A Contribution to the Management of 
General Atrophy (Sclerosis/) of the Con- 
ducting Apparatus of the Ear. 
BY 
S. O. RICHEY, M. D., 
of Washington, D. C. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 
April, 1S87. Extracted from the 
American Journal of the Medical Sciences for April, 1887. 
A CONTRIBUTION TO THE MANAGEMENT OF 
GENERAL ATROPHY (SCLEROSIS?) OF THE CONDUCTING 
APPARATUS OF THE EAR. 
By S. O. Richey, M.D., 
OF WASHINGTON, D. C. 
When discussing the nature of this affection in the Archives of Otol., 
vol. xv., No. 1,1886, attention was called to the fact that local stimulation, 
applied immediately to the diseased tissues, promises the most efficient 
results yet obtained, but no attempt was made to elaborate the details of 
management, or to describe the means of producing the desired effect in 
this peculiar region, difficult of approach, sensitive to and resentful of 
the presence of instruments and medicaments to which it is unaccus- 
tomed, and located so near the centre of the senses that many unexpected 
manifestations of their displeasure occur, which, though merely func- 
tional and temporary, are very disagreeable while they last. The neces- 
sity of repeating the manipulations and applications for a long time 
divests the procedure of any sentimental impressions it might otherwise 
leave. In the ratio of the rapidity of the increase of the impairment 
of hearing may we find an indication as to the length of time requisite 
for its proper treatment; for, the slower its progress, the more firmly 
will the disease changes have established themselves, and, therefore, the 
more difficult, and the longer the time necessary to remove them. 
Empirically repeated incisions of the membrana tympani may, by 
the contraction of their cicatrices, restore the membrane to a shape more 
nearly normal, but what will be the ultimate effect of this scar tissue? 
May it not be worse than the condition it was devised to relieve? 
No good reason, based upon pathology, is given for such interference, 
and I am convinced no thinking man will advise such a course, without 
a better reason than any yet advanced in its favor. An air-douche to 
the middle ear, unaccompanied by any other agent, is questionable thera- 
peusis: it is a mechanical shock to a sick organ to be resented sooner 
or later; generally, at such a time that no connection can be traced. 
Depressions of the membrana tympani, alteration in its translucency, 
thickening of its tissues, and the appearance suggesting adhesions are 2 
RICHEY, ATROPHY OF MIDDLE EAR. 
probably due to changes in the mucous layer of the membrane and that 
lining the cavity. 
Division of the tensor muscle, the use of Siegle’s otoscope, forcible in- 
flation, etc., have been resorted to for the purpose of relieving these 
features, often with the hearing improved to some degree after each, 
only to relapse into a worse condition with less prospect of improvement 
than before. 
More frequently a flapping drum-head results, with pain and dizziness 
when blowing the nose, if there is not stenosis of the Eustachian tubes. 
The writer has often seen this condition following the too free use of the 
Eolitzer or the Valsalvan method of inflation, and generally in the ear 
not intended to be treated. With gentleness and care this misfortune 
may be corrected, but forms a long and tedious introduction to the 
necessary treatment of the original affection, when it happens to an ear 
already diseased, though it could be avoided by prudence in the begin- 
ning. 
Too much stress is laid upon the fact that a drum-membrane is de- 
pressed, except as an evidence of the affection behind it, and producing 
it, the improvement of which establishes the proper position and condi- 
tion of the membrana tympani in a perfectly natural way, by a removal 
of the cause: just as a pannus may often be cured by treating the con- 
junctivitis. 
The morbid process in the cases under discussion does not, to our 
knowledge, cause death, and hence our opportunities are limited for com- 
pleting their history by an autopsy, after close observation during life; 
and in this way only can the question be definitely settled; but it is not 
my impression that depression of the membrana tympani is so fre- 
quently due to retraction of the tensor muscle, or to adhesions to the 
inner wall of the cavity, as has been supposed, but, reasoning clinically, 
to shrinking of the mucous layer of the drum-head from atrophy, which 
slowly involves the whole membrane. The membrana tympani has, 
moreover, been seen to change in this feature, and in translucency, with 
the improvement from dryness and atrophy in the middle ear cavity, and 
that without special force from within. With the change in the mucous 
membrane toward health is associated a tendency of the membrana tym- 
pani to resume its natural and original position, and the less the solution 
of continuity of tissue has been in the membrana tympani, the better it 
should perform its function. 
