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The General Therapeutics Of Ear Affections

The General Therapeutics Of Ear Affections

THE therapeusis of disease in the ear, while conforming to that of surgical and medical practice in general, still presents certain points of difference which may be briefly noticed for practical purposes of reference.

In local medication departures from the general rules are necessitated by the peculiar structure of the external and middle ear, the comparative inaccessibility of the latter, its intimate relation to other important structures and cavities, and the necessity of choice made important by these conditions; while in general medication the internal administration of drugs, the selection and method of administration, have to be considered, not only in regard to the general therapeutic effect in which the ear may participate, but also with reference to the special effects which may be induced in the organ of bearing itself. In the local application for the treatment of eczema, for instance, while the rules to be observed are those which deal with the treatment of eczema in other parts of the body, attention must be paid to the fact that the external auditory canal is not only a passage which may be easily obstructed by the detritus of the skin mixed with a bard ointment, but that the lining of the canal itself is a skin which changes its characteristics from a thick hairy, glandular structure to a thin pavement epithelium within a shorter space than does the skin in any other part of tile body. An example of general medication may be taken in that administration of pilocarpin which seeks to produce an effect in the limited area of the labyrinth at the expense of a very general constitutional disturbance.

Following the usual course of arrangement in treatises on diseases of the ear, and proceeding from without inward, the diseases of the external ear for which other than surgical treatment is demanded are anomalies of secretion, inflammations of the external ear and of the external auditory canal, eczema, herpes, lupus, and syphilitic inflammations.

The anomalies of secretion include, usually, the evidence of mechanical disturbance in the accumulation of the secreted mass, and a simple ceruminous plug mixed with particles of desquamated epithelium may sometimes require more than the use of warm water, which is usually its sufficient solvent, to effect its entire removal. Under these conditions the addition of sodium bicarbonate to the water used in syringing, or the previous instillation of some weak alkaline solution, properly warmed, or of a solution of potassium iodid in a mixture of equal parts of glycerin and water, will serve to facilitate the removal of the accumulation. In the cases of dense accumulations of epidermis where the ceruminous secretion serves only as a mask on the outer surface of the deeper seated and more serious obstruction, or forms an unimportant element in the epithelial plug, it may be necessary, especially if the plug has been so long retained as to have become at all lardaceous, by the use of such stronger alkalies, as solution of caustic potash, carried on a cotton tipped probe into the center of the mass, for the purpose of forming with the fatty acids resulting from the lardaceous degeneration of the epithelium, a soap which can be easily washed away, to favor the breaking up of the epithelial mass and its removal piecemeal by syringing or the forceps. In all cases of the use of the caustic potash in this manner the skin of the external canal should be moistened with weak acetic acid to neutralize the effect of any excess of caustic potash which would otherwise irritate the skin.

In the fluctuating hyperemias of the auricle, which are often a great source of discomfort in neurotic subjects, there is demanded not only the local application of cold and mild astringent solutions, but also an attention to the general health which comes more distinctly within the domain of the general practitioner; while for the chronic hyperemia the application of astringent solutions and Of cooling ointments may be further accompanied by galvanization of the sympathetic.

As primary erysipelas of the auricle is very rare, and as the implication of the skin of the auricle occurs usually in the course of an attack of erysipelas originating elsewhere, the general treatment is that indicated by the demand for antipyretics and antiphlogistics; and the local treatment may be limited to the application of cooling solutions, antiseptic or astringent, as, for instance, of oleates and powders, oxid of zinc, and starch exception being taken to such us discolor the skin, and thereby interfere with local observation of the progress of the case.

