SURGERY.
On a simple Method of ascertaining, without the use of the Catheter
whether the Eustachian Tubes are pervious ; with some observations on
the Treatment of cases of Obstruction in these Tubes. By Joseph Toyn-
bee, F. R. S.—The author pointed out the objections to the two ordi-
nary modes of exploring the Eustachian tubes—viz. that the use of the
catheter is liable to produce pain and discomfort; that, without expe-
rience, it is not easy to ascertain whether it be really in the tube; that
the plan of attempting to distend the tympanum by a forcible expira-
tion, while the mouth and nostrils are kept closed, is not always success-
ful, from the fact that the young and nervous cannot be taught to
perform the act, and that sometimes, when it is properly done, the gut-
tural orifices of the tubes seem to be pressed together so as to preclude
the air from entering. In a paper recently read before the Royal
Society, the author endeavored to show that the guttural orifice of each
Eustachian tube is generally closed, and that the air in the tympanum
is not continuous with that in the cavity of the fauces, except during
the momentary act of deglutition. In proof of this the following
experiment was cited : If the mouth be shut, and the nostrils be held
closed by the finger and thumb, and then the act of swallowing be per-
formed, a sensation of fulness or pressure is experienced in each ear;
and this sensation does not disappear upon the removal of the pressure
from the nose, but it vanishes at once when the act of swallowing is
again performed, while the mouth and nostrils are open. During the
first act of swallowing, a small quantity of air was forced into the tym-
panitic cavities through the Eustachian tubes, and it therein remained
until the second act of swallowing again opened the tubes and permitted
the air to escape. The muscles whereby the Eustachian tubes are
opened are the tensor and levator palati, which it is well known take
origins from the cartilaginous walls of the tubes. As, during the act
of swallowing with closed mouth and nostrils, air is forced through the
Eustachian tubes into the tympanitic cavities, it is evident that the
permeability of these tubes can be ascertained by making the patient
swallow ssme saliva while the mouth and nose are shut. Nor need the
surgeon depend upon the statement of the patient respecting the sensa-
tion of distension felt in the ears; for, by listening with the otoscope,
should the Eustachian tubes be pervious, the air will be distinctly heard
to enter the tympanitic cavities, and produce a gentle crackling sound.
The author next proceeded to consider the treatment of cases of obstruc-
tion of the Eustachian tubes, especially in reference to the use of the
catheter. It having been ascertained that these tubes are obstructed, is
it desirable to attempt to open them by means of the catheter? Believ-
ing that obstruction in the Eustachian tubes generally depends upon a
thickened state of the mucous membrane covering the guttural orifice,
and that this state is always associated with a thickened condition of the
faucial mucous membrane and of the mucous membrane of the tym-
panum, the author suggests—especially to those inexperienced in the
use of the catheter, not to attempt to pass this instrument—firstly, be-
cause, in such eases, the mucous membrane of the Eustachian tube is
often so tumefied that no ordinary degree of pressure will force the air
into the tympanum ; and, secondly, because, should the surgeon succeed
in transmitting a few air-bubbles, the relief obtained is only partial and
endures for a very brief period, since the mucous membrane remains as
thick as before, and the ill effects of the obstruction soon recur, from
the air in the tympanum becoming of a different density from that
without. The membrana tympani becomes more or less fixed. The
treatment recommended is such as shall tend to reduce the thickened
mucous membrane of the guttural orifices of the Eustachian tubes to a
healthy size, so that their muscles may be able to open them. For this
purpose, besides the use of general remedies, the solid nitrate of silver,
or a strong solution of hydrochloric acid, may be applied to the mucous
membrane of the fauces and to the apertures of the tubes, and gentle
counter-irritation is to be kept up over the region of the fauces. By
these measures, as a general rule, the mucous membrane can be reduced
to its natural state, and the tubes become again opened by their muscles.
Should this not take place, the Eustachian catheter may now and then
be introduced, and air be gently blown through it. A modification in the
shape of the Eustachian catheter is suggested—viz. that it should be
oval instead of round, the advantages derived being, that it not only
can be passed through the nose with less discomfort to the patient, but
its presence in the Eustachian tube is much less disagreeable from the
absence of the convex surfaces which, in the rounded catheter, press
against the nearly flat surfaces of the tube. In conclusion, the author
expresses his concurrence in the opinion of Harvey and Kramer, that
enlarged tonsils are never the cause of obstruction in the Eustachian
tubes, and that any benefit that may have followed their extirpation has
arisen from the loss of blood consequent upon the operation.—Lancet.