mostly within the last ten years, there have
been 14091 cases of suppuration of the middle
ear, or about 30 per cent. Of these, 2647 cases are
recorded as acute suppurative, and 11444 as
chronic. In this 44147 cases there have been 247
recorded as mastoid disease, or about one-half of
one per cent of the whole number of ear diseases,
which include every form, from a pimple on the
auricle to the gravest lesions of the nerve. This
is a percentage of about 2 1-5 per cent to the
chronic purulent cases, which is certainly a suf-
ficiently frequent complication to have its possi-
bility borne in mind.
1 am satisfied this does not represent the true
130
COURSE AND CONSEQUENCES
proportion, but that it is somewhat greater, for
this reason; it is the habit of many hospitals to
record the diagnosis of the disease from which a
patient may be suffering upon his entrance.
After complications are noted in the history of
the case, but do not appear as a separate diagno-
sis. For instance, a patient applies at the N. Y.
Ophthalmic Hospital suffering from a chronic
suppuration of the middle ear, and no complica-
tions; his diagnosis is entered as Otitis Media
Suppurativa Chronica. After a few days treat-
ment he disappears for a short time, undergoes
some exposure, and returns with a mastoid in-
flammation. While a note is made of the addi-
tional trouble in his clinical history, the former
diagnosis is not changed. If however, he is suf-
fering from a mastoid trouble at his first appear-
ance, then the diagnosis appears as such. So I
am convinced that the proportion of mastoid
complications is actually much greater than
the above figures would indicate.*
involved it
When this portion becomes
is usually in one of three ways. Either the
lining membrane of the mastoid cells takes part
*The above figures have been compiled by myself from the
reports of the four largest special hospitals in this city-the New
York Ophthalmic, the New York Eye and Ear Infirmary, the New
York Ophthalmic and Aural Institute, and the Manhattan Eye and
Ear Hospital.
OF SUPPURATIVE INFLAMMATION
131
in the general inflammatory process in the middle
ear, or its outer covering, the periosteum, becomes
involved, or the bone itself takes on a carious or
necrotic process. Primary inflammations are ex-
ceedingly rare. It is the consecutive forms we
wish to study.
When this complication is about to occur, the
patient complains of an unusual amount of pain.
This he may locate in the ear or behind it. Fre-
quently he will say it is sore behind the ear.
Inspection at this time may show a slight redness
over the mastoid, and sometimes a little swelling.
This swelling increases, the pain grows more in-
tense, the tenderness so great, that the patient
cannot bear to have it touched. The swelling
may become very great indeed, extending down
the neck, even to the clavicle, and to the me-
dian line behind. Sometimes the parotid becomes
involved. Occasionally this swelling is very
hard. In one case to which I shall refer later,
upon cutting through the tissues it was like
cutting cartilage. This swelling is by no means
proportionate to the amount of pus that may be
found, which not infrequently is none.
In some
instances a localized abscess makes its appearance
directly over the mastoid, comes to the surface,
points and breaks, accompanied by but little
surrounding swelling. These are the easy cases.
In certain cases in which the bone itself becomes
132
COURSE AND CONSEQUENCES
i
involved, it softens down and offers no more
resistance to the knife than wet leather.
One of the marked features of the disease is a
displacement of the auricle. This stands out
further than the other, in some instances almost
at right angles. This may be more or less at
short intervals, being the most noticeable during
paroxysms of pain. It is looked upon as a
marked diagnostic feature. For a picture of the
disease I cannot do better than quote the graphic
description of Burnett. "The tendency of mas-
toid pain to exacerbations, chiefly at night, is
worthy of note. As the mastoid symptoms in-
crease in severity, the general appearance and
condition of the patient are most striking and
pitiable. The pain deep in the ear and head is
most intense; the pulse often weak and slow at
first, becomes very rapid; sleep is out of the
question; the appetite fails, nausea and vomiting
ensue, the tongue becomes dry and rough, and the
face becomes peculiarly haggard and bathed in
cold sweat. Though very weak, the patient may
still continue to walk about, not infrequently
coming regularly to his physician. But gradu-
ally, unless relief is obtained by evacuation of the
products of inflammation which have accumulated
in the mastoid, it is observed that the answers of
the patient are becoming incorrect respecting his
name and place of residence, that his intellect is
OF SUPPURATIVE INFLAMMATION
133
A
confused, and his strength is failing. Rigors and
irregular fevers set in; every movement of the
body now causes almost indescribable agony in the
head; stupor and coma with alteration in the size
of the pupil on the affected side of the head, are
noted in rapid succession, and unless speedy re-
lief comes, death supervenes.'
""
Such is the condition to which a neglected
suppuration," one that the patient will outgrow,” (!)
but too often leads. This may occur at any
time in the course of the purulent affection, but
is more common after it has existed for some
time. The mastoid then seems more prone to
take on inflammatory action than at an earlier
stage.
The exciting causes which start up the mas-
toiditis, may be exposures producing a sudden
checking of the secretion, or accumulations with-
in the ear preventing a free discharge of pus.
Polypoid growths occluding the meatus are in-
stances of this.
The manner in which death occurs is as follows.
The inflammatory process may spread inwards to
the dura mater and other coverings of the brain,
producing a meningitis, or breaking through the
thin inner wall next the transverse sinus, set up a
fatal phlebitis, or carious destruction of the bone
may occur, and permitting the escape of pus into
the cranial cavity, there induce cerebral abscess. A
134
COURSE AND CONSEQUENCES
recent case illustrates this. Wm. B., aged 64, was
admitted to the New York Ophthalmic Hospital,
suffering from chronic suppuration and mastoid
abscess, involving the parotid on the left side.