In the treatment of eczema the different manifestations of this skin¬ disease must be considered, and these vary not only with the stage of the disease, but in the external auditory canal with the portion of the skin impli¬cated. At the outer end of the canal, for instance, where the skin is thick and studded with cerumen and oil glands, a very considerable edema some¬ times marks that stage of the affection in which the skin of the inner por¬tion may be bathed in a serous exudation or firmly encased in dried serum crusts. In the moist stage the surface should be carefully dried and powdered, either with simple rice powder or r rice powder mixed with equal parts of powdered calomel; and in the cases of intertrigo in children, in addi¬tion a light gauze compress may be placed behind the auricle, in' order to support it and prevent the apposition of the denuded surfaces of the posterior portion of the concha and mastoid region. Where crusts have formed as a result of the drying of the serum mingled with the desquamated epidermis, they should be removed only with care, and may require softening to effect this, which may be done with vaselin applied by means of the cotton tipped probe or a camel's hair brush. After removal of the crusts the exposed parts should be smeared with a diachylon ointment or with some astringent oint¬ment having vaselin for its base, the auricle being protected at night by com¬ presses soaked in ointment, and the external auditory canal carefully anointed in a similar manner by means of a cotton tipped probe. In cases of obsti¬nate exudation at the inner end of the canal pencilling with weak solutions of nitrate of silver are of service, and this application is also especially useful in the squamous stage. Internal treatment, except in so far as directions as to general hygiene and diet are concerned, is rarely demanded, except in children, in whom the administration of tonics, especially iron, the iodids, and arsenic are sometimes indicated.

Herpes, which is an exceedingly rare disease and which requires very little local attention, is accompanied by very severe pain, which may be sometimes relieved by local application of solutions of cocain, or, in default of the operation of the local remedy, by the internal administration of a narcotic.

In cases of lupus, in addition to, or sometimes as a substitute for, the surgical procedure of curetting, applications may be made of caustic potash, nitrate of silver, or of the thermocautery, the surfaces to be treated having been previously cocainized.

The most common manifestations of syphilis in the external ear are those occurring in the form of condylomata and ulcerations of the external canal, which require, in addition to the general treatment, cauterization of the granulations with silver and dusting with calomel, the latter powder being especially useful in cases in which the granulations and ulcerations are accompanied by an eczema of other and adjoining portions of the skin.

In furunculosis of the external canal, in addition to the surgical treatment and the application of ear baths, carbolized oil or oleate of morphia saturating a soft pledget of absorbent cotton, is of service. The possibility of infection from the micro organisms which have been found in the boils should always be borne in mind; and where this is the case instillation of sublimate alcohol, of borated alcohol, and insufflation of boric acid should be resorted to in addition to the surgical treatment. After subsidence of the follicular inflammation the skin is very apt to be somewhat thickened, dry, and desquamating, and there is, as would be expected under these circumstances, often considerable itching, the attempt to relieve which by ordinary methods of scratching or rubbing often serves only to bring about a further infection of the skin and a repetition of the furunculosis. Under these conditions, the gentle application, on a cotton tipped probe, of an ointment of salicylic acid and tincture of benzoin with vaselin, lightly smeared over the skin, is often of service; while other interference on the part of the patient than this should be limited to pressure upon the tragus or rubbing only of the external ear.

Diffuse inflammation of the external canal usually occurs as the result of injury or in the course of a follicular inflammation. The prognosis is speedily favorable, and treatment, in addition to instillation of warm antiseptic solutions and cold applications about the ear, may include the application of leeches in front of the auricle in the severe cases, or the more distinctly local phlebotomy of incisions into the skin of the canal itself.

The plant growth most commonly found in the external auditory canal is the aspergillus, but in all cases of parasitic otitis externa the prognosis is good, as the plant growth is speedily and effectually removed by frequent and judicious syringing, and, after drying of the ear, the instillation of alcohol and the insufflation of powdered boric acid.

In acute inflammation of the middle ear internal medication sometimes plays a very important part when it is made to include the attention which should be given to the general causative condition, as well as to the local manifestation in the ear.

In the acute congestion of the tympanum accompanying the closure of the Eustachian tube, incident to coryza in childhood, as well as in the congestions which occur in the course of the exanthemata, bromid of potassium or of sodium, given in small and repeated doses, is an important adjuvant to other treatment; while in more prolonged congestions of the lining membrane of the mastoid cells consequent upon acute otitis media in the adult, a small and continued dose of calomel has seemed to have a favorable effect.

