THE

AMERICAN MEDICAL INTELLIGENCER.

Vol. III.

October 1, 1839.

No. 13.

For the American Medical Intelligencer.

ART. I.-PHILADELPHIA HOSPITAL, (BLOCKLEY.)

DR. DUNGLISON, ATTENDING PHYSICIAN.

Case of Apoplexy-Extensive softening of the left corpus striatum. Reported by JOSEPH B. COTTMAN, M. D., Resident Physician.

George Freeborn, æt. 21, labourer; born in Ireland; came to this country about four weeks ago; landed in New York; was then in perfect health; came to Philadelphia soon afterwards; was much exposed to the sun during his passage over, and for several weeks since he has been in this country; attacked with vomiting and intense pain in his head on the 15th of July; a physician was called to see him, who had his head shaved; cups, leeches, and blisters were applied to the nape of his neck, blisters to the lower extremities, and he took some medicine internally; he gradually grew worse until the 3d of August, when he was deprived of speech; on the 4th, rigidity of right arm and leg was observed, which continued to grow worse until the 9th, when he was brought to the hospital.

State. Very much emaciated; decubitus dorsal; left leg slightly flexed; right side completely paralysed; extremities very rigid; skin warm and moist; pulse 120 in right armi, and scarcely perceptible in left; face flushed, distorted; mouth drawn to left side; pupils dilated; nostrils dilate very much on expiration; tongue coated with a dark brown fur; gums and teeth covered with sordes; respiration laboured, costal; a wheezing noise in breathing; takes no notice of any thing; has to be confined to his bed by means of straps to prevent him from falling out.

Treatment.-Blisters were applied to the nape of the neck and to the

extremities.

August 10th, A. M. Slept none; restless during the night; this morning is improved in appearance; observes objects; pupils not so much dilated; skin warm and perspirable; pulse 120 in right arm; passes his evacuations, which are thin, watery, and yellowish, in bed.

P. M. Very restless; face very much distorted, and expressive of pain; lies on his back, with his left hand constantly applied to his head; the right hand lies powerless by his side; arm and leg on right side very rigid; loss of sensation; temperature of right side, as indicated by a thermometer placed in axilla, 99°, left side 104°; subsultus tendinum in both extremities; skin of left side natural temperature, and perspiring; pulse 126 in right arm, full and bounding; blister drew well. It was ordered to be dressed with the ung. hyd. fort.; blistered surfaces on extremities discharge freely; dressed with the same. Applicentur hirud. American. No. xxxvi ad tempora.

11th A. M. Slept none through the night; found him asleep at the morning

P. M. Intelligence clearer; observes when spoken to; endeavours to protrude his tongue when asked to do so; tongue still coated with a dark fur; teeth covered with sordes; pupils slightly dilated; respiration easy; pulse 112, full and regular. Continue the mercurial dressings, and give the following enema every night.

. Ol. terebinth. 3ss. muc. lini 3vss.

12th P. M. Expression calm; face not so flushed; skin of left side of natural temperature; respiration easy; pulse of right arm 98, regular, scarcely felt in left; drowsy; slept a greater part of the day; asleep at present ; intelligence at times better; recognised some acquaintances who came to see him to day.

Continue to dress the blistered surfaces with the unguentum hydrargyri, and give the stimulating injection at night.

13th A. M. Slept very little during the night; very noisy; constantly moaning; pupils somewhat dilated; mouth drawn more to left side; extremities of right side more rigid; passes his evacuations involuntarily. Continue the

treatment.

14th. No change since yesterday. Continue the treatment.

17th. Somewhat improved; expression better; stronger; is able to raise himself in bed by the aid of his left arm alone; pupils slightly dilated; mouth still drawn to left side; tongue cleaner; gums very much swollen; mercurial fœtor of breath; teeth covered with sordes; respiration easy; pulse 98, regular; passes his evacuations in bed.

No change in the treatment since last note; apply another blister to the nape of neck; blisters on lower extremities still open, dressed with the unguentum hydrargyri.

21st. More intelligent; observes when spoken to; extends his left hand when asked to do so; expression improved; pupils more natural; tongue and gums clean; pulse 120 on right side; right arm and leg still very rigid; very noisy at night; moans almost constantly; sat up yesterday in an arm chair a greater part of the day, a strap being put around him to prevent him from falling out. Continuent. remedia.

22d. Improved; allowed to sit up during the day.

23d. Became faint yesterday afternoon; very drowsy; could not be aroused; pulse failed; extremities became very cold; means were made use of which brought about slight reaction; he, however, soon sank back into the same state, and died August 25th.

Necroscopy ten hours after death.-Exterior very much emaciated; on dividing the scalp and dissecting it off, two marks of contusions were observed on the parietal bones on each side.