Incision gave vent to large quantities of pus,
which continued to flow freely. One afternoon
he suddenly died, giving no evidence of cerebral
complication till about an hour before death. The
autopsy revealed a tortuous sinus exuding pus
between the two tables of the skull. A carious
condition on the anterior surface of the petrous
pyramid was quite extensive, and at one point
was an opening from which the pus had poured
into the brain, softening and breaking down a
large portion in the middle lobe, and extending
beyond the median line.
The facility with which the purulent process
may extend to the brain, without mastoid in-
volvement, is readily seen if we recall the anatom-
ical bearings. Reference to the earlier portion
of these pages will show the relations existing,
which should be borne in mind when dealing
with a suppuration, for you know neither the day
nor the hour when you may be confronted with
something more serious than perhaps you have
been accustomed to consider a running ear.
The methods of extension to the brain are for-
mulated by Politzer as follows. He says, a fatal
issue occurs in suppuration of the middle ear:
OF SUPPURATIVE INFLAMMATION
135
A. When caries of the temporal bone extends
to adjacent vital organs, thus:
(1). By purulent meningitis, or by the forina-
tion of cerebral abscesses, the surface of the pet-
rous bone which is directed toward the cranial
cavity, being fenestrated in one or more places,
and the suppuration spreading to the meninges
and the brain.
(2). By septic phlebitis, thrombosis, embolism,
and septicaemia, consequent upon the extension
of the purulent process to the venous sinuses on
the petrous bone, or the sinus of the jugular vein.
(3). By bleeding from the ear; the internal
carotid artery on the anterior section of the tem-
poral bone, or the lateral sinus on the inner side
of the mastoid process being eroded.
B. Without bursting of the suppuration into
the cranial cavity:
(1). By phlebitis of the cerebral sinuses; more
rarely by meningitis and cerebral abscess.
(2). By the reception of septic matter into the
blood, from cavities in the temporal bone (pyæ-
mia), or by a general cachexia proceeding from
the local disease, especially tuberculosis.
A case reported by J. Orne Green* illustrates
very clearly the first subdivision of the first
general class, as well as the case just cited. In
this instance there was large loss of bone from
* Transactions of American Otological Society, 1871.
136
COURSE AND CONSEQUENCES
caries, and a general meningeal inflammation
supervened, with the deposition of various mor-
bid products in the cranial cavity.
In the second class, Dr. Houghton's report of a
case* is typical. From carious loss, the suppu-
rative inflammation had involved the internal jug-
ular vein by direct continuity, and the resulting
phlebitis ended in death.
The third class of fatal cases, viz., by erosion of
a vessel wall is much rarer, but thirteen cases
having been described. Politzer says, the portion
of the anterior wall adjoining the carotid artery,
in every case has been defective or carious to a
certain extent. The carotid arterial wall being
bathed in pus, inflammatory softening occurs, and
in time the impact of the blood wave against
it, causes it to give way. The duration of the
purulent disease lasted from seven to eleven years.
The diagnosis of this disaster is of course by the
hemorrhage which is profuse, of a bright red
color, and cessation on the compression of the
carotid. Death occurred in every case.
In the second general division, a case of won-
derful interest occurred in the practice of Dr.
Wreden of St. Petersburg. This was followed by
recovery, but it illustrates the course a fatal in-
flammation can take, as perfectly as if death had
been the result. In this case a general inflamma
*New York Journal of Homoeopathy, March, 1873.
OF SUPPURATIVE INFLAMMATION
137
tion of the cerebral sinuses ensued from exposure
during intoxication, while suffering from an acute
attack of otitis media. This can be found at
length in Knapp's Arch. O. and O., vol. iv., p. 52.
Enough perhaps, has now been said to show
the importance of attending to these suppurative
cases, so we will now proceed to discuss the treat-
ment.
UorM
CHAPTER XII.
TREATMENT OF SUPPURATION OF
MIDDLE EAR.
Local measures are indispensable. One might
as soon attempt to treat a sloughing ulcer by
medicine alone, as to think most of these cases
can be cured by a few powders or pellets.
Cleanliness is the first requisite. In the major-
ity of cases this is best accomplished by means
of the cotton holder. It is astonishing how much
pus will sometimes be found in the ear, and the
number of cotton tufts required to remove it. The
cotton used is preferably the absorbent cotton, on
account of its great capacity for taking up
liquids. Now and then a case is found in which
the pus has become so inspissated, that it is like
a soft paste, and resists the cotton, which in fact
only serves to pack it more tightly. In such an
instance it will be necessary to resort to the
syringe. The method of its use has been previ-
ously described.
Some aurists recommend the use of the syringe
altogether as a means of cleansing. Sometimes,
THE MIDDLE EAR
139
as just remarked, it is indispensable, but since
the so-called "dry treatment" has been in vogue
I use it as little as possible. Patients frequently
say, "I keep the ear as clean as I can, doctor,
syringing it every day." Such practice I consider
radically wrong, for in many instances I am con-
vinced it serves to aid in keeping up the dis
charge. As a method of treatment, though for-
merly very generally used by aurists, it is now
almost universally discarded.
As an agent in removing these masses of in-
spissated pus, I have used for some time a 12 per
cent solution of peroxide of hydrogen. This
agent was first recommended by Landolt of Paris,
in purulent and croupous conjunctivitis. To Dr.
