Imagens das páginas
PDF
ePub

CHAPTER VII.

RESULTS OF CATARRH OF THE TYMPANUM.

(a) Accumulation of Mucus in the Tympanum. THIS result of the milder and more chronic forms of catarrhal inflammation of the tympanum comes before us in two forms, or rather stages; those, namely, of recent secretion and of old accumulation. Every case of catarrh, in which the secretion does not discharge itself thro' the membrane, or completely escape by the tube, presents the former condition. In how large a proportion of cases the latter condition-that of old accumulation remaining after all inflammatory action has ceased-exists, and constitutes a main cause of impaired function, is a question for the future. My own little experience would tend to assign it a very important part.

For recent collections of mucous secretion in the tympanum three methods of treatment are presented for our choice; two that seek to effect the removal of the fluid, and the ordinary treatment, relying on general means, and seeking to induce its escape or re-absorption. I do not feel that the question between these methods is yet decided. Under the latter, more or less success for the time can almost always be gained; but the point that

needs decision is whether the results are permanent. When the appearance of the membrane, the sound on inflation, the history of colds, the condition of the throat, indicate that swelling and congestion of the mucous membrane of the tympanum with excess of secretion are present, certain remedies are obvious: occasional inflation with Politzer's bag; iron, or nitrate of silver, or spray to the naso-pharyngeal mucous membrane, or syringing of alum, &c., thro' the nostrils; counter-irritation, very slight but long continued; the use of an ointment containing pot. iod., with tincture of capsicum, behind the jaw; and purgatives combined with steel and other tonics. To these may be added, in the more confirmed cases, an injection into the tympanum, once or twice a week for a few times, of a warm solution of sulphate of zinc, gr. i.—ii., ad zi. Nor will these means often palpably fail, altho' their use may be very tedious, and relapses will be very apt to occur. It has appeared to me, indeed, that the presence of an excess of secretion in the tympanum has kept up the irritation in the throat and prevented it from subsiding, as if there were a nervous sympathy between them. But supposing the treatment to have been apparently successful, little doubt can remain that if the secretion have been profuse and viscid, it will not have been entirely absorbed, nor probably have completely escaped by the tube, so that there will still remain a certain residuum of the more solid portions, which may lay a basis for permanent deafness in the future.

Accordingly two methods have been proposed for the evacuation of the secretion: one, the incision of the. membrane, revived recently by Schwartze; the other the introduction of a very thin elastic catheter thro' the Eustachian tube completely into the tympanum, to withdraw the contained secretion by suction; suggested by Weber-Liel. Of these two plans, both having their advocates, I should certainly incline to the incision, as being, if more formidable in sound, certainly less irritating in reality, and likely to be much more effective.

Schwartze has most fully reported on incision of the membrane in this class of cases. Out of 163 of his cases only five remained quite unimproved; and 87 were

66

completely cured."-The incision was repeated in 47 cases only; in 16 cases the treatment lasted only eight days, and only in 23 did it extend over four weeks; showing a great advantage in point of brevity. The operation was repeated twelve times in one case, with the use of various solvents, with no benefit but without ill effect. But Schwartze has found irritation (without permanent mischief) follow in every fifth case; tho' Politzer in 220 cases has never seen inflammation follow. Also, without any local irritation, he has seen on the third day fever with frequent vomiting, in a child, without any apparent cause. In one case also, in which I incised at the same time both membranes in a young child, in a case of intense deafness, convulsions occurred on the next day, but with no permanent ill result. I do not now

incise both membranes at the same time, or very rarely indeed; but Schwartze not only does this in cases of double disease, but even incises sometimes a healthy membrane for the sake of being able better to pass fluid thro' the Eustachian tube of the diseased side: so convinced is he [and, indeed, so far as my observation goes, truly convinced] of the harmlessness of the proceeding.*

In most chronic cases, Schwartze finds the secretion not muco-purulent but purely mucus; and it is not found that serous and mucous accumulations respectively are characteristic of acute and chronic inflammation. It is often very tenacious, drawing out into long threads like isinglass. It contains numerous cells like white bloodcorpuscles, mucous corpuscles in all stages of destruction, some squamous epithelium, and often cholesterine. Sometimes it is citron yellow from previous destruction of the corpuscular elements; or grey from black pigment. In 97 chronic cases, the contents were serous in 8; seromucous in 14; purely mucous in 67; muco-purulent in 8. Carbonate of soda has no effect on lumps of the mucus, but they dissolve in a few minutes in a 3 or 4 per cent. solution of caustic soda. It has an alkaline reaction.

If after closure of the wound bubbling is still heard on

* A most exaggerated feeling prevails respecting the danger of making incisions in the membrane, which is curious when we consider how freely the cornea is operated upon. Voltolini in doubtful cases makes an incision to examine the condition of the intra-tympanic structures. It is difficult to keep the cut open for so long as four days.

inflation, Schwartze uses alkaline injections to insure absorption of the remaining mucus or its escape thro' the tube; and if the tube is not freely pervious, weak injections of zinci sulph. may be used to render it so.

The following is a case of this kind in which the treatment was thoroughly successful, while no other means seemed to me to afford any real hope.*

Repeated attacks of tympanic catarrh on each side; at length bulging of the right membrane; incision, and escape of much thick matter; return after nine months; re-incision; permanent recovery.

H. C-, healthy and strong, but with a decided hæmorrhagic diathesis, frequently suffering from epistaxis which ceased only on his becoming faint. No deafness in the family; his own attacks most frequently following bleedings of the nose. At the age of four or five he had a slight discharge from one meatus, and had been occasionally hard of hearing at that time and since. At nine he had an attack of deafness attended with pain in the head, especially at the back part, and great tinnitus, with feverishness. Throat relaxed, and tonsils somewhat enlarged. Each membrana tympani appeared dull and rather flattened. Iodine was painted around the ears for a few days. In two months the hearing was nearly perfect; but again fell back after an attack of epistaxis; the ears feeling stuffed and stopped up, and the tinnitus violent; membranes of a pearly opacity. From this attack he soon recovered, and the hearing continued pretty good for about a year, the left, however, being the better; he had occasional tinnitus. During the attacks of catarrh he could not inflate the ears, and on account of the tendency to epistaxis air was not passed in artificially until a later period, and then but seldom and very gently.

June 3rd, 1864 (at age of ten) an attack of fulness and tinnitus in

* See Atlas, Plate XI., figs. 1 to 4.

« AnteriorContinuar »