How much are we indebted to an atrophied condition of the conduct- 
ing ear, for that variety of tinnitus, due, probably, to anaemia, which 
begins before there is any other prominent symptom of disease; which 
increases slowly, is very intractable, and often is not relieved until long 
after the hearing is improved? When this tinnitus is dependent upon 
disease of the naso-pharyngeal space, it is variable; that is, it is heard RICHEY, ATROPHY OF MIDDLE EAR. 
3 
sometimes in one ear ; again, in the other; and, at another time, in both. 
It is relieved by restoring in the nasopharynx the natural relations for 
resonance. 
Is persistent tinnitus in a given ear, when cerebral, circulatory, or 
nasopharyngeal causes can be excluded, not due to a disturbance in the 
character of the cavity ; its moisture, its tension, form, size, etc.? Does 
not a modification of this alteration, by a topical application of thera- 
peutic agents, offer us the best prospect of success ? 
The anatomical peculiarities of the tympanic cavity, its impatience of 
artificial control, and its resentment of the presence of foreign substances, 
limit, for the purpose of stimulation, the means at our command. 
No fluid having this therapeutic value can with safety be carried be- 
yond the isthmus of the Eustachian tubes, the danger being that, reach- 
ing the cavity, it will settle in the depressions, and by undue action there 
cause inflammation. We are thus confined to vapors for this purpose, 
because they diffuse themselves throughout the whole cavity without 
partiality and affect the entire lining membrane, producing no more 
influence in one locality than in another; they, at least, do this better 
than any other form of medication. 
Chloroform or ether vapors have not been very efficient in my hands; 
for, while they cause considerable hypersemia, this as readily passes off, 
unless so much vapor is used as to make the danger of acute inflamma- 
tion so imminent that I have not felt justified in persisting with it. By 
very frequent application in moderate quantity, it might serve the desired 
purpose with diminished risk, but the object to be obtained is an almost 
constant fixed action, an approximately continued influence, and it is not 
easy to see how, with this agent, it can be accomplished. The mere odor 
of either chloroform or ether will cause nausea at once in some indi- 
viduals, and generally does so with all, sooner or later; another reason 
for abandoning it. 
My intention was to try a vapor of chloroform and turpentine, but the 
objections to chloroform were so pronounced, and the dread that the 
vesicular eruption and obstinate ulceration, which turpentine sometimes 
produces when applied to the skin, might be repeated in the mucous 
membrane, has so far deterred me from the experiment, which will prob- 
ably be left to some one bolder. 
Ammonia might be serviceable if it could be confined to the middle 
ear cavity, but its extreme volatility diffuses it through the pharynx and 
nares in a most uncomfortable way. 
In circumstances of extreme difficulty we are apt to be content with 
what has answered the purpose in our hands, and my reliance has been 
almost entirely upon the vapor of iodine, with good, though not with 
uniformly satisfactory results. 
The method adopted early in my practice is that which I first saw used 4 
RICHEY, ATROPHY OF MIDDLE EAR. 
by S. J. Jones,1 of Chicago, which is a modification and combination 
by him of several other methods. It differs from the Politzer methods 
in the substitution of the local anaesthesia bulb for the large bag, and the 
use of the catheter, which should be of malleable silver, as this may be 
readily adjusted in shape to passthrough the nostril and reach the Eusta- 
chian orifice, anatomical variations being frequent on even the two sides 
of the same individual. In addition, being made of metal, it may be 
sterilized by dipping it in alcohol, and burning it out. 