Liebold belongs the credit of first applying it to
the cleansing of purulent secretions in the ear.
It cuts and dissolves the pus wherever it may
exist in the middle ear. I apply a few drops by
a dropping tube. Soon it commences to effervesce
and run out of the meatus, subsiding in a few
minutes. I apply it several times until little or
no effervescence follows, then thoroughly dry the
ear with cotton. Two other excellent applica-
tions for cleansing the ear, and also possessing
decided healing properties, are solutions of sili-
cate of potash, and silicate of soda, prepared by
Merck of Darmstadt. These, diluted, one part to
twenty-five of water, may be used in the same
140
TREATMENT OF SUPPURATION
way. As the patient becomes accustomed to
their slightly stimulating effect, they may be
used stronger, one to ten. Dr. Liebold, to whom
I am indebted for a knowledge of these prepara-
tions, speaks of them very highly. He also uses.
them in a dilution (3rd or 4th) internally in those
cases in which potash, silicea, etc., would be in-
dicated. Many times I use the Siegle speculum.
This draws the pus from the remote parts of the
middle ear, so that the cotton holder can remove
it. This method of using the pneumatic specu-
lum is of excellent service in drawing out pus, and
establishing a free flow in threatened mastoid
complication.
Patients should be instructed to clean their
own ears every day with a bit of cotton twisted
on a match, wooden toothpick or similar article.
I usually give them a two drachm vial of this
peroxide of hydrogen, telling them to use it twice
a day. It is perfectly limpid, and transparent
as water, and produces no pain or irritation.
It also seems to possess antiseptic properties,
frequently removing the disagreeable odor in a
short time. After thoroughly cleansing the ear
and being assured that it is perfectly dry, I pro-
ceed to the next step, which is the application of
various agents.
The articles which are next applied to the
cleansed and dried surface are various. The
OF THE MIDDLE EAR
141
most universally used article at the present time
is powdered boracic acid. There are several ways
in which this is used, both in the matter of pro-
portion, and in combination with other things.
The pure, 90 per cent, 75 per cent, and 50 per
cent, are employed by different physicians. In
my private practice I use the pure. At the hos-
pital we are using the 90 per cent. This is blown
into the meatus through a powder blower, cover-
ing all the secreting surfaces.
Dr. Houghton has called my attention to the
superior efficacy in some instances of boracic
acid when mixed with the tincture or fluid extract
of Plantago. It is prepared in this way. Take
of sugar of milk half the quantity you wish to
prepare. Moisten it quite thoroughly with the
Plantago. Triturate this in a mortar, adding
gradually as much boracic acid as you have milk
sugar. Triturate until dry. The result is a
brownish powder. With this he claims to have
had better results in some cases than with the
acid alone. I have tried it to some extent and it
certainly did nicely. Another excellent prepara-
tion is the following, in this proportion.
B
Iodoform,
Tannic acid,
Sach. lac., -
Thoroughly triturate.
gr. ix.
gr. j.
gr. xc.
.
142
TREATMENT OF SUPPURATION
This, in certain profusely discharging, obstinate
cases, has worked like a charm, but in the vast
majority the boracic acid alone will accomplish
all that the various mixtures will.
It is a very desirable thing to have your pa-
tients come every day at first, until the disease is
to a certain extent arrested. Then the intervals
may be longer. Treatment given at long inter-
vals is unsatisfactory, because between the visits
the effect of the local measures has passed off,
and you have to commence where you were at the
previous time. When patients will come every
day, an excellent plan of applying the boracic acid
is as follows, for which I am indebted to Dr. G. S.
Norton. After cleaning and drying the ear, make
a small pellet of cotton that can easily pass into
the meatus. Smear this with vaseline, then cover
it with the acid. Taking it in the forceps, carry
it carefully to the drumhead and leave it there.
The next day remove it, and apply another in the
same way. The advantage of this method is that
the secretions do not wash the pellet out of the
ear, as they are very apt to do with the loose
powder. If your patients will come every day,
this is an excellent method, but if they remain
away a week at a time it is not wise to leave the
cotton in, as it becomes very offensive.
I have been using for a little time past among
other things, a preparation of eucalyptol, the es-
OF THE MIDDLE EAR
143
sential oil of the Eucalyptus Globulus. This re-
duced with fluid vaseline, in the proportion of
one part of eucalyptol to eight parts of the vase-
line (3 j. ad 3), I either apply on a twisted bit of
cotton, or direct patients to use three or four drops
in the ear at night. It possesses antiseptic and
stimulating properties, and I have been very well
satisfied with its use, especially in the offensive
cases. Dr. Warner first introduced this to my
notice.
Various astringent preparations are in use by
aurists, chief among which are alum powder, and
solutions of the acetate or sulphate of zinc, and
nitrate of silver. The zinc is used in strengths
varying from one to five grains to the ounce; the
nitrate of silver from twenty or thirty grains to
the ounce, to saturated solutions (480 gr. ad 3).
I have little to say about them. I rarely use them
and I know their use is very limited among my
colleagues. The preparations I have previously
named are efficacious in the great majority of
cases.
As said before, one of the annoying complica-
tions that is frequently met with, is the presence
of granulations in the suppurating ear. If they
are small and within the tympanic cavity, do not
attempt instrumental interference with them, un-
til you have had some experience, and more
familiarity with the treatment of diseased ears
144
TREATMENT OF SUPPURATION
than this little book is designed to give. In many
cases they will disappear under the measures
given above. If however, they are larger, pro-
jecting into the meatus, you will have to take
cognizance of them. There are various devices
for their extraction, special forceps, hooks, scis-
sors, snares, etc., but a better way is to kill them.
