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three minutes, and disease of any of the structures that can be examined is immediately determined. This method can be used in cases where, by complication, the use of the rhinoscopic mirror is either unsatisfactory or impossible.

Dr. Whittaker,* speaking of diagnosis in adenoid growth of the pharynx, says: "The rhinoscope was next to useless. The diagnosis," he further remarked, "can be made best of all by the finger which was to be carried up behind the palate. Even an inconsiderable increase in the amount of adenoid tissue might be recognised in this way." In the exploration of the naso-pharynx with the finger, the sensation, in a well marked case of adenoid vegetations, to the finger has been well described as that of a bunch of worms. If any growths be present, the contact of the finger usually causes them to bleed. Having introduced the finger in the manner before described, and which manœuvre must be rapidly and gently executed, a few lateral movements will then give a very fair idea of the state of the walls of that cavity, and of the nature, size and situation of growths which may be present. In children and refractory adults it is well to guard the first phalanx of the forefinger with a ring, (an India-rubber ring can be used in the place of the regulation silver ring), and the finger may with advantage be lubricated with cosmoline or a mixture of glycerine and water.

I take special pleasure in calling attention to this muchneglected method of examination. I would have every member of our National Association possess such an intimate knowledge of the anatomy and physiology of the parts under consideration, and his or her sense of touch educated to a degree of acuteness which but few of our aural specialists can justly claim for themselves. I would hope to excite an interest not alone in otological researches, but make clear the proposition that dry facts are not deficient in interest, and that anatomy is not alone a "mere preparatory drill to the practical branches," but a source of ever varying utility in all the walks of professional life.

* In the course of a discussion on a paper on "Adenoid Vegetations in the Vault of the Pharynx," before the Cincinnati' Academy of Medicine, April 5th, 1880. See. Lancet and Clinic, Vol. 4, p. 357.

The pharyngeal orifice of the Eustachian tube and fossa Rosenmüller lying immediately posterior, are structures which maintain very important etiological and pathological relations to the middle ear, and which can be directly examined by the digital method. The cavity containing these anatomical structures admits of inspection and examination by methods direct; especially when the patient has a large mouth and wide faucial opening, which is not at all infrequent; then by rotating the inferior maxilla to the side opposite to the orifice of the tube to be examined, at the same time depressing the angle of the mouth, the orifice of the opposite Eustachian tube often lies in a direct line and can easily be seen, together with the fossa posterior to it. This procedure is aptly shown in the work of Prof. J. Solis Cohen, a case of cleft palate affording the extensive view there presented.

By digital examination I can immediately determine the normal or pathological condition of parts within reach, namely: the pharyngeal orifice of the Eustachian tube, the fossa posterior known as that of Rosenmüller's, Luschka's tonsil occupying a central position in the posterior wall of the pharynx and terminating laterally in this fossa, the posterior nares immediately in front; and here by this method of examination I am able to diagnosticate the existence of polypi and hypertrophy of the membranous covering of the inferior turbinated bones. A most important point gained by the method is the direction of the Eustachian tube at its pharyngeal extremity, and the existence of delicate contracting bands in the fossa of Rosenmüller. Whenever you find it difficult, by the ordinary method, to pass your Eustachian catheter, you should immediately make a digital examination, and you will find many times the difficulty lying in the misdirected orifice, this being drawn backward by contraction of bands or by constriction of the membrane itself lining the fossa posterior to the orifice, as is frequent in the condition known as the pharyngitts sicca. Thus by your finger passed up and behind the soft palate, frequently you can succeed in grinding the covered end of your Eustachian catheter into an otherwise practically closed tube; if necessary you can rup

ture the bands with your finger, introduce the catheter, inflate the ear by the bag, and thus sufficiently increase the hearing to warrant the successful treatment of a case which you could not have otherwise undertaken. Cohen and Mackenzie mention the existence of these bands, but they are more numerous and perplexing than the writers would lead the inexperienced operator to suppose.

It is not too much to predict that this method of examination will yet become one of routine-practice in diagnosis of disease in these parts, and that the close aural relation of the naso-pharynx will become a more generally recognised element among the profession in the study of the pathology and therapeutics of ear-disease.

