and it is impossible to differentiate them when we find them in persons
who are addicted to the abuse of both of these drugs; consequently, for
a time, in Germany, there was a disposition to underrate the potent
destructive agency of the latter drug, but every practitioner of
experience in eye disease must have seen cases of tobacco amblyopia in
which there has been no abuse of alcohol. The best proof of the
deleterious influences of tobacco on the eyesight is the improvement
which results by simple abstinence from its use where the vision has
been seriously affected by its influence. In the earlier stages of both
forms of amblyopia there is a contracted pupil and a slight dimness of
vision, the patients claiming that they see better in feeble light and
twilight. The ophthalmoscope shows a slight oedema of the disc with
tortuosity of the veins, the rest of the eye-ground appearing normal.
Later, the usual appearances of blue-gray atrophy set in. In the
earlier stage there are often color scotomata, which are usually ovoid
in form and lie between the disc and the macula lutea. Unless carefully
looked for with color squares of one to two millimeters in diameter,
they are apt to be overlooked. Later, there is a marked reduction of
central vision. When the atrophy has progressed farther, there is
decided contraction of the field.
LEAD-POISONING.--The deleterious effects of lead on the eyesight are
undoubted, although rare in proportion to the cases of colic and
wrist-drop produced by this metal. When amaurosis develops, it is
usually either in acute lead-poisoning or after a gradual saturation of
the system, as is shown by repeated attacks of lead colic. In either
case the amaurosis is usually accompanied by dilatation of the pupils,
delirium, and convulsions. The amaurosis generally passes off, and the
pupils contract with the return of vision, although it may remain
permanent, and leaves the patient with atrophic nerves, as in a case
observed by Trousseau, where the patient was subsequently transferred
to the Salpêtrière. The only two cases which the writer has had an
opportunity of witnessing showed {804} marked choking of the discs and
severe cerebral symptoms. One of these cases died and one recovered:
both were results of the use of white lead as a cosmetic. Rognetta[307]
quotes Vater as reporting a case of hemianopia produced by
lead-poisoning, which recovered when the lead colic was cured.
Trousseau[308] quotes Andral as giving a case of diplopia due to the
same cause, and disappearing as the patient recovered.
[Footnote 307: _Recherches sur la Cause et la Siège d'Amaurose_.]
[Footnote 308: _Thèse de Concours_.]
QUININE.--Over-doses of quinine seriously impair the eyesight, and in
some cases have produced temporary but absolute blindness. The usual
symptoms are a deterioration of central vision and a contraction of the
field. The ophthalmoscopic examination reveals a pallid disc with
marked diminution in the size of the retinal arteries and veins. In
many of the reported cases it is difficult to decide positively how
much of the amaurosis is due to the quinine and how much to the disease
for which the patient is under treatment. This is especially true where
the patient has been suffering from severe intermittent fever or from
exhausting hemorrhages complicating uterine disease, which are well
known frequently to produce more or less complete atrophy, with
shrinking of the vessels. There are, however, a sufficient number of
well-observed cases on record to satisfactorily establish the lesion.
One of the most striking is a case of poisoning recorded by Giacomini,
where the patient took at one dose three drachms of sulphate of quinia
by mistake for cream of tartar. This was followed by severe headache,
pain in the stomach, dizziness, unconsciousness, with slow and scarcely
perceptible pulse and infrequent respiration. The pupils were widely
dilated. On regaining consciousness the patient found that he was
almost blind, the weakness of sight lasting a long time. As the
poisoning occurred in the preophthalmoscopic era, there is of course no
description of the eye-ground. In all recorded cases, while central
vision has been either partially or entirely regained, the field of
vision has remained permanently contracted.
SANTONIN.--In very large doses santonin produces dilatation of the
pupil, amblyopia, and complete color-blindness. Smaller doses produce a
shortening of the violet end of the spectrum and cause yellow vision.