So large is the supply of blood to the lining membrane of the tympanum and mastoid cells, and so subject is it to vaso motor influences, that the demand for relief in acute cases is one which sometimes requires medical as well as surgical interference ; and, while the latter affords certainly the readiest and often the most efficient remedy, the fact that the intimate relationship of the middle ear through the circulatory and nervous systems with the general economy makes the influence to be exerted upon it by general medication a peculiarly favorable one. The experiment of Roosa and Hammond upon the effects of quinin internally, as shown by ocular observation of the bloodvessels in the tympanic membrane, is an illustration of the effect of a drug internally administered under actual observation of its ultimate effect; and similar observations upon the action of bromid of potassium in cases of artificially produced congestion of the middle ear show that while the larger ,doses, from 15 to 50 gr., according to the age of the patient, produce a more immediate effect in the lessening of the capillary circulation the smaller and continuous doses, from I to 5 gr. every hour, have a cumulative effect in the same direction, which is desirable in the more protracted cases. In the simple, uncomplicated acute congestion of the middle ear in childhood, in addition to the administration of the bromids, there may be instilled into the painful ear, providing always that no perforation of the tympanic membrane exists, the solution of sulphate of atropin in equal parts of glycerin and water the purpose of this mixture being to provide a fluid which shall not only retain beat, but shall furnish on the outside of the tympanic membrane a fluid of greater density than the serum, and one which, therefore, will favor exosmosis through the dermoid layer; while such absorption of the atropia as is possible under the conditions of blood tension tends to allay pain. How far the relief experienced in the cases of acute earache in childhood on instillation of this solution of atropia, as recommended by Theobald, is due to the absorption of the atropia, and how much to the simple effect of a warm application, it is impossible to say; but the clinical observation of its use certainly commends it. Where there is much swelling of the nasal mucous membrane, with acute closure of the Eustachian tube, the intranasal injection of a few drops of a weak solution of cocain, by, causing temporary subsidence of congestion and swelling, favors the opening of the Eustachian tube, the drainage of fluid from the middle ear and makes inflation by means of the Politzer air douche or catheter more easily possible. The treatment here indicated applies equally to those cases of implication of the middle ear in the acute stages of the exanthemata, but internal medication may be of service also in the aural sequele of these diseases. In the persistent swelling of the tympanic mucous membrane which sometimes follows measles in young children, and which apparently lays the foundation for a permanent and progressive thickening of the mucous and submucous tissues of the middle ear in later life the administration of the iodids, or, preferably of the syrup of hydriodic acid, is apparently of marked benefit: the administration of the latter drug may begin shortly after recovery from measles. It should be given in doses of a teas spoonful twice or thrice daily between meals and in prescribing may be combined with one fourth part of sherry wine or other alcoholic stimulant The effect of the drug should be watched, and in the event of the appearance of an acute coryza or facial eruption its use should be suspended until these symptoms have disappeared; and, as a rule, better effects are obtained by giving it only two and three weeks at a time, with intervals of one and two weeks' abstention. This same remedy has also been found useful in the cases of nasal and naso pharyngeal catarrh which are apt to have an important and deleterious influence upon the middle ear; and even in adults in cases of chronic catarrhal inflammation, with gradual thickening of the mucous membrane in the tympanum, the continued use of the syrup of hydriodic acid has seemed to be of service.