Brain.-Dura mater natural, slightly adherent to arachnoid; a few vessels were detached on separating it; arachnoid injected and slightly opaque on the summit of both hemispheres, more particularly the left; no fluid in the longitudinal sinus; about a gill of fluid between the membranes and the brain, immediately anterior to the medulla oblongata; on cutting down into the right ventricle, a small quantity of fluid was found-about two drams; substance of brain, on the right, natural; the substance of the corpus striatum on the left side, in its upper portion, to the extent of about one fourth of an inch, was reduced, to a greenish yellow pulpy mass; portions of it were reduced to a yellowish pus; the medullary substance of the brain on that side, as far up as the base of the convolutions, was softened, to the extent of two and a half inches in the antero-posterior direction, and two inches in the transverse, extending more particularly to the anterior portion of the brain; choroid plexus very finely injected; the arachnoid membrane, extending over the base of the cerebellum, was more than ordinarily injected; over the pons varolii and about the medulla oblongata very minutely injected; substance of the cerebellum of good consistence; of the medulla oblongata also. The other organs of the body were normal, with the exception of the kidneys, which were atrophied J. B. COTTMAN.

ART. II.-CLINICAL OBSERVATIONS ON THE USE OF THE AIR-DOUCHE IN THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE EAR.

BY T. WHARTON JONES, ESQ.'

Circumstances having of late forcibly drawn the attention of the profession to catheterism of the Eustachian tube, and injections of atmospherical air into the tympanum, it behoves every one to contribute what mite of information he may possess, at all calculated to clear away the difficulties or doubts which hang about the subject; for, like most new modes of treatment, considerable misconception prevails regarding it, both as to the principle and performance of the operation, as well as its advantages, being on the one hand overrated, and on the other underrated.

Carefully observed and faithfully reported cases, it is obvious, are the only means of guiding to a correct judgment. Many cases are to be found in the works of Deleau and Kramer, but they do not record the daily progress of the treatment: for this reason I have thought the following cases, extracted nearly word for word as they occur in my case-book, might be read not without interest. And here I would express a hope that these contributions will be received as they are offered, viz. as imperfect observations on a subject not, indeed, of easy investigation, but by no means incapable of ita subject, which, it is hoped, surgeons will see the propriety of attending to more than hitherto, so as to be able to discriminate what can from what cannot be done, and what it is safe from what it is unsafe to do. In all this we must keep in mind the precept-"Nil fingendum, nil excogitandum, sed inveniendum quod natura ferat-quod natura faciat."

It is to be premised, that we endeavour to form our diagnosis of the state of the Eustachian tube and cavity of the tympanum on the principle already adopted in diseases of the chest, viz. to hear when it is impossible to see or touch the disease, the only difference being, that the air producing the sounds in the tympanum is put into motion artificially by the air-douche.

In regard to the air-douche as a means of treatment, all that can be effected by it is the gradual dispersion of any accumulation of mucus which may exist in the middle ear, or the rendering pervious the Eustachian tube, the walls of which have been glued together by thickened mucus.

The eye and ear, though apparently so very different from each other, coincide in many respects both in their structure and in their diseases. As the diseases of the former are much better known than those of the latter, the cautious use of this analogy will be of material service in our examination of the morbid conditions of the ear. Thus, for the sake of example, it may be mentioned that the conjunctiva, that part of the eye which is the seat of some of its most important diseases, is a mucous membrane situated at the peripheral surface of the eyeball. In the ear some of the most common cases of the derangement of its function depend, in like manner, on the morbid condition of a mucous membrane-that lining the cavity of the tympanum-which, being situated at the peripheral surface of the labyrinth, the essential part of the apparatus of hearing, bears exactly the same anatomical relation to it as the conjunctiva does to the eyeball. Again, the nasal duct, a mucous canal, is the seat of some not unfrequent and very troublesome affections of the eye. The Eustachian tube, which resembles the nasal duct in every anatomical particular, does so also in a remarkable degree in its pathological states. Many more examples might be given of the similarity between the structure and diseases of the eye and ear, but these are sufficient to direct attention to the fact. It is to be borne in mind, however, that in consequence of the difference of conditions required for the exercise of the functions of the two organs, the same elementary form of disease shall have a very different effect on vision and hearing. For ex

1 Lond. Med. Gaz. Aug. 3, 1839, p. 670.

ample, inflammation and obstruction of the nasal duct has not such a direct effect on the exercise of the function of the eye as the same state of the Eustachian tube has on that of the ear.

In the case of the eye, we can readily remove any accumulation of thickened mucus by means of a sponge and warm water; but the more inaccessible cavity of the tympanum requires to be cleared out by more complicated means. In applying the air-douche for this purpose, or for the purpose of diagnosis, we ought to go on much the same principle as is followed when it is wanted to blow dust, &c. out of the pipe of a key, viz. give free room for the regurgitation of the air, both where the catheter is inserted into the mouth of the Eustachian tube, and where the nozzle of the tube of the airpress is inserted into the dilated end of the catheter.

But as in catarrhal ophthalmia, for instance, it is not enough to wipe away the discharge from the eye, but also necessary to make some local application to the conjunctiva, if not to employ some general remedy; so in many cases we must medicate the membrane lining the cavity of the tympanum at least (if we do not think it necessary to adopt any more general treatment,) after the accumulated mucus has been removed by the air-douche; or in the event of no accumulation existing, there may still be a morbid state of the membrane lining the cavity of the tympanum, admitting of being as beneficially acted upon by some local stimulating application as the conjunctiva in chronic conjunctivitis.