Removing them, they will grow again, but per-
sistently attacking them with suitable agents will
finally tire them out, so to speak, and they suc-
cumb. I have found no preparation so useful as
a saturated solution of the bichromate of potash.
Dipping a cotton tuft on the end of the holder in
this, I carry it through the meatus, and touch the
end of the granular mass, being careful not to
bring the solution in contact with the walls of the
canal, the next visit I do this again, and keep re-
peating, and after a few applications, if not too long
between, the discouraged polyp gives up the
struggle. Care must be used, as some ears are very
sensitive to this agent, and if an excess is used,
and it comes in contact with the skin of the
meatus, it may set up quite a violent irritation.
Chromic acid is another powerful agent, and may
be used in the same way but with even greater care.
Crush a few crystals and moisten with water, with
which moisten the cotton tuft. I have also found
great benefit in some instances from the use of a
saturated solution of boracic acid in equal parts
OF THE MIDDLE EAR
145
of alcohol and water. Some granulations yield
very readily, while in other cases stronger agents
must be used.
TREATMENT OF MASTOID DISEASE.
The local treatment of mastoid disease is essen-
tially surgical. It varies in degree from the
mere lancing of a superficial abscess beneath the
skin, to extensive incisions deep into swollen
tissue, and perforation of the bone with special
instruments. When you are confronted with this
complication, and your remedies do not allay the
trouble, as many times from mechanical causes
(obstructions, etc.) they cannot, you have only
one resource, the knife. This, used boldly and
wisely, will carry you safely through many a
tight spot, where otherwise failure and criticism
would be your portion. The incision should be
made vertically, directly over the mastoid pro-
cess, and carried down to the bone, unless in the
case of an abscess which is merely subcutaneous.
From the enormous swelling which sometimes is
present in these cases, it is often impossible to
tell where the mastoid is by the touch, but it al-
ways bears a definite relation to the external
meatus. Commencing your incision at a point
on a line with the superior wall of the meatus,
and about one-quarter of an inch from the attach-
146
TREATMENT OF SUPPURATION
ment of the auricle, carry it downwards for about
three-quarters of an inch, parallel with the auri-
cle, going through the tissues until you strike the
bone. The posterior auricular artery and one of
its branches are near here, and one or the other
may be severed, but it is of no consequence. The
bleeding can usually be arrested by pressure, or if
not, by torsion, and the loss of a little blood will
be of benefit rather than harm. The depth to
which the knife may go before reaching the bone
is variable. In two cases under my observation
and care during this past year, the knife was
buried upwards of an inch before the bone was
touched. Frequently you will get no pus, but
the benefit may be just as marked, from the relief
given to the infiltrated and tense tissues. The
wound should be kept open, and it is an excellent
plan to syringe it every day with a solution of
corrosive sublimate, one part to two thousand of
water, especially if there is communication
through the wall of the mastoid by carious de-
struction. If after a day or two no relief is ob-
tained from this incision, it will be necessary to
perforate the bone. For a description of, and
instructions for this operation, you must consult
the larger treatises and works on surgery.
The other consequences of chronic suppuration,
caries, necrosis, cerebral abscess, pyæmia and
paralysis, do not come within our scope to dis-
OF THE MIDDLE EAR
147
cuss. They are to be treated on general princi
ples, as they represent a condition beyond a
lesion of the ear.
HOMEOPATHIC REMEDIES.
Aurum.-When after suppuration has been
present some time, the bone or periosteum becomes
affected. Pain like a bruise, worse at night by
uncovering, and at rest; better by motion, by
washing, and though sensitive to cold, yet relieved
by going into the open air, even in bad weather.
Pus of a fetid odor, as of necrosed bone. Denu-
dation of the osseous meatus. Sinuses in the
bone. More useful for the consequences of a pro-
longed suppuration than in the active stage of
the suppuration. The mental despondency which
is characteristic of this drug, will, if present,
make its selection the more clearly indicated.
Arsenicum.-The indications given under this
remedy in diffuse external otitis are of equal
value in the suppurative otitis media. When to
these are added the constitutional symptoms of
Ars., thirst frequent, aggravation after midnight,
and the weakness, no other remedy will be of the
same efficiency.
Bryonia.—Swelling, redness, painful sensitive-
ness and heat of the external right ear; mem.
brana tympani soaked and sodden. Discharge
profuse of a whitish, watery character, serous in
148
TREATMENT OF SUPPURATION
its nature.
In acute otitis media with mastoid
periostitis, but not after pus has formed in the
cellular tissue "-(Lewis). In a recent case with
the profuse watery serum like discharge, one
prescription of Bryonia stopped the whole
trouble.
Capsicum.-With strong tendency in chronic
suppuration to mastoid complications. The tis
sues about and below the mastoid process are
swollen, infiltrated, and tender way down the
neck. A reddish hue is observed over the mas-
toid, fading away as the distance from the mas-
toid increases. Itching deep in the ear, and a
pain just under the ear, opposite the angle of the
inferior maxillary. The discharge from the ear
is thick, yellow pus. Its especial value is in the
first stages of mastoid complication, in chronic
suppurations, with swelling and tenderness, be-
fore pus has formed. Thus used it will frequent-
ly abort the threatened abscess. In acute cases,
i.e., very recent, it is of less use, and of scarcely
any, after pus has formed outside of the bone.
Dr. Allen first drew attention to Caps. in this con-
nection in 1872, by pointing out to Dr. Houghton,
the similarity of its pathogenesis to certain stages
in mastoid disease.