The disturbance of vision usually lasts only a few hours. The poison
seems to be eliminated by the urine, as the sight is said to become
normal while traces of the drug can still be seen in the secretion of
the kidneys. Rose has given us a most careful study of this subject in
his papers entitled "Color-Blindness from Santonin"[309] and
"Hallucinations in Santonin Intoxication."[310]
[Footnote 309: _Virch. Arch._, Bd. xx., 1860 (Separat Abdruck, S. 48).]
[Footnote 310: _Ibid._, Bd. xxviii., 1863 (Separat Abdruck, S. 12).]
SALICYLATE OF SODIUM.--Gatti[311] reports a case of transient
amblyopia, due to the ingestion of one hundred and twenty grains of
salicylate of sodium, in a sixteen-year-old peasant-girl who had acute
articular rheumatism. There were no changes in the eye-ground except a
fulness of the veins, which persisted after the eyesight had returned.
There was mydriasis. No phosphenes could be produced. As the urine did
not present any traces of salicylate of sodium, it would seem to show
that it was not eliminated by the usual emunctories.
[Footnote 311: _Gaz. d. Ospital Milano_, p. 129, 1880; _Nagel's
Jahresbericht_, 1882 (Lit. 1880), p. 245.]
{805}
MEDICAL OTOLOGY.
{806}
{807}
MEDICAL OTOLOGY.
BY GEORGE STRAWBRIDGE, M.D.
In this article on Medical Otology it is proposed to include those
diseases of the ear that are frequently seen by the general
practitioner, and especially those that exist as sequelæ to some
general disease, and where the ear complication would be treated in
connection with the general disorder.
Examination of a Patient.
As nearly all ear patients are afflicted with varying degrees of
deafness, one of the first points of inquiry will be as to their
hearing power. There are three tests commonly employed for this
purpose: the ticking of a watch, the human voice, and the tuning-fork.
1st. The Watch.--By this method of examination the patient is placed
with closed eyelids, so as to exclude the visual power as a factor in
the examination, as it is a curious fact that many people are
apparently unable to distinguish between seeing a watch and hearing its
tick, and therefore so long as they can see the watch they will imagine
that they can hear it ticking. Bring the watch (held by the physician)
from a distance toward the patient until the tick is heard, and note
the distance in inches. The plan of holding the watch close to the ear,
and then slowly removing it until the extreme limit of hearing is
attained, gives an incorrect result as regards the distance that the
watch can be heard, due to the fact that the impressions produced on
the terminal endings of the auditory nerve by the watch-tick continue a
sensible time after the watch-tick has passed out of the nerve-limit,
and therefore the watch-tick can still be noted. Prout has prepared a
convenient method for recording the hearing power. Note the number of
inches that the watch-tick can be heard by a normal ear, and let this
serve as a denominator of a fraction, the numerator of which is the
number of inches that the same watch-tick can be heard by the ear of
the person under examination. For instance: a normal ear can
distinguish my watch-tick at a distance of twenty inches; if, now, the
patient's ear can perceive the same sound at only five inches, the
hearing power would be noted as 5/20. By this it is not meant that the
hearing power is one-fourth of normal hearing, as it would be only
one-sixteenth of normal hearing, as the volume of sound is inversely in
proportion to the square of the distance.
2d. The human voice tells more about the hearing power for practical
purposes than does the watch. There are many persons who can readily
{808} hear the watch-tick at several inches, and yet who hear very
imperfectly ordinary conversation, and also many who hear very well the
human voice and very badly the watch-tick. The method of examination is
to speak ordinary words in a tone that can be heard by the average ear
a given number of feet, and to note the distance in feet that the ear
under observation can detect the words that are spoken. In this way can
be noted the hearing power of the human voice, the numerator of the
fraction being the distance that the word can be heard by the observed
ear, the denominator being the distance that the word can be
distinguished by the normal ear.
The patient should always be examined with closed eyelids, as deaf
people quickly learn by watching the movements of the lips of the
speaker to know the words that are being spoken. Another precaution is
to have the ear to be tested directly opposite the mouth of the
observer, the other ear being firmly closed.
3d. The Tuning-Fork.--Bone-conduction of sound is used by this method.