In cases of acute perforation of the tympanic membrane in very young children, as well as in the suppurative processes accompanying and following the acute exanthemata, more especially scarlet fever, local medication, which accompanies the process of cleansing, needs to be adapted to one or more of two or three conditions. In the serous discharge from the ear which in infants, mingling with the particles of desquamated epidermis in the canal and with light colored cerumen, often, to superficial observation, simulates pus, syringing with a warm weak solution of the sulphocarbolate of zinc is more serviceable than the alkaline washes, because the congestion at the inner end of the canal incident to the congestion of the middle ear favors an exfoliation of the delicate epidermis, and renders a slightly astringent application acceptable. In cases of perforation, with distinct mucous or, muco purulent discharge from the ear, especially if the discharge has, as is not infrequently the case, a slightly acid reaction and an irritating effect upon the skin of the external canal, syringing with mild alkaline waters or with a weak solution of bicarbonate of soda has often a more serviceable effect than the use of astringent solutions or the insufflation of astringent and antiseptic powders. In this connection it may not be improper to express an opinion in regard to the forcible inflation of the middle ear by Politzerization in cases of acute suppurative inflammation of the middle ear with perforation of the tympanic membrane in very young children. This procedure, which is sometimes strongly advised, and which has for its purpose the passage of a column of air through the Eustachian tube into the middle ear and out through the opening in the tympanic membrane, carrying with it the accumulated products of the mucus secreting glands, and of a suppurative process while effective in its purpose in temporarily emptying a cavity of small capacity subjects the structures of the middle ear to an indefinite degree of disturbance ; and the cavity, moreover, if the secretion is copious, immediately refills. Where the perforation in the tympanic membrane is sufficient to permit a free egress to secretions from within, the outflow of fluid will correspond in degree to the degree of its production; and the complete emptying of the cavity, therefore, has for its purpose the opportunity afforded for the intratympanic instillation of medicated solutions which may have a favorable and deterrent effect upon the freely secreting lining of the middle ear. The attempt to effect both these purposes, as proposed by Van Millingen, in syringing through the Eustachian tube into the middle ear, with exit for the fluid through a perforation in the tympanic membrane, was found to result in a degree of violence to the affected parts entirely inconsistent with their delicacy of structure. In the acute suppurative process in the middle ear, both in children and in adults, it being bad in mind that congestion and edematous infiltration are prominent conditions of the early stages, it stands to reason that palli measures, both local and general, are first in order. Locally, these may include, in addition to the direct surgical phlebotomy, the instillation into the ear of mild alkaline and antiseptic.

solutions, the application of dry warmth or, in cases of early mastoid congestion with pain and rise of temperature, the application of cold to that region either by means of compresses, the ice bag, or the Leiter coil, with internal administration of the bromids, of opiates, if necessary, of saline laxatives (upon the value of which much stress is laid by the early English authorities), and the observance of a light, non stimulating diet. In these cases in the adult also the freeing of the bowels, followed by the continuous administration of a mild laxative like calomel, is apparently a useful adjuvant to other treatment. The use of calomel in the small and continued dose in cases of localized inflammation was suggested by the late Dr. E. H. Clarke, whose administration of this drug was based upon long experience at a time when a much higher value was put upon its effect than at present obtains.

In chronic suppurative disease of the middle ear, in addition to the ordinary cleansing process for the removal of the discharge both from the external and middle ear, and the use of the alkaline solutions for that purpose, as already indicated in the more acute cases, it is sometimes necessary to apply astringent solutions or powders for the purpose of acting upon the inflamed Or ulcerated surfaces of the mucous membrane of the middle ear or the dermoid lining at the inner end of the external auditory canal, or to act as a deterrent to the undue formation of granulomata. In all cases, after the cleansing has been effected either by the ordinary syringe or the middle ear syringe, the surfaces to be medicated should be dried as thoroughly as possible by means of a cotton tipped probe or by pledgets of absorbent cotton; and in old cases of chronic suppurative disease, especially where the epitympanic space has become involved or where there are evidences of caries of the bony wall of that cavity or of the ossicles, the drying process should be made the occasion for a careful examination of the parts with a view to more direct local application of astringents, acids, or other escharotics.

