EXPERIENCES OF AN EAR, NOSE AND THROAT SPECIALIST AT ONE OF THE BASES. BY
Captain
J.
Our work here is those of
as
which
was
a
P. I.
Harty, R.A.M.C.T.,
arranged
civil clinic.
sanctioned
on
practically
We have the
by the
D.D.M.S.
the
F.R.C.S.
same
principle
out-patient system,
owing
to the
numb
for consultation from the various hospi treatm while those from the base depots, etc., receive daily
of
cases
,
attending
in addition where necessary. We have a special hut set
department.
holding
This is divided
80 to 100, and
that two officers
can
an
out pat apart for the into a waiting-room capabl
examination
screened
room
work there, and also
a
dark
o
room
trans-illumination.
month after
y
Captain Just came to assist me about a much as arrival, and even with his help the work is as can accomplish. an Our largest number of new cases in one day was 52, time one the number attending for daily treatment at one day reserve averaged 120. We found it necessary to week for operations, seeing no new cases on that day, daily attendances only receiving treatment. the perio The appended statistics are compiled for January 1st to May 15th, 1916, inclusive.
CAPTAIN
40
J. P. I.
1.
Full list of cases, their
2.
List of
HARTY
diagnosis
and
disposal. operations. One great advantage which we have is that the treatment is administered daily by skilled hands, and not left to the patients themselves. This is especially valuable in the treatment of one of the biggest leakages of the army, viz. middle-ear suppuration, and we have found that in suitable cases these dry up soon, and we are able to return to duty a number of men who were large previously being sent to England. We have been very lucky in obtaining the assistance of a most capable sister, and one who takes an interest in the work.' I
fortunate
was
modelled
enough the
diagrams Bristol Royal Infirmary, on
to obtain
same
differences and
a
very
only
to
frequent, are working
on can
of
indication
a
the
Sinusitis is
we
can
nasopharynx is made, and on exploration is undertaken and the case of suspected frontal sinusitis. which appear amongst our statistics
nose
casualties
and
following
:?
Gunshot wounds of the face,
B.
Results of shell concussion ears.
little less
say without hesitation that them, as in every case a complete I
A.
and external
by
a
the fact that
sinus
consulted in
war
comprise
enlistment.
be accounted for
missing
examination of the
The
civilian clinic the
almost
with males.
a case
skiagrams
work,
great. complete absence of malignant cases small percentage of tuberculous. This discrepancy be expected on account of the age limit and the an
and this
any
a
our
and concise.
not
are
chest examination
it is not
complete
cases
the statistics with those of
We have is
cards with
those used at the
as
and these have minimised
and made the records of the
Comparing
principle
printed
jaws
on
and
ears.
the middle internal
41
EXPERIENCES AT A BASE HOSPITAL.
The neurasthenic
C.
which is
fairly
We have
complication functional aphonia,
common.
a
great
preponderance
suppuration, possibly due to
the
of cases of middle-ear
difficulty in eliminating
such
fully at the medical examination for enlistment, had ha\e this complaint 50 per cent, of those examined with it when they joined. of the It may be of interest to summarise our experience be divided results of shell concussion on the ears. They may as
cases
into the
following groups
:?
Otitis externa without
1.
implication of
the middle
estimate, but
percentage of these cases is hard to undoubtedly some are due to this cause. 2. Rupture of the membrana tympani. Of these three sub-groups may be mentioned The
(c)
:
without infection of the middle
(rt) Perforation (&) Perforation
ca>.
ear.
with infection.
Perforation
complicated
with
nerve
deafness.
With regard to the rupture, we have found that practically of the form is the kidney shape, with the apex
pathognomic
the handle of the malleus at the hilum. In
one case
I have
perforations, the smaller rather postero-superior quadrant, and one
seen two
being situated in the some small indicating it to have been due to direct violence, of the foreign body having been driven through as a result explosion.
The
larger
Infection is,
as
would be
above.
type described expected, fairly common owing
one was
of the
carried in either from is outside or from the meatus, which under war conditions with but Nerve deafness is uncommon
to the fact that
anything
the
force is taken It is
of dirt
are
aseptic.
perforation, internal
particles
ear
simple explanation being that the concussing
by
the membrane and its
in most
possible
rupture
saves the
cases.
that in the
perforation
cases
there is
a-
CAPTAIN J.
42
rapid
P.
I.
reflex action of the tensor
HARTY
tympani tightening
the
of the concussion is borne in
membrane, and the brunt
this way. It has been, however, our experience that nerve ?deafness without perforation is often associated with an
atrophic
condition of the membrana
tympani.
Nerve
3. deafness. This has been classified into two
sub-groups
:?
concussion.