The great use of the tuning-fork is in determining diseased conditions
of the auditory nerve and internal ear, and it enables one to make a
differential diagnosis as to whether deafness is due to a diseased
condition of the sound-conducting apparatus or whether the nerve
portion of the ear is at fault. For instance: a patient complains of
deafness. This may be due to some obstruction in the external auditory
canal, such as impacted cerumen, or it may be due to a diseased middle
ear, with thickening of its membranes, or it may be due to a diseased
internal ear. The watch and human voice would only show the ear to be
defective in its hearing power, and it may be from any of the
above-mentioned causes. The tuning-fork, in vibration, placed on an
incisor tooth or on the frontal bone, would bring out the fact that if
the deafness was due to a diseased middle ear or obstruction in the
external auditory canal, the tuning-fork would be heard best by the
defective ear; but if due to a disease of the internal ear, it would be
heard the least distinctly by the defective-hearing ear. Mack explains
this by the supposition that the sound-waves are prevented from freely
escaping through the sound-conducting apparatus, and are reflected back
on the auditory nerve-elements, and thus make a double impression.
Tuning-forks having the note C are best adapted for this examination.
EXAMINATION OF THE EXTERNAL CANAL AND TYMPANIC MEMBRANE.--This can be
done by direct or by reflected light, better by the latter. A mirror
and speculum are needed. The mirror should be concave, with a focal
distance of from 5"-7" and a diameter of 2½"-3", with a
ball-and-socket-joint and head-band, so as to allow of the two hands
being free, the head holding the mirror in the required position. The
mirror should have a central perforation of 2'''-3''', with a brass
back, rendering it less liable to break. As a light-source can be used
the light from an argand burner, but preferably sunlight reflected from
a cloud or white wall.
The Ear Speculum.--The Wilde or Gruber speculum answers equally well.
The Wilde speculum is cone-shaped, and best of German silver: it is
easily cleansed and has four sizes. The Gruber speculum has a larger
mouth and gives a large visual field. It has a parabolic curve, for the
purpose of admitting more light; there are also four sizes. The {809}
speculum should be warm when in use, and is to be held in position in
the canal by the thumb and forefinger of the left hand. Often in the
examination of an external canal an angular-toothed forceps is needed
to remove foreign substances.
The cotton-holder is a most important instrument, furnishing a means of
thoroughly drying the external canal of any fluid with the least
possible amount of irritation--much less than that caused by the use of
the ear-syringe. It is a slender steel rod 6" long, having a number of
serrations at one end to more easily allow cotton to be wrapped around
it; the other end has a convenient handle. In using this instrument a
small tuft of well-cleansed cotton is wrapped around the holder, so
that one half of the length of the cotton tuft projects beyond the end
of the instrument. By slight adaptation with the fingers the cotton
roll can be made soft or quite firm, and large or small in proportion
to the amount of cotton used. The cotton-holder should always be used
under the light from the head-mirror.
The curette is of the same length as the cotton-holder, but is made of
heavier steel, and terminates at one end in a small ring of a diameter
of from 2-3 mm. It is useful in removing scabs, etc. from the external
canal, also in loosening impacted cerumen.
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
{810} 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.
{811} 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.
Marked itching and burning and a sensation of fulness occur, both in
the acute and chronic forms.
COURSE.--The acute variety may last only a few days, but as a rule
tends to recur at frequent intervals. The chronic variety can last
almost any length of time, and will often prove to be most obstinate.
TREATMENT.--Acute Variety.--The first indication is to relieve the
burning and itching. This is often best done by the use of some mild
anodyne powder which protects the part from the air and tends to
relieve the existing skin irritation. Finely-powdered starch dusted
over the part is a good remedy. One of the best anodyne powders is that
of McCall Anderson:
Rx. Pulv. camphoræ, drachm iss;
Pulv. zinci oxid. ounce ss;
Pulv. amyli, ounce j.
To be dusted over the inflamed surface.
