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ARTICLE I. - METHODS OF INFLATING THE MIDDLE EAR. By Thos. F. RUMBOLD,

M.D., of St. Louis, Professor of Diseases of the Nose, Throat and Ear, in the College for Medical Practitioners, St. Louis. Mo., and Editor of the

St. Louis Medical and Surgical Journal. (Illustrated.) Forcing air through the Eustachian tube into the tympanum is a means frequently resorted to for both the examination of the ear and the treatment of catarrh of the Eustachian tube, also for the purpose of preventing or correcting a partially ankylosed condition of the ossicula auris, and for detaching synechia of the membrane to the promontory.

There are several methods of inflation, but no one of them is adapted for all varieties of cases. It is taken for granted, at once, that the method which will accomplish the inflation and produce the least irritation to the mucous membrane of the part operated upon is the one to be preferred. To be enabled to make a selection of the method suited to a particular case necessitates an analysis of all of them, namely: Valsalva's method ; Eustachian catheterization; Politzer's method ; and Gruber's modification of the last named.

THE VALSALVIAN METHOD.

This method of inflation should not be employed as a rule. It is performed by the patient closing his nostrils with his thumb and finger, and forcing air from his lungs into the pharyngo-nasal cavity, and through the Eustachian tubes into the middle ears. This method, if frequently practised, is liable to aggravate the congestion of the mucous membrane. I have treated several patients who claimed that their tinnitus was caused by the continued employment of this means of inflation.

EUSTACHIAN CATHETERIZATION.

The popularity of the Eustachian catheter has varied, according to the good or negative results following its use, by those who have employed it. If the

author of a work on the ear has been dextrous in its application (while it was a popular method, every one claimed to use it with facility and success), he will pronounce it an instrument that fills indications that cannot be filled by any other means.

If the aurist is a young man, he will know how to use it, and will attempt to do so because he must appear to the general practitioners in his neighborhood to be perfectly familiar with it. However this may be, it is true that the majority of aurists of experience reserve this very irritating instrument for those cases only in which other pleasanter means for inflation have failed.

The cavities into which the extremity of the catheter is introduced are the nasal and pharyngo-nasal and the mouth of the Eustachian tube. These cavities are traversed by a larger number of important nerves than any other part of the organism of the same extent. The mucous membrane here takes on a tumefied condition from apparently slight causes, because of the existence of long-continued catarrhal inflammation that always precedes and accompanies the disease of the ear. The tumefaction of the mouth of the Eustachian tube will have an injurious effect upon the hearing, as it always decreases the calibre of the tube, thus preventing the slow and continual ingress of air to the middle ear, which is essential to good hearing.

Can it be expected that a favorable result will follow the introduction of the Eustachian catheter, when it is thrust so roughly against the sensitive mucous membrane that its extremity, by frequent propulsion and retraction in the endeavor to place the end of the instrument within the mouth of the tube) abrades, and in some instances penetrates, the membrane; or, when air is so forcibly introduced that an emphysema of the part results; or, when it is pushed through a nasal passage so narrow and irregular as to cause an abrasion of sufficient severity to produce hæmorrhage; or, when its introduction will cause an irritation or swelling of the nasal mucous membrane sufficient to give rise to a copious flow of tears; or, when its extremity is thrust into a mass of mucopurulent secretion, lodged in the pharyngo-nasal cavity, in the neighborhood of the Eustachian tube ? Is it possible to make a favorable introduction under any of these circumstances ? To receive the smallest benefit, its introduction must always be a painless operation.

In my practice I have resticted the employment of the catheter to patients suffering from cleft palate, or from its perforation, or those who are afflicted with a paresis of the velum, and to those very old chronic cases who require a warm spray to be thrown directly into the Eustachian canal.

Fig. 1.-Soft rubber Eustachian catheter.

The curved extremity is formed of soft rubber tubing.

Since 1871 I have used a Eustachian catheter, the curved extremity of which is flexible (Fig. 1). By its use the liability to injure the mucous membrane of the nose, or mouth of the Eustachian tube, is reduced to a minimum. It con

sists of a metal tube, the diameter of an ordinary catheter. At one extremity is fastened a ring to indicate the position of the curved extremity, at the other a piece of watch-spring, bent to the proper curve, is fastened. At the further end of this is soldered a small ring. Over the tube, curved watch spring and small ring is drawn a piece of soft, smooth rubber tubing. This covers the whole instrument, makes it a non-conductor of heat, and prevents the yielding, curved extremity from injuring the nasal passage in its introduction. The yielding or spring portion of the catheter is easily bent in any desired position. Besides being almost painless in its introduction, the rubber extremity prevents abrasion of the mouth of the Eustachian tube.

It has been my custom to direct the patient to hold the outer extremity of the catheter, after it is once introduced into the mouth of the tube. I do this that undue pressure of the catheter against the tube may be avoided, and to prevent the mucous membrane from closing the orifice of the catheter. I direct him to move it slightly from place to place, in order to find a position which allows the air to enter most freely into his middle ear, of which he is by far the best judge. At the first few treatments, the patient may not hold the instrument in the right position, perhaps, but it is very much better to fail in inflating the ear at the first trial than to bruise the mouth of the Eustachian tube once. Yet in most instances the tympanum may be inflated at the first sitting.

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FIG. 2.-Warm spray producer for treating the anterior nasal cavities and inflating the Eustachian

tubes A, boiler ; B, soft rubber tubing connected with the boiler and spray producer. C, Faucet for controlling the amount of air that is to enter the boiler ; D, large tube i hat contains the medicine to be made into spray ; E, the spray. I have arother slight modification of the method of forcing the air through

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