By these means we may be satisfied that the vapor reaches the objec- 
tive middle ear cavity first, though the reflux reaches the air passages, 
from which it is not always desirable to exclude it; and, when it is, the 
severity of the application may be limited. The smaller bulb may be 
easily and firmly grasped in the hand, is readily compressible, and a 
measure of the obstruction of the tube, or of the pressure to which the 
membrana tympani is being subjected, may be ascertained by the resist- 
ance of the bulb to the hand. The light and flexible tubing, between 
the Buttle’s inhaler and the hand-bulb, removes the risk of dragging 
upon the catheter when compressing the bulb ; or of bending or break- 
ing the catheter, as some of the books warn us, in describing the use of 
the Politzer bag with the catheter. Hard-rubber catheters are brittle, 
and require the aid of heat if a change in shape is desired, and for this 
reason are cumbersome. Besides, they are unclean, because they can- 
not be as easily and efficiently purified as can the silver instruments, as 
above suggested. Some silver catheters are rudely and inartistically 
made, and can be handled with no more facility than those of rubber, 
but the delicacy and ease of manipulation which can be acquired with 
the silver instrument, properly made, and the complete security against 
the danger from inoculation when it has been “ purified by fire,” add 
greatly to the comfort of the surgeon, and the comfort and safety of the 
patient. 
The mechanical force arising from the quick shocks of air propelled 
by the hand-bulb has seemed to me as objectionable, only in a much less 
degree, as those inflicted by the large Politzer bag. The pressure in the 
middle ear cavity is temporarily very great, and a more steady and less 
forcible pressure must commend itself to our judgment. This I have 
secured by means of condensed air, with the aid of the air-pump and 
receiver ordinarily used by laryngologists in spraying the pharynx and 
the contiguous regions. With the “cut-off” which accompanies this 
instrument, we may have absolute control of the air-pressure in the 
middle ear, and if at any time the sharp impulse of air is desired, or 
deemed advisable, it is easily secured by this means. 
1 Trans, of the International Medical Congress, Philadelphia, 1876. “ Modifications of the Methods 
of Treating Chronic Non-suppurative Inflammation of the Eustachian Tube and Middle Ear.” RICHEY, ATROPHY OF MIDDLE EAR. 
5 
In the cases of so-called “ dry aural catarrhthe Eustachian tubes are 
usually without obstruction, and a pressure of air sufficient to carry the 
vaporized medicament into the deep recesses of the ear seems sufficient. 
In my experience, this can be accomplished with a pressure varying 
from one-fifth to one atmosphere (three to fifteen pounds). The vapor, 
during the continued pressure, escapes into the pharynx and nares by 
the side of the catheter, and the return current meeting the advancing 
current near the orifice of the catheter produces a slight rustling sound, 
which is perceptible by means of the auscultation tube. The impingement 
of the advancing current of air upon the membrana tympani is also to 
be distinguished, if it reaches the cavity of the middle ear, by a light 
blowing sound. 
It is best to suspend the pressure during inspiration, and to continue 
it during expiration ; in this way avoiding, as much as possible, the 
extension of the vapor to the bronchi, and lungs, rendering it 
less disagreeable, and, with the assistance of the column of air expired, 
securing a more efficient application to the cavity. Besides, the expira- 
tion relieves the pharynx and nasal passages of the presence of the 
reflux of vapor as it escapes from the Eustachian tubes. A white 
handkerchief held to the nose has often been observed to be stained by 
the iodine vapor, which could reach it in no other way. 
It has become my practice to moisten the sponges only when fitting 
them into the Buttle’s inhaler, for by drying they adapt themselves to 
its shape better; not afterward, for the crystals of iodine evaporate with 
the air passing over them, as well when the sponges are dry as when 
they are moist. Constant use of the muscles of the forearm in com- 
pressing the hand-bulb is not without its risks to the surgeon, as it may 
induce morbid growths there; another reason for the use of condensed 
air. 