Often there will be difficulty in preventing the powder from falling
off. When this is the case a very thin coating of the skin with the
oxide-of-zinc ointment furnishes an excellent ground for the powder to
adhere to. The oxide-of-zinc ointment alone is also an excellent
application.
In the chronic variety a more stimulating application is needful, and
some preparation of tar will prove valuable, such as--
Rx. Ungt. picis liquidæ, drachm j-drachm iij;
Ungt. zinci oxid. ounce j.
The crusts that collect on the auricle are best removed by a poultice
of bread and milk, or a cotton pad moistened with olive oil can be
bound over it for a few hours, and will serve to cleanse the part. In
the very chronic cases, where points of suppuration are found, a
caustic application like nitrate of silver is needed. Careful
regulation of the diet and habits of the patient is indicated; an
outdoor life, abstinence from alcohol and tobacco, nutritious food,
will greatly aid. Iron, quinine, cod-liver oil can be used frequently
with good results, while in teething children incising of the gums will
sometimes give temporary relief.
Diseases of the External Auditory Canal.
IMPACTED CERUMEN.--This disease occurs very frequently, and, as a rule,
is considered a matter of very little moment by the profession at
large, whereas, in fact, it is often a symptom of grave disorders of
the middle ear. Roosa mentions that in 1448 cases observed by him in
private practice, only 101 were cases of inspissated cerumen alone, the
great majority showing in addition serious disorders of other parts of
the organ of hearing. The ceruminous glands are found chiefly in the
cartilaginous portion of the external canal, and, according to Kessel,
resemble the sweat-glands not only in the time and manner of their
development, {812} but also in their external form and minute
histology. This is also true of the contents of the ceruminous glands,
as far as the microscope allows us to judge, the only difference being
that in cerumen masses of very fine corpuscles of coloring matter are
found.[1] The ceruminous glands secrete but slowly, and the cerumen
tends to harden and become dark in color as it grows older. The removal
of the secretion is probably effected by several factors. Numerous
experiments prove that the epithelial lining of the external canal has
a constant motion from within outward; necessarily any substance
resting on it will move with it. Cerumen could in this way be
constantly extruded from the external canal; and the cerumen, becoming
dry and hard by exposure to the air, would tend to separate from the
skin by curling itself into small rolls, and so drop out from the
external meatus. The question naturally arises, Why does the cerumen
form such impacted masses as are met with? We submit the following
explanation:
In many of these cases the secretion is largely above the normal, and
catarrh of the naso-pharynx is found associated with it. Pomeroy first
noticed this connection, and suggested the probability that the
ceruminous function is greatly affected in catarrhal disease, on the
theory that the earlier stages of catarrh would result in hyperæmia,
and consequently augmented function, of the ceruminous glands, which if
continued may result in atrophy with abolition of function, precisely
as results in inflammation of the mucous membrane lining the fauces.[2]
[Footnote 1: Vide Stricher, _Textbook_, p. 951.]
[Footnote 2: _American Otological Soc. Trans._, 1872.]
The pneumogastric nerve by its pharyngeal branch is connected with the
pharynx, and by its auricular branch with the external auditory canal,
so that irritation of the pharyngeal branches of the nerve, as would
occur in pharyngeal catarrh, could readily excite reflex irritation in
the auricular branch, with increase of function of the parts to which
it is distributed, causing increase of the ceruminous secretion.
Conversely, atrophy of the nerve would be followed by atrophy of
function of correlated parts. The external canal often presents a sharp
angle in its course near the meatus, and this also would tend to cause
an accumulation of cerumen.
It is a well-established clinical fact that the great majority of cases
of impacted cerumen are found to be associated with serious diseased
conditions of the middle ear especially, and probably the diseased
middle ear is often an important factor in causing impaction to take
place; so that it frequently happens that the patient will experience
no increase of hearing after removal of such an impacted mass, owing to
the diseased middle ear that may be present. I remember one case where
the hearing was absolutely lessened after removal of a ceruminous plug;
doubtless in this case the solid conduction through such a mass was
better than through an air-filled auditory canal.