In the simple uncomplicated chronic 'suppurative disease, after cleansing and drying, insufflation, with or without packing, of antiseptic powders, preferably boric acid, acetanilid, or a combination of the two, may, suffice as treatment ; although the instillation of a saturated solution of boric acid in alcohol or of alcohol alone diluted with water to a point at which it can be easily borne in the ear, will serve to shrink the smaller granulomata, which, springing from ulcerated surfaces, both tend to increase the volume of purulent discharge and sometimes, by their unfavorable position to block its exit. Further and localized applications to the granulations or polypi may be made by use of a saturated solution of nitrate of silver on a cotton tipped probe, or of such astringents as muriated tincture of iron, ferric alum, or, in the case of firmer polypi, of escharotics; while weak sulphuric acid, the contiguous surfaces being guarded by moistening them with a weak alkaline solution may sometimes be employed as an application to carious bone and as a substitute for the use of the curette.

In cases of chronic non suppurative disease of the middle ear local medication, except such as is limited to applications through the Eustaebian tube, is of comparatively little service, unless we may include under this bead the mechanical operations which affect the circulation in the tympanic membrane and the middle ear, such as the use of the Politzer method of an air tight seal at the outer end of the external auditory canal, absorption of the enclosed air by the dermoid lining of the canal producing a partial vacuum. This not only results in a preponderating atmospheric pressure on the inner surface of the drumhead, but also in an increase of the capillary circulation of the lining, not only of the external canal, but also in a lesser degree of that of the middle ear' The various processes of massage, having for their purpose an increase in the mobility of the drumhead and other portions of the sound transmitting apparatus, tend also by increasing the circulation in these parts to stimulate the absorbent glands, and so favor a decrease of the thickening already existing in the mucous and submucous tissues of the middle ear.

In the course of a progressive non suppurative middle ear disease, however, general medication and attention to general hygiene sometimes play an important part, since the effects of faulty nutrition which result from general overtire and nervous overstrain, increased still further by the fatigue incident to a considerable degree of deafness, interfere with the nutrition of the more delicate structures of the body, and so favor trophic changes which are evidenced in the ear by still further impairment of hearing. The circulatory tinnitus, which accompanies many cases of chronic progressive middle ear disease, often becomes an important factor in the general nervous condition of the patient; and remedies tending to decrease the cerebral circulation or to lessen the sensibility of the nervous system are often of important temporary benefit. This is specialty the case where the neurasthenic condition makes both the impaired hearing for sounds aerially conveyed, and the correspondingly increased bearing of the cerebral and intra aural circulation a matter of grave annoyance and sometimes of detriment. While they need not be specified here, the measures applicable to the treatment of abnormal conditions in the nose and naso pharynx are very important considerations as a part of the treatment of the aural disease.

In diseases of the internal ear where local medication is out of the question, and dependence for an effect upon this portion of the organs of hearing and of equilibration must be placed upon such drugs, internally administered, as materially affect the circulation in these parts, the range of remedies at our disposal is necessarily limited aside from those which may be employed in improving the general hygienic Condition of the patient. One decided exception must be made in those cases of syphilitic disease of the labyrinth where, in the event either of an affection of the cochlea with impairment of hearing, or of the semicircular canals with disturbance of equilibrium, prompt administration of the iodids and mercurials sometimes has a markedly favorable effect: as has been shown by Politzer and other observers, the use of muriate of pilocarpin in these cases is also especially serviceable. In the non specific cases of high grades of deafness and vertigo the drug must often be administered for a longer time and in larger doses than in the specific cases; and Dr. Gorham Bacon cites a case of a high degree of deafness, with vertigo, following a chronic suppurative disease of the middle ear in a man of middle age, in whom the daily administration of this drug in gradually increasing doses up to three quarters of a grain finally resulted in a marked improvement in hearing and in stability. In simple congestion of the labyrinth, remedies which serve to decrease the cerebral and also the intralabyrinthine circulation, such as the bromids and ergot, and in cases of anemia, tonics and stimulants are indicated; while in cases of auditory vertigo, with occasional sharper vertiginous attacks, consequent upon sudden suspense of vaso motor inhibition, the sulphate of quinin, given in the small and continued dose, is often of value in equalizing the circulation.

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