(a) Auditory (b) Labyrinthine hemorrhage. We have not had the opportunity as
the main differences
seem
of
investigating these,
to be that the former will at all
partially recover after some months, while the latter is permanent. 4. Nerve deafness superimposed upon ears, either in a state of chronic suppuration, or with dried-up perforations, the results of earlier suppuration. events
We have had
a
fair number of these, and in the absence of
influence of the membrane the internal
the
protecting naturally suffers.
Subluxation
5.
of
the
stapes.
Two instances of the above have where there with
a
was a
inflation
markedly
negative Rinne,
combined with
clear
a
by means
come
under
indrawn membrane
and
a
history
our
of concussion.
Concussion
A
1
"the
.
nerve
a
cases :?
Internal Ears.
..
.
.
perforation
.
3 15
com-
deafness1
Subluxation on the left side and included in the above.
right
single
31
perforation without infection perforation with infection perforation without infection
bined with
side
of the Eustachian catheter cured these,
Nerve deafness Concussion
notice
on one
normal bone conduction
positive Rinne and perfect hearing resulting. Subjoined here are the statistics of these Shell Concussion Effects on the Middle and Concussion
ear
5 with
nerve
deafness
on
43
EXPERIENCES AT A BASE HOSPITAL.
Concussion perforation with infection combined with
nerve
Concussion chronic
&
deafness
nerve
deafness
suppurative
superimposed
on
old 10
otitis media
1
Subluxation of the stapes
83 Included in the above
illustrating Two
these
are two
types. up together.
men came
rather
On
ears,
non-infected and without any
perforations
nerve
cases
the first, he
examining
found to have the characteristic
was
interesting
in both His
involvement. him five
days history was that a trench mortar had burst but the first, near was man The second standing previously. near
he
was
buried by the explosion, and had
when he
was
free another trench mortar
to be
dug
exploded
Just
out.
and buried
second time, and sad to relate on extricating himself third burst quite close. This man on the right side had
him
a
a a
perforation, evidently produced by the first explosion, and a pronounced nerve deafness superimposed by the later explosions. On his left side he had
characteristic
concussion
?escaped
a
a
with
negligible
amount of
nerve
involvement and
subluxation of the stapes cured by inflation. With
regard
to the sinusitis cases, our
of the
explorations
maxillary and sphenoidal sinuses have been made by the suction syringe method of Watson-Williams, which has proved reliable. The actual number of explorations made has been
:?
Sinus. 75 13
Maxillary antra Sphenoidal
Negative
Result.
Result.
32
43 8
....
5
Sinus operations have been
advisable,
Positive
and if necessary the
performed
cases
where
thought
to
England
transferred
CAPTAIN
44 for
a
J. P.
I.
HARTY
continuance of treatment, but
returned to
operations exception,
been
fair number have been The intranasal
direct from here.
duty, cured, have
a
performed
frontal sinus
in
all
cases
with
one
in the late
stage where the osteomyelitis of the frontal bone had already started. This was treated by the external method with obliteration of the sinus, but unfortunately proved fatal owing to rapid extension of the osteomyelitis with infection of the meninges, etc. a
seen
anterior wall had necrosed and
The endonasal method of Watson-Williams used for very after
the frontal sinus, and
entering satisfactory, enabling short
a
The
period
statistics
of
our
us to return some cases to
duty
out.
daily washings a large number obstruction, especially
show
for nasal
has been
results have been
of
operations-
those due to
performed septal deflections. In this war clear nasal passages are absolutely essential, as when a man is wearing his gas helmet he is solely dependent on his nasal respiration. The history most frequently is that the man is unable to wear the gas helmet, or when he has it on that he is incapable of performing any active movement. I am including short notes
might
on a
few
cases
which I think
be of interest.
1.?Sergt. G. W. This man complained of pain in the left ear, especially after being on the rifle range. On examination he was found to have a small scar just in front of the left tragus, which he said was due to the removal of an accessory auricle in childhood. Otoscopy revealed a small horn-like ecchondrosis growing from the anterior meatal wall which curved inwards and almost touched the membrane. A patch Case
of hemorrhage was seen on the membrane at what must have been the point of contact during any excessive excursion of tfr? conducting mechanism. The ecchondrosis was successfully removed by the meatal route and the man returned to duty. On Case 2.?Lance-Corpl. M. Admitted here May ist. April 25th a trench mortar burst close to him, and a fragment was driven through the left side of the bridge of his nose,fracturing
Plate II.
Fig.
-
i,
Case 2.?Lateral
skiagram.
Nose to
right.
Viv
'w ftlW
9 '
i
..
wm
1
-
..
2.?Antero-posterior skiagram showing the shrapnel 2.?-Antero-posterior fragment in the right sphenoido-pituitary sphenoido-pitnitary region.
Fig. 2, Case
?'-
EXPERIENCES AT A BASE HOSPITAL.