But I must recur to the further consideration of the etiological and pathological relations of the Eustachian tube. The experienced aurist can often predicate the existence of disease in the naso-pharyngeal region as the patient enters the consulting room, with mouth open, dull expression, thick voice and thick hearing, since interference with the sense of hearing -in some cases amounting to almost complete deafness-is a frequent concomitant of its many and varied pathological conditions. Chassaignac, at an early period, recognised the fact that compression of the Eustachian tube by hypertrophy of the tonsils, played the principal part in the production of "throat-deafness ;" and the observations of Harvey at a later period developed the fact that as the tonsil enlarged by disease the Eustachian aperture becomes more patent than in the normal state. Hence this form of cophosis was attributed to chronic swelling and congestion of the mucous membrane of the tube, and more recent researches by Michel have shown that one of its chief causes is pressure of Luschka's tonsil on the posterior lip of the Eustachian orifice. In almost all severe attacks of quinsy the hearing is affected, and occasionally the extension of the disease up the tube gives rise to inflammation of the middle ear.

In the most pronounced cases of granular pharyngitis, as the disease impinges on the naso-pharyngeal space, impair

ment of the sense of hearing, as a consequence, will be noticed in proportion as the orifice of the Eustachian tube, or its lining membrane participate in the morbid process.

Tinnitus aurium results principally from obstruction of the tube, and extension of the morbid condition to the middle ear, producing structural changes in its lining membrane; these changes causing abnormal pressure at the fenestra ovalis, or fenestra rotunda. In catarrhal cases, either acute, subacute, or chronic, engorgement of the mucous membrane will act directly upon the fluids of the labyrinth by way of the foramen rotundum, or by forcing the stapes at the foramen ovale. In subacute and chronic catarrh the subjective sounds are continuous; musical tones of a high pitch; but in the acute form there is added the pulsations of the arteries, synchronous with the action of the heart. In the proliferous form of catarrh, when the mucous membrane becomes atrophied and tense, the variety of subjective tones is unbounded. All these effects find reasonable causes in structural changes originating primarily at the naso-pharyngeal orifice of the Eustachian tube.

Temporary closures of the tube are often the result of ordinary influenza. Scarlet fever, diphtheria, measles, smallpox and similar diseases produce this condition and leave the patient more or less deaf in one or both ears. The closure may be the result merely of the swelling of the lining membrane, or it may be caused by the formation of a mucous plug, which forms by the inspissation of this fluid in the tube. The opening of the tube is often indicated to the patient by a sudden snap in the ear, with an equally sudden increase in the acuteness of hearing. The swelling subsides and the inspissated mucus is thrown out, thus leaving the passage open.

Permanent closures are the results of the same causes, and particularly of chronic inflammation which produces a permanent thickening of the lining membrane, a plug which becomes semi-organised and fixed, or one or more strictures, which close the passage. Great care should be observed after scarlet fever, diphtheria, acute catarrhs, etc., to have the passage cleared out; otherwise a more permanent closure results, which will at first be followed by partial, and finally in many

cases, by complete deafness. It would appear that the natural outlet of the tympanum being closed, disease sooner or later sets in and perforates the membrana tympani, or involves other portions of the internal ear. According to Dr. Byran,* "these closures of the Eustachian tubes are more certainly followed by lesions inducing entire cophosis than affections of the external meatus or tympanum itself."

The consequences indicated are the more likely to follow, inasmuch as the general practitioner frequently fails to consider the gravity of the symptoms attending such closures, and as the tube is somewhat difficult to explore, and also as one tube may be closed for a long time in cases where a competent aurist is not consulted, before the patient or friends may detect it. Frequently very grave pathological conditions are passed over as being a simple "earache." Furthermore, as neither a discharge, deafness, nor any other serious result 'characterises very many of the earaches of young children, the parents or friends are very likely to draw the conclusion that all earaches are equally harmless, and that they may be allowed to run on for days or even weeks without any further attention than that ordinarily prescribed by the physician, viz. a hot poultice, or a few drops of sweet oil and laudanum.

These remarks I concede are again of the nature of a digression, but I am anxious before closing this paper to call attention to the proposition that while we may not all be specialists, yet that special knowledge should take the place of guesswork in the management of aural and allied affections, and the present opportunity seems to be a good one for the purpose. As before stated, there is a certain foundation for the belief that "earaches" are harmless; but this notion could scarcely have become so deeply rooted in the public mind, unless physicians themselves had in a measure confirmed it. While the non-professional person may be excused for such a belief, the physician should not thus err in judgment. He should know that earache is a prominent symptom of some very serious disorders of the ear; such, for instance, as acute catarrh of the middle ear. He should know that the tendency in many cases of "earache" is right on to the more destructive, if less painful, form of suppurative inflammation.

* Treatise on the Ear, p. 36.

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