China.-Meatus full of sanguineous, sanious
discharge; tissues infiltrated; indolent ulceration
with passive hemorrhage, rather than exuberant
OF THE MIDDLE EAR
149
granulations. In old suppurative cases, indolent
in character, with frequent bleedings, it has often
changed the whole face of the condition:
Calcarea carbonica. — Discharge viscid, whit-
ish, fetid, pappy; granulations from edge of
perforations on drumhead, filling canal. Dr.
Houghton says, "When these enlarge and form
polypi of the mucous variety, we have found these
exuberant granulations yield more promptly to
the Calc. iod. than to the Calc. carb."
Calcarea phosphorica.—The indications given
for this remedy under diffuse inflammation of the
canal are equally applicable in the suppurative
process in the middle ear. There are also many
cases in which there seems to be no particularly
indicated remedy. In such cases Dr. Norton in-
forms me he often uses the Calc. phos. with
excellent effect. I very frequently employ this
remedy with great satisfaction, both alone and
in alternation with Kali mur.
Chininum muriaticum. In cases in which
there is much pain and little discharge. Either
in acute cases where there is pus in the tympanic
cavity, but not enough to rupture the membrane,
or having ruptured, the discharge is scanty; or in
chronic cases where exposure has suppressed the
discharge. Pain is great in both cases. Accom-
panying is a condition of profound weakness and
exhaustion. Marked periodicity is another indi-
150
TREATMENT OF SUPPURATION
cation. A summary for its use would be, pain
with suppressed exudation, prostration and peri-
odicity. In such cases it will rarely fail to give
relief. I can answer for its use only in the lower
potencies. Dr. Houghton first called my atten-
tion to the value of this drug in the above con-
ditions.
Elaps corrallinus.-Discharge offensive and
yellowish green. Congestive lancinating frontal
and occipital headache, made worse by motion
and stooping. Especially valuable in naso-
pharyngeal catarrh with suppuration in children;
"mouth breathers." (Houghton).
Ferrum phosphoricum.-When in the course of
a chronic suppuration pains occur with or with-
ont a suppression of the discharge, traceable to
exposure, and accompanied by feverish symptoms.
Hepar sulphuris.-"Ulceration angry; discharge
small amount, sour fetid odor; tissues very sen-
sitive, often covered with white shreds which
cling to the ulcer; soreness in small spots about
the ear; itching; worse at night and by cold air.”
(Houghton). Hepar is a remedy of immense
value in the earlier stages of an acute suppura-
tion, either before the membrane ruptures or
after, if in connection with the pain and dis-
charge there is sensitiveness to the touch. In
those cases in which the patient shrinks even
before he is touched, and complains how much he
OF THE MIDDLE EAR
151
is hurt, even under the gentlest manipulation,
Hepar finds its especial field. It is useful with
this symptom in all stages from an inflammatory
earache to an involvement of the mastoid. Some-
times in its other form of Calcium sulphide it is
more prompt in its action.
Hydrastis Canadensis.-In the muco purulent
forms of discharge, thick, with more mucus than
pus. Tenacious agglutinated discharges.
Kali bichromicum.-Similar to Hydrastis, but
the discharges here as elsewhere in Kali. bich.
cases, have the peculiar ductile quality in their
tenaciousness, permitting them to be drawn into
long strings, while in Hydrastis they are more
sticky.
Kali muriaticum.-A standard remedy after
suppuration has become well established, and the
acute symptoms of the earlier stage have passed
away. At the hospital clinics it has become.
almost a routine practice to administer this salt
in cases under the above conditions, when there
are no positive indications for another remedy.
Frequently, as said before, it is used in connection
with Calc. phos. with the happiest results. In
case after case the discharge has been entirely
arrested by Kali mur., even with little or no local
treatment.
Kali phosphoricum.-The discharge is of a dark
color and offensive smell; thick, grumous or
152
TREATMENT OF SUPPURATION
granulous. When the external meatus is con-
secutively involved, and upon cleansing, the tis-
sues appear rough, easily bleeding, or covered
with small granulations. Lining of the tympanic
cavity of same type; bleeds easily with most
delicate touch of cotton holder. (Houghton).
Kali sulphuricum.-The character of the pus
indicating Kali sulph. is a thin, yellow fluid. I
have used it satisfactorily in cases tending towards
an offensive condition.
Lycopodium.-In the sequela from the exan-
themata. Sluggish, disinclination to heal. Pus
offensive and moderate in quantity. Similar to
Hepar cases, but lacking the sensitiveness of the
latter. Often good as an intercurrent when an
antipsoric is needed.
Mercurius vivus.-In chronic suppuration, with
enlarged and sensitive cervical glands. Pus
fetid, whitish or bloody. Discharge readily
checked by cold, which increases pain, much
worse at night, and the characteristic perspiration.
In these aggravations Merc. contends with Ferr.
phos. for first place in frequency of indication.
Magnesia phosphorica. With neuralgic
symptoms as given under the acute catarrhal
indications.
Psorinum.-A remedy of untold value, in old
foul smelling, dirty, scabby cases. The worse the
case, the more the indication for Psor. This is
OF THE MIDDLE EAR
153
not the place to enter into any discussion as to the
homoeopathicity of this agent or its origin. Any
one who has seen (as can be seen at any
time) hundreds and hundreds of the foulest
nastiest cases of suppurative ears in tene-
ment house children, either relieved altogether
of their disgusting otorrhoea, or its character so
changed that it becomes pleasant by comparison,
must indeed be prejudiced to refuse to use it. In
the N. Y. Oph. Hosp. clinic it is used daily with
such results. Dr. Houghton gives the symptom
in addition : "Excessive itching in the ears so
that children can hardly be kept from picking or
boring in the meatus." I always use it in the
200th.