45
the left nasal bone and making a distinct window. His mental condition was good, but lie was suffering from a ptosis of the right eye, and on more careful examination he was found to have right-sided complete ophthalmoplegia with anaesthesia oyer the distribution of the frontal nerve. Skiagram, prints of which
be attached, showed the irregular shaped foreign body to situated in the region of the pituitary fossa. On May 4th, under general anaesthesia and using Killian's long speculum, the missile
are
found to have tracked across the nose perforating the uppsr portion of the septum; it then passed through the right sphenoidal sinus, and the foreign body could be seen through a hole in the posterior wall of the sinus. Attempts to remove it with forceps and also with the magnet were unsuccessful. Hay 5th another attempt was made, and this time the aperture in the posterior sinus wall was carefully enlarged, and a rightangle seeker passed so as to curve behind the foreign body, .which was thus dislodged, and after some difficulty, owing to the depth, seized with a pair of nasal packing forceps and extracted. The dura mater on careful inspection seemed to be intact. The cavity was swabbed out with collosol argentum, and subsequently spraying with the same fluid frequently employed. The patient, although never feeling very bad, said he was much better, and a slight headache he had previously was
disappeared.
Captain Pringle examined the eye condition for me, and agreed with the ophthalmoplegia diagnosis. The fracture had evidently run into the sphenoidal fissure and implicated all the nerves. He still had at this later date, May 22nd, almost complete loss of all ocular movements. Paralysis of accommodation with a dilated pupil. "
Ptosis.
for
The vision is not impaired beyond what by the loss of accommodation. Visual fields full.
can
be accounted
Discs normal. Vessels normal.
movement of the globe is due to the external Whether this indicates the initial stage of recovery starting in the sixth nerve time alone will show, but Captain Hngle thinks the prognosis is bad. on The patient has been able to get about for some days, and ay 22nd I freshened up the edges and brought them together, closing the entrance wound.
The rectus.
slight
,
Case 3.?Private B. Shrapnel ball in right maxillary antrum. This man was seen on January 28th. He was orbit. wounded on January 10th, the ball entering the right at nucleation of the on January nth was
globe
performed
CAPTAIN J.
46
P. I. HARTY
the C.C.S. Admitted here February 7th. The skiagram show? clearly the size and position of the ball. Rhinoscopy revealed a perfectly clean and roomy right nasal cavity, but no sign of the foreign body. After careful localisation by stereoscopic radiology, operation was undertaken on February 13th. Under general anaesthesia an intranasal entrance to the antrum was made, and a little finger introduced could feel the foreign body partially fixed in the roof. It was easily dislodged, but owing to its size extraction was difficult, so the patient was taken into the X-ray room, and a forceps having been passed in, with the help of the screen it
was an easy matter to seize the ball and extract it, although the combined girth necessitated a strong pull when passing through the anterior naris. Recovery was very rapid, no temperature, and the antrum perfectly clean after a few washings out. The patient was sent to England on February 18th. Skiagram print attached.
This case, unfortunately, had Case 4.?Private M. termination. Admitted here April 30th.
fatal
a
struck by a rifle bullet in His eye was removed at the C.C.S. He came down with a tube inserted along the track of The tube was taken out and a glycerine and saline the bullet.
the
History.?-On April 27th left infraorbital region.
of Observation
Dates
he
was
r
I 36
8
Captain
J.
Our work here is those of
as
which
was
a
P. I.
Harty, R.A.M.C.T.,
arranged
civil clinic.
sanctioned
on
practically
We have the
by the
D.D.M.S.
the
F.R.C.S.
same
principle
out-patient system,
owing
to the
numb
for consultation from the various hospi treatm while those from the base depots, etc., receive daily
of
cases
,
attending
in addition where necessary. We have a special hut set
department.
holding
This is divided
80 to 100, and
that two officers
can
an
out pat apart for the into a waiting-room capabl
examination
screened
room
work there, and also
a
dark
o
room
trans-illumination.
month after
y
Captain Just came to assist me about a much as arrival, and even with his help the work is as can accomplish. an Our largest number of new cases in one day was 52, time one the number attending for daily treatment at one day reserve averaged 120. We found it necessary to week for operations, seeing no new cases on that day, daily attendances only receiving treatment. the perio The appended statistics are compiled for January 1st to May 15th, 1916, inclusive.
CAPTAIN
40
J. P. I.
1.
Full list of cases, their
2.
List of
HARTY
diagnosis
and
disposal. operations. One great advantage which we have is that the treatment is administered daily by skilled hands, and not left to the patients themselves. This is especially valuable in the treatment of one of the biggest leakages of the army, viz. middle-ear suppuration, and we have found that in suitable cases these dry up soon, and we are able to return to duty a number of men who were large previously being sent to England. We have been very lucky in obtaining the assistance of a most capable sister, and one who takes an interest in the work.' I
fortunate
was
modelled
enough the
diagrams Bristol Royal Infirmary, on
to obtain
same
differences and
a
very
only
to
frequent, are working
on can
of
indication
a
the
Sinusitis is
we
can
nasopharynx is made, and on exploration is undertaken and the case