It is as simple a matter to put a drop into the eye as to wipe away a discharge; but in the case of the ear, it is as complicated a proceeding to apply a remedy directly to the membrane lining the cavity of the tympanum as to disperse accumulated mucus. Watery injections are inconvenient in their application, and cause pain. The vapour of acetic ether, admitting of being easily sent in, and exciting no pain beyond a prickling sensation, has been found the best adapted.

The cases which derive advantage from the injection of ethereal vapour, Dr. Kramer considers cases of nervous deafness; but I believe some change in the membrane lining the tympanum, will, in many instances, be found a more likely cause of the symptoms than any affection of the auditory nerves, as well as the more likely condition to be benefited by the contact of the vapours of acetic ether.

We have, as yet, no correct knowledge of the diseases of the labyrinth. A correct diagnosis, as far as may be, having been formed, of course it is advisable to employ, before or in addition to purely local treatment, leeching, blistering, or whatever other more general remedies may be indicated, the same principles that guide in the employment of general treatment in diseases of the eye, &c. guiding us here.

To place in a striking point of view how far the air-douche serves as a means of diagnosis, and how far as a means of treatment, I take the following calculation from Dr. Kramer's "Tabular view of the frequency and curability of diseases of the ear," remarking that it corresponds with my own, though less extensive experience here. Out of 300 cases of diseases of the ear of all kinds, 200 in round numbers require the air-douche to assist the diagnosis, but about 30 only are curable by it. Of the remaining 170, about 30 are put down as cured, and about 50 as relieved, by the injection of vapours of acetic ether; this treatment having been continued for months. Of the remainder, 80 were considered as incurable from the first, and not treated (farther than the exploratory treatment, I suppose ;) the rest remained rebellious to treatment.

As, in the following cases, admeasurement of the hearing distance by a watch is constantly referred to, it may be well to remark that the capability of catching conversation is not always in proportion to the power of hearing a definite and equable sound, like that of a watch. The power to follow conversation is, in fact, sometimes greater than we might suppose indicated by the distance at which a watch is heard; but, on the other hand, it is also

sometimes considerably less, and this I have particularly remarked in cases treated, and so far improved, by the injection of vapours of acetic ether. Notwithstanding this, an approximate conclusion regarding the state of the hearing, sufficient to regulate our diagnosis and treatment, can be made by means of the ticking of a watch, particularly as the sound can be admitted to the ear under examination, always under similar circumstances.

CASE I.-Accumulation of wax in external auditory passages-Obstruction of Eustachian tubes-Cavity of the tympanum free.

A. B. a woman servant, aged 40.

Wednesday, August 8, 1838.-Left ear: Hearing distance by a watch, two inches, with noise in the ear sometimes like a waterfall.

A year last January, the affection came on for the first time, in conse, quence of cold. The deafness continued for about six weeks, and then went off suddenly. About the end of the following summer the deafness came on again, and then went off as before. Was attacked again in the following winter, but that time the deafness and noise in ear continued three months. The present attack has continued six weeks.

Right ear-Hears the same watch at the distance of nine feet ten inches. Had noise in the right ear last year, but not now. The right ear was as bad as the left when first attacked.

Throat a little red, but not swollen. formerly, and nostrils rather dry.

Sense of smell not so acute as

Considerable accumulation of dark brown wax in both auditory passages. Wax ordered to be syringed out preparatory to further examination. Thursday, 9th.-Has had both ears syringed out. The passage on the right side is now quite clean, and free from any accumulation of wax ; but the lower wall, about the middle, has been fretted by the point of the syringe. The membranum tympani on this (right) side, is opaque and slightly yellow; the handle of the malleus, however, can be distinctly seen.

Still some wax in the left passage, so that only the lower part of the membrana tympani can be seen; and this part appears to be in the same state as the membrane is on the right side.

Noise in the left ear entirely gone, but still feels stuffed.

Hearing distance of the right ear, fifteen feet, seven inches; of the left ear, fifteen feet, four inches.

Ordered the left ear to be syringed again, and a solution of the acetate of lead (gr. iij. aq. dest. 3j.) to be poured into the auditory passages two or three times a day.

Friday, 10th.-Hearing distance of right ear, thirteen feet, nine inches; of left ear, nine feet, six inches.

Still some wax in left auditory passage, which was ordered to be syringed out again.

A feeling of stuffing in both ears, proceeding from the nose, as if she could not breathe.

Applied the air-douche to the left side, and found that the air did not penetrate to the tympanum.

To take a little medicine.

Saturday, 11th.-Still some wax adhering to the upper wall of the left auditory passage, but the whole of the membrana tympani can be seen. Has had some noise in the left ear like the singing of a tea-kettle.

Hearing distance of the right ear ten feet, six inches; of the left ear fourteen feet, nine inches.

Applied the air-douche again to the left ear, but the air did not penetrate. Applied the air-douche also to the right ear. The air penetrated at first in a small whistling stream, and then with some gurgling, but yet not very freely. Stuffing on the right side a little relieved, but still exists on the left side.

The right ear heard the watch, after the application of the air-douche, at