Silicea.-Pus scanty; when bones involved. In
cases after stoppage of the discharge to repair
perforations in the membrane.
"It has been our view that more repairs of the
membrane occur under the use of this remedy,
in chronic disease, than under any other single
remedy." (Houghton).
The
Telluriun.--Cases similar to Psorinum.
especial indication for Tell. is the peculiar fetid
odor, like decaying fish brine, and the excoriating
character of the discharge, making the auricle
raw and sore.
Thuja Occidentalis. - Discharge smells like
putrid meat.”
CHAPTER XIII.
DISEASES OF THE INTERNAL EAR.
(Otitis Interna).
The diseases which affect the internal ear are
much less clearly understood than lesions of the
other parts, for they are entirely removed from
observation. There are no local symptoms or ob-
jective appearances by which we are enabled to
make a diagnosis, as in catarrhal or suppurative
troubles. The history of the case, and certain
constitutional manifestations are the only things
to suggest that we have a trouble of the auditory
nerve to deal with, which we confirm by the
tuning fork test, as mentioned in the earlier por-
tion of this work.
One of the most prominent of the diseases of
the labyrinth is known as Meniere's disease, be-
cause he first grouped the symptoms characteris-
tic of the lesion. Though there has been some
discussion as to the exact pathology of Meniere's
disease, the weight of opinion is in favor of con-
fining it to the effects produced by a sudden
hemorrhage into the semicircular canals, and
possibly into the vestibule as well. For this
DISEASES OF THE INTERNAL EAR
155
•
reason it is sometimes known as apoplectiform
deafness. Its usual symptoms are a sudden gid-
diness or vertigo, staggering gait, or tendency to
lose one's balance, nausea or actual vomiting,
sudden and great deafness, and frequently falling
to the ground, without however, a loss of con-
sciousness. Sometimes, however, there is a tem-
porary loss of consciousness, but, although this
may soon return, the other symptoms do not
abate. Sometimes the deafness is not sudden,
but comes on more gradually, though always
quite rapidly in comparison to other forms of loss
of hearing. With this there is frequently a great
complaint on the part of the patient of subjective
noises in the head or ears, singing, rushing, roar-
ing, buzzing, and other forms of tinnitus.
The prognosis in this disease is usually un-
favorable. It depends somewhat on its intensity.
There are several cases reported in which the
symptoms gradually disappeared and a degree of
recovery ensued, but complete restoration is
rare.
There are many cases in which vertigo occurs,
· consequent upon lesions of the middle ear, which
are incorrectly diagnosticated as Meniere's dis-
ease. They are however, a secondary form of
labyrinthine trouble, while the true Meniere's
disease is a primary lesion, not dependent upon
disease of the condncting apparatus.
156
DISEASES OF THE INTERNAL EAR
Dr. Knapp of this city, has taken issue with
some of the points as stated above. His position
in brief is as follows. He claims first, that the
disease is not limited to the semicircular canals
or vestibule, but involves the cochlea as well,
citing in evidence the loss of perception for cer-
tain tones in the musical scale. In the second
place, he asserts that the exudation is not neces-
sarily of a hemorrhagic character, but may be
serous, or both. Thirdly, he claims that it is not
always a primary disease, but may be secondary
to affections in the tympanum. A case however,
in which there had been no previous symptoms
of an ear trouble, suddenly attacked with dizzi-
ness, nausea, uncertain gait, or rotatory move-
ments, tendency to fall down, without a loss of
consciousness, accompanied by impairment of
hearing, might safely be diagnosticated as a case
of Meniere's disease, whether the exudation were
serous or hemorrhagic, or the lesion confined to
the semicircular canals or involving the whole
labyrinth.
There is another lesion of the labyrinth which
Voltolini has described, analagous in some re-
spects to that which has just been described,
which he claims is idiopathic, and peculiar to
young children. He says, "It must be regarded
as a specific disease of childhood, as specific as
croup." He calls it "Otitis labyrinthica." In this
DISEASES OF THE INTERNAL EAR
157
affection a child in perfect health is suddenly
attacked with violent vomiting, accompanied
with chills and febrile movement. Soon the
hearing becomes very much impaired, and finally
total deafness is present. This may last for two
or three weeks, when convalescence sets in. For
some little time the child experiences difficulty
in walking, but gradually learns to use its limbs,
and all the symptoms disappear except the loss
of hearing, which remains permanent. This dis-
ease simulates meningitis in many respects, and
doubtless has often been diagnosticated as such,
but it is accepted by aurists as an independent
disease, confined to the labyrinth, for at no time
has there been an impairment of the intellect or
consciousness, which is a pathognomonic or diag-
nostic mark. Death is very rare in the disease,
which is an additional feature in differentiating
it from meningitis.
Cerebro-spinal meningitis itself is frequently
followed by deafness which is often total. The
exact conditions present are not well understood
even by specialists. It is an unfortunate sequela
as the prognosis is very unfavorable. It may
occur as late as six months after the primary
disease.
There has been a very general acceptance
among aurists of late years, even those of the old
school, as to the power of large doses of quinine
158
DISEASES OF THE INTERNAL EAR
to produce permanent changes in the auditory
nerve. This fact the general practitioner should
remember.