Finding the hand-pump troublesome and inconvenient, my resort has 
been a hydraulic automatic air-pump,1 which, being connected with the 
aqueduct water, gives a pressure of air equal to the pressure of water 
in the pipes supplying the house. It pumps air into the receiver as it is 
being exhausted, and maintains an approximately regular pressure. If 
the pressure of the water in the pipes reaches twenty to thirty-five 
pounds, it will be sufficient for all ordinary purposes, as the pump wil 
act until equality is established betw'een the pressure of the air and of 
the water. It is a great saving of labor and attention. The one in my 
office is known as “ The Reliance,” and was promoted from its original 
purpose of furnishing air pressure to beer barrels, to its present use. It 
is a handsome fixture, and can be obtained from Mr. Harvey, of Wash- 
1 Since the writing of the above and after using the apparatus, I find an account of something o 
the kind used for experimental purposes. Barth, Archiv. Otol., vol. xv. p. 160. 6 
RICHEY, ATROPHY OF MIDDLE EAR. 
ingtori, put in position, for about forty dollars. A metal pipe runs from 
my receiver (which is on the floor) over my table, and is attached to the 
wall. This contains several stop-cocks, to which may be attached as 
many different apparatus for spray ; between them and the reservoir is 
a governor which can be set to give the measure of air-pressure desired. 
By this last item guessing at the amount of pressure is avoided and 
accuracy may be secured. 
The local application of iodized air will be followed by a feeling of 
warmth and an increase of secretion from the nares and pharynx, before 
it is perceptible in the ear by the patient, or before the surgeon can 
assure himself of its effect upon the ear by inspection. The feeling in the 
ear has been aptly described by a young woman, as “just like when you 
blush.” As the vapor is driven into the ear first, the reflux into the 
pharynx and nares serves as a measure of the impression being made in 
the cavity of the middle ear, for, in some instances, it is not possible to 
produce any sensation in the tympanum, or to derive any information 
from an examination of the membrana tympani in the early stages of 
the treatment. In advanced cases of the disease no sensation is caused 
by the vapor for months ; but, from the time it is first felt, there is steady 
increase in sensitiveness, and the severity of influenza following a sitting. 
This artificial influenza resembles any other, except that it is self-limited 
and of shorter duration, continuing from two to eight or ten hours ; it is 
more easily produced and lasts longer as the treatment progresses. The 
use of the vapor has not, under my observation, occasioned anything 
resembling general iodism. 
As it is needful only to maintain a state of hyperaemia as continuous 
as possible, the intervals between the interviews may be lengthened with 
the time the effect persists. Increased impairment of hearing and 
aggravation of any existing tinnitus may occur during the first week of 
treatment, and this naturally would not be unexpected in a state of 
tissue-thickening, a result of the hyperaemic condition of the membrane. 
It is apt to be alarming to the surgeon, unless he has had one experience 
or more; to the patient it will be disheartening, unless he has been pre- 
viously advised of its probability, although it has not been observed in 
all cases. Why it should happen in some instances, only, is not clear, 
and the percentage of cases in which it does occur has not been ascer- 
tained. That it is due to congestion is proved by its occurrence each 
time the treatment is begun, after an interval of rest, and by the relation 
it bears to the intensity of the congestion. An improvement in these 
symptoms, corresponding in extent to their aggravation, takes place 
upon a discontinuance of the manipulations, which is noticeable in a 
month, or less, afterward, if the treatment has continued for several 
months. 
If improvement takes place during the use of the vapor, this will be RICHEY, ATROPHY OF MIDDLE EAR. 
7 
increased, as indicated, after its suspension. Tims, generally, a gain can 
be decided only after a rest, which will not interfere with the ultimate 
result unless it lasts too long. 
If the applications be too severe, or if the effect be increased by 
exposure to draught, or otherwise (and individuals vary greatly in lia- 
bility to this accident), I have been able, with one exception, to control 
the resulting inflammation, bv pressing against the membrana tympani 
a tampon of “ prepared cotton,” the end of which, in contact with the 
membrane, has been saturated with a solution of argenti nit. 1 :100 parts. 
This, done early, often gives as immediate relief from pain as an ames- 
thetic. It should be left in position for some hours. The astringency 
reduces the local hypersemia, and the tampon supports the membrana 
tympani and prevents its motion during the act of swallowing, or blowing 
the nose. The patient should be advised of the possibility of the acci- 
dent, how best to avoid it, and to see the surgeon immediately when it 
occurs. 
