A system of practical medicine. By American authors. Vol. 4

by Unknown

Probes are also needful. A good middle-ear probe is made of a single piece of silver, of the same length as the cotton-holder, and tapering down to a slender shank with a small knob-like ending.

The ear syringe, a most excellent instrument, is now made of rubber, holding two ounces of fluid, and has a bulbar extremity, so as to avoid injuring the external canal or tympanic membrane. The syringe has a finger-rest, with the piston ending in a ring, so as to admit of its use with one hand. In using a syringe warm water should be always employed, and at a temperature that the finger would indicate as being quite warm. Also at first force the water very gently into the meatus, so that the patient shall not be startled; also it is well to bear in mind that many patients become very giddy under its use, necessitating either very gentle use or its being abandoned for the time.

EXAMINATION OF THE EUSTACHIAN TUBE.—The main point is as to whether the tube permits the free passage of air up to the middle ear. This can be ascertained by three methods: 1. Valsalva's method; 2. Politzer's method; 3. Catheterization of the tube.

Valsalva's method consists in forcing air through the tube by a forced expiration, the mouth and nasal passages being at the same time firmly closed. The patient can distinctly feel the air pressing against the tympanic membrane, causing it to bulge outwardly, provided the tube is open. This proceeding has certain disadvantages, sometimes causing head congestions and giddiness.

Politzer's Method.—In this proceeding a gum air-bag is used as the means of forcing air into the tube. In the act of swallowing the soft palate is drawn against the posterior wall of the pharynx, and at the same time the pharyngeal mouth of the tube is well opened, so that air forced through the nasal passages at such a moment, being prevented from passing downward by the up-drawn palate, is forced up through the Eustachian tube into the middle ear. The success of this procedure depends entirely upon the inflation being made at the same moment that the soft palate is drawn up against the pharyngeal wall; otherwise the air would naturally pass by the widest passage, in this case downward into the stomach. The usual plan of inflating at the moment that the patient is told to swallow fails, from the fact that patients differ so materially in the quickness with which they respond to an order. Many in their anxiety will swallow before the word is given, others will allow an appreciable time to pass before swallowing, so that the inflation will fail. For this reason I have adopted the following plan: It is well known that in the act of swallowing the larynx is drawn forcibly upward, and also that the moment of the extreme elevation is nearly coincident with the moment that the soft palate is drawn against the wall of the pharynx. The prominence of the thyroid cartilage (the so-called pomus Adami) enables one to easily watch until the maximum elevation of the larynx is reached, and then quickly, by a forcible contraction of the air-bag, to thoroughly inflate the middle ear. The Politzer method so thoroughly accomplishes the object, and with the least possible irritation, that the use of the catheter in the majority of cases is no longer indicated. The method of Politzer is as follows: The patient takes some water in the mouth; the air-bag has attached to it a short piece of gum tubing ending in a nose-piece in shape like an olive, or sometimes a small gum catheter is attached to it. This is placed in the lower nasal passage and the nose held firmly closed over it with one hand, the second hand grasping the air-bag. The patient is then told to swallow, so as to cause elevation of the soft palate (this can also be accomplished by the patient speaking quickly some word like hoc), and the air-bag is forcibly pressed. In this way the air is quickly driven, viâ the nasal passage and Eustachian tube, into the middle ear. In little children it is sufficient to quickly inflate, as the crying of the child elevates the soft palate to a certain degree, and so cuts off the downward passage into the stomach.

External Ear Diseases of the Auricle.

ECZEMA.—This disease occurs very frequently in infants during dentition, where irritation of the dental branches of the fifth pair of nerves causes irritation in other branches of the same nerve, including those distributed to the skin of the face and auricle, causing acute attacks of the disease. It is also frequently observed that successive teeth penetrating the periosteum will cause fresh attacks of this skin irritation, so that as long as the teething process continues, so long is the eczema apt to continue, and treatment will probably prove only palliative. Eczema occurs also in both the male and female approaching the period of adolescence, a time when other forms of skin disease are especially common.

The aged do not escape this annoying malady, where it is apt to occur in the chronic form, and is due to want of nerve-force in the skin branches of the nerves distributed to this part—a wise provision of nature allowing nerve-power to fail first in the nerves distributed to parts where the harm done is a minimum one, rather than in the nerve-centres, where disease fatal to life would result. The treatment in this class of cases would be radically different from the preceding divisions, where nerve-irritation is the cause.

DIAGNOSIS.—The acute form shows the same diagnostic appearance as does eczema occurring elsewhere—the same redness and swelling of skin, followed by the vesicular eruption with serous oozing and loss of epithelium. In the chronic variety there is marked thickening of the skin, and the auricle is often covered with crusts, but here and there a deep fissure in the skin, from some one of which pus will exude.