Syphilis is accepted as among the causes which
may produce alterations in the labyrinth. A
sudden loss of hearing in a person with specific
history should certainly be looked upon as sus-
picious.
The labyrinth may be the seat of occasional
tumors or morbid growths which destroy hearing
by pressure.
It goes without saying that direct violence may
injure the nerve, as a blow upon the head, etc.
The petrous bone is very difficult to fracture, and
it is not common. Sometimes this is manifested
by symptoms that are visible, as a serous or
bloody discharge from the ear after a fall. Such
a symptom gives a very bad prognosis. Some-
times no symptoms except loss of hearing are to
be found in the ear.
Those exposed to prolonged loud sounds often
lose their hearing. Such a condition is so fre-
quently observed in boiler-makers that it has
given rise to a definite classification known as
"boiler-makers' deafness." The particular chan-
ges occurring are not known. The reader who is
interested in the subject of lesions of the internal
ear is referred to the larger treatises on the sub-
ject.
DISEASES OF THE INTERNAL EAR
159
In considering the treatment of diseases of the
labyrinth, we are met at the outset by two diffi-
culties; one is the difficulty in recognizing many
cases of labyrinthine disease, or recognizing it, we
are as yet, largely in ignorance as to the actual
changes occurring. The second is the compara-
tive rarity of the disease, and from the nausea and
dizziness accompanying many of its manifesta-
tions, the difficulty in deciding whether they are
primary or reflex from the stomach.
Again, we are almost in total ignorance of the
action of drugs upon the internal ear. Our path-
ogeneses have as yet to be differentiated. There-
fore we are compelled almost entirely in seeking
for symptomatic indications, to be confined to the
statement, "In such and such a case, with such
and such symptoms (frequently none), such and
such a drug was given." This would be of great
value, if we had enough cases, but the reported
cases of otitis interna cured by homoeopathic
remedies, with enough symptoms to draw conclu-
sions from, may almost be counted upon one's
fingers. It is to be hoped that this feature in
aural cases will receive from homeopathic spec-
ialists more attention in the future, than has
been the case in the past. This must be my
apology for the extreme scantiness of the indica-
tions under the drugs given.
160
DISEASES OF THE INTERNAL EAR
HOMOEOPATHIC REMEDIES.
Arsenicum iodatum.-Dr. Park Lewis writes
me: "A few years ago I had several cases in which
Ars. iod. 3× seemed to do excellent service. In
two was inherited syphilis. One was cured after
the hearing had been very much impaired. The
other was very much improved. Unfortunately
the second relapsed, and is now absolutely deaf.
The other still retains good hearing. There was
very little middle ear complication. The remedy
was prescribed because of the characteristic eye
symptoms (keratitis parenchymatosa). There
seemed no special indications as far as the ears
were concerned, except those common to disease
of the auditory nervous structures. No tinnitus,
no pain, eustachian tubes pervious.”
Argentum nitricum.--This has relieved the
following: "Staggers when walking in the dark;
has to hold on to things; buzzing in the ears;" in
connection with general debility.
Cinchona.-Dr. Houghton suggests for the use
of this drug; "vertigo from loss of blood; gid-
diness from anemia; fainting, ringing in the ears,
and in some cases associated with a general ner-
vous erethism." He says it acts upon both cochlea
and semicircular canals.
Gelsemium.-In acute inflammation of the in-
ternal ear. A cured case (48 hours) proved its
DISEASES OF THE INTERNAL EAR
161
value. Vertigo, confusion of the head, extending
from the occiput upwards and forwards. Dulness
and apathetic condition generally. Pulse slow
and full. Fever with little thirst or restlessness.
Sudden loss of hearing, with rushing and roar-
ing.
Petroleum. The symptoms for which this rem-
edy has been given, and which have been re-
lieved by it, are especially the dizziness and
deafness. Three of Dr. Woodyatt's cases were
very much benefited by this drug given for the
above symptoms. He used it in the 6×. In one
case of my own now under treatment, with com-
bined middle and internal ear lesions, the dizzi-
ness, staggering and tinnitus are relieved while
taking Pet., to reappear as soon as it is discon-
tinued.
Pilocarpine muriate.-A little four year old
patient in the hospital clinic has been put upon
this drug by Dr. Houghton, for deafmutism re-
sulting from cerebro-spinal meningitis. She has
been taking it now some two or three months.
From an apparent unconsciousness of any sounds,
she has improved so that she can hear her mother
call her, in a loud tone, across the room.
Phosphoric acid.-"Phos. acid has done much
in one case in which I think a general depression
of the nervous tone had excited some auditory
troubles, but there is slight middle ear catarrh,
162
DISEASES OF THE INTERNAL EAR
and I cannot say how much the deeper structures
are involved." (Lewis).
Salicylate of soda.-Dr. Houghton in his Con-
tribution to Aural Therapeutics, at the World's
convention in 1876, remarks: "We have no ex-
haustive proving of Salicylate of soda, but exper-
iments on lower animals show that toxic doses
cause hemorrhagic exudation in the labyrinth.
It has proved curative in cases of sudden deaf-
ness in which vertigo was a marked symptom."
Since that time it has been used in quite a large
number of cases at the New York Ophthalmic
Hospital, with good results in some cases. It has
been of late used more in children with the deaf-
ness following cerebro-spinal meningitis (otitis
interna secondaria). I am hardly able to speak
with positiveness about them, but know that some
have improved. In a number of adults where
symptoms of labyrinthine disease had followed
middle ear disease, they have been very much
helped. This symptom especially has been re-
lieved; viz., pitching forward. Dr. Woodyatt
cured the nausea and giddiness remaining in a
patient with labyrinthine disease, with this rem-
edy in the 1*, in connection with Strych 3*.
Silicea and Strychnia.-Both of these remedies
were used a number of times by Dr. Woodyatt
but generally following or in connection with
DISEASES OF THE INTERNAL EAR
163
Petrol. and Soda sal. He gave no definite indi-
cations.
Besides the remedies mentioned, the following
have been suggested as bearing relations to this
disease. Creasote, Carbolic acid, Alumina, Cheno-
podium, Hydrobromic acid, Cocculus, Nitrum.
As has been said before, the homoeopathic
symptomatology is full of apparent indications
seemingly applicable to labyrinthine disease.
These must be carefully studied, and the remedy
selected for a definite reason. By thus carefully
working and noting results, we shall in time,
doubtless be able to possess a much more com-
plete list of therepeutic indications. This is a de-
partment where we are compelled to rely upon
internal medication alone, and for this reason, the
careful prescriber in general practice has an equal
chance with the specialist to verify the patho-
genesis of drugs, and placing on record the results
of his observations, contribute his quota to the
therapeutics of labyrinthine disease.
CHAPTER XIV.
ADDITIONAL MEANS FOR THE RELIEF OF
DEAF PERSONS.
It is in order to refer to a few of the the artifi-
cial aids which have been devised to assist the
impaired function. These consist of artificial
membranes, audiphones, dentaphones, earphones,
various kinds of trumpets, conversation tubes,
etc.
The artificial membrane consists of a small
disc, very thin and vibratile, which is passed into
the meatus in close contact with the drumhead.
They are made of india rubber, sized paper, and
various materials. To the center is attached a
delicate wire by which they are placed in
position. Their object is to take the place of the
lost substance in perforated or destroyed mem-
branes, and render support to the ossicles. They
are only to be used in cases where the integrity
of the drumhead has been impaired. From an
ignorance of the principle of their application,
they have been widely advertised as an aid in all
kinds of deafness, and many, both physicians and
RELIEF OF DEAF PERSONS
165
laity have accepted the idea. They are worse
than useless in cases where the membrane is
whole and should never be used. Very many
times what is termed the "cotton pellet" can be
applied with great benefit. This was a little de-
vice first used by a patient of Dr. Yearsley's of Lon-
don, and by the latter given to the profession, and
sometimes called after his name. It is merely
the placing of a small, tightly rolled pellet of
cotton against the drumhead. Sometimes a long-
er twisted roll is used. This may have to be
applied several times to get it in the exact posi-
tion where it gives the best support. Its effect is
frequently quite wonderful, I have seen many
patients with whom conversation was carried on
with great difficulty without it, hear with perfect
ease after its successful application. Patients
often acquire great facility in the adjustment of it
themselves, even better than the surgeon in some
cases. I know one case who has been under the
care at different times of several of my colleagues
as well as myself, not one of whom can adjust
this with the same satisfaction that he does him-
self.
The audiphones, dentaphones, etc., are all con-
structed on one of two principles, viz., either the
magnification of the sound waves conveyed to the
ear, or on the principle of bone conduction, by
communicating sound vibrations to the nerve by
166
ADDITIONAL MEANS FOR THE
means of the bones, preferably the teeth. Of
these, the most satisfactory I have seen is
North's Earphone.* This comes in three sizes, at
a price varying from five to ten dollars. The best
aid however, I have yet seen, is a modification of
the old conversation tube, recently completed by
Dr. Houghton after long experiment. This con-
sists of a flexible tube about thirty inches long,
with a vulcanite cup at each extremity. This
cup is so fashioned, as to imitate as nearly as
possible the function of the auricle. One end is
applied to the deaf ear, the other near the mouth
of the person speaking. It is entirely free from
the metallic quality of tone inseparable from
metal instruments.
I cannot close these pages without reference to
the improved methods of teaching deafmutes both
to comprehend oral conversation and answer
orally. This consists in teaching them close ob-
servation of the lips of the speaker, and to imitate
the positions of the organs of speech. I have seen
persons unable to hear the least sound, converse
intelligibly with me for weeks before I learned
of their infirmity, and then only by accident,
speaking to them when they were not looking.
This method has been brought to great perfection,
and in the case of children, where some lesion of
the nerve, as after cerebro-spinal meningitis, or the
* To be obtained of Meyrowitz Bros., 297 4th Ave., N. Y. city.
RELIEF OF DEAF PERSONS
167
neglected results of scarlet fever or similar dis-
eases have brought about incurable deafness, it is
of such inestimable value, I should consider my-
self derelict if I did not advert to it.
Young children learn this method very rapidly,
and it is important that too much time does not
elapse before they are placed in a position to
receive the instruction. There is no other lesion
of the five senses which so impairs the intellect,
dulls the perceptions, sours the temper, produces
a suspicious, morbid state of mind, as loss of
hearing. Our usefulness as members of society
is in proportion to our intercourse with it. Though
much is obtained by reading and observation,
very much more knowledge in daily affairs is ob-
tained by oral intercourse. The man shut off
from this is indeed in a pitiable state. As a mat-
ter of choice in punishment for capital crime, I
would personally prefer death to the judicial
destruction of my hearing.
There are several institutions in this country
where this method of oral imitation is taught.
The one in this city is doing an excellent work,
and the authorities in charge are always ready
to give information and show specimens of the
proficiency acquired by their pupils.

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