Iodized cotton in the external meatus is another means of using iodine. 
“Prepared” cotton placed in a closed vessel with crystals of iodine ab- 
sorbs iodine, and parts with it again in the meatus. That this produces 
the symptoms, hypersemia of the membrana tympani and external 
meatus, with some itching of the meatus, is proved in cases where the 
cavity is exposed by a perforation of the membrana tympani, as pain 
will result (though not when the drum membrane is entire) and will be 
relieved by removal of the cotton. The vapor applied to the cavity 
causes, in time, itching of the meatus in those cases which do well, and 
this fact induced me to use the iodized cotton in the meatus for its pos- 
sible effect on middle ear nutrition, and that of the dermis of the meatus 
and the underlying glands. This application to the meatus is cleaner 
and more manageable than others, though it may be an advantage to 
substitute for it, sometimes, the ungt. hydrarg. nit. (pure, or mixed with 
lanolin in quantity varying to suit the condition), to the dermis. It is 
not in my power to say how much these aid the case, having never 
relied upon them alone in any instance, but they do service when the 
meatus is dry and exfoliating. 
Electricity may serve to improve regional nutrition, as it does in tri- 
geminal neuralgia, if a galvanic current be passed from the inferior 
cervical ganglion to the external meatus and to the Eustachian orifice, 
the difficulties being the time on the part of the surgeon required for 
each sitting, and the uncertainty of the result, for it would have to be 
tried alone to reach a decision as to its value. 
To select a proper subject for this purpose, and to do it justice in 
respect to the individual and the agent both, is not a question of a short 
time. My reliance upon electricity, in controlling the action of the vaso- 
motors of the region supplied by the branches of the fifth nerve, is 8 
RICHEY, ATROPHY OF MIDDLE EAR. 
decided. In none but subacute cases lias my observation, however, led 
me to think it acts promptly, and though my limited experience of its 
influence in cases of atrophy is not satisfactory, yet it is my hope at some 
future time to make more exact and reliable statements concerning it. 
Where stenosis of the inferior nasal strait exists, electrolysis accomplishes 
more than any other agent, except, perhaps, thermocautery. If a small 
silver catheter can be introduced at all, if not, a silver probe will make 
an excellent conductor, and with one pole at the nape of the neck, and the 
probe converted into the negative pole, absorption of morbid material 
may be caused, sufficient to admit the passage of a small catheter at a 
second interview. The current need not be strong enough to cause 
much pain. Absorption seems to continue for from a week to a month. 
Whether absorption of bone-hypertrophy takes place, I cannot yet say. 
Mayhap some further advantage would arise from the substitution of 
needles inserted into the diseased tissue, under the influence of cocaine, 
and electrolysis tried through them. It is a decided gain to avoid the 
removal of any essential part of an organ. 
The use of the steam atomizer, in preparing the mucous surfaces for the 
action of the vapor, unnecessarily consumes the time of the surgeon and 
his client, without compensating advantage, as the stimulation by the 
vapor increases the quantity and fluidity of the secretion, and accom- 
plishes the same purpose. 
A spray through the catheter to the pharynx and posterior nares, and 
even into the Eustachian orifice, of argent, nit., t ; acidi borici, 7 ; gly- 
cerine, 20; aquae, 500 parts, gives admirable results, when astringency 
is desirable. Unless forced into the superior meatus of the nares, or 
beyond the isthmus of the Eustachian tube, it is painless. 
In this paper, discussion of the hygienic management is beyond the 
consideration. 
A surgeon who is not full of courage both for himself and his client, 
who is afraid of labor, or who cannot persist patiently without seeing 
positive and rapid tissue change, should not undertake this class of cases, 
for the results cannot be brilliant in the length of time required, nor in 
their impression upon the ignorant, but are important chiefly to those 
who suffer. After a spasmodic, which always means an unsuccessful, 
effort, the difficulty is increased by the additional discouragement to that 
usually felt by these people. The object is not to claim anything 
miraculous even in appearance, but to make a decided statement that 
all these cases a re not incurable, even when far advanced. The condition, 
the course of treatment necessary and its annoying accompaniments, and 
the possible expense, should be contrasted with the probable outcome if 
the disease is neglected, and the individual should be left to decide for 
himself what he should do. He will often conclude to take the chance 
of relief, thinking he will persist, but growing weary of the slow im- RICHEY, ATROPHY OF MIDDLE EAR. 
9 
provement he may give it up. This, in a measure, is his own affair; 
but, with this possibility in view, the surgeon does not feel very desirous 
of the responsibility, though he may have the satisfaction that he has 
done right in so far as he was permitted. I have never seen an instance 
in which there was not an amelioration of one or more of the symptoms 
after a time; a better feeling about the head; an improvement in 
conscious mental vigor, or in the memory; less tympanic neuralgia, or 
less tinnitus; increased ability to sleep, which is more refreshing ; or an 
improvement in the power of hearing. In the event that the hearing is 
not improved, the surgeon, unfortunately, has only the consciousness of 
duty performed, as the better condition being confined to the patient 
himself, and not being perceptible to his friends, there is no credit to the 
surgeon, because the individual “ did not get back his hearing.” The 
organ is beyond the vision of all interested, except the medical adviser, 
and no one appreciates the influence of the subjective disturbances, except 
the physician and the patient, or realizes what relief from them means 
to the sufferer. The patient’s friends, with the best intentions, are, in 
fact, because of their ignorance, his worst enemies, and a stumbling- 
block in the path of the surgeon, for they will, by united effort, some- 
times convince the patient, contrary to his better knowledge, that there 
has been no change, as any advantage is so slowly gained that they 
become accustomed to it. Not infrequently the patient will say, “ If I 
never hear any better, it is worth all the time, expense, and trouble to 
be relieved of the confusion and weight I have had in my head.” One 
individual said some time ago, that “ he would be glad to continue the 
treatment once a wreek for the rest of his life for this effect alone, as it 
had, for some years, been growing more difficult to do brain work, and 
he thought he must soon give it up.” He was one of those who could 
hear only a loud voice in a moving car, or a din of some kind; a con- 
dition which we know to be very intractable, fie now hears the ordinary 
conversational tone three or four feet distant in a quiet room. 
This affection is one of such importance to so many people, interfering 
with their usefulness to society, their personal comfort and happiness, 
and the convenience of those brought in contact with them, that all 
knowledge in regard to it repays the endeavor. A faithful consideration 
of my contribution will prove it rational and in the right direction, so 
far as it goes, and it is hoped my confrbres will give the patient attention 
and trial that the establishment of a reliable means of relief from this 
disease would deserve. Whatever this means may be, it cannot be 
speedy in face of the character of the disease. The treatment described 
unquestionably relieves some cases; it has been serviceable to nearly all 
for whom it has been tried. If some exist who would derive no benefit 
from it, why not ? This is an important question, and it may be properly 
answered, that the trial was not long enough continued. 10 
RICHEY, ATROPHY OF MIDDLE EAR. 
We must bear in mind that in all these cases the individual, or his 
friends, have been aware that something was wrong for years, and, 
knowing its rate of progress after the disease manifests its presence, we 
may confidently reason that it had been existent a very long time before 
that, so to impair the organ as to produce troublesome symptoms. A 
proportionate time and effort must be given to its relief. We patiently 
and persistently treat a chronic conjunctivitis and its se<]uehe, and are 
encouraged to continue by our observation of the structural changes 
resulting from our efforts, and we must be guided and encouraged in the 
same way while attempting to improve this condition. We cannot rely 
entirely on restored function as evidence, for these people are more 
miserable than the blind, when they become profoundly deaf, without 
the element of maddening tinnitus which is so often present, and which 
so wears on the physical strength and the mental equilibrium, ceasing 
neither day nor night, that it must be an important factor in the causa- 
tion of insanity and suicide. From a humanitarian view the result 
striven for is great, and any one who has even temporarily suffered in 
this way can appreciate what it must mean to be without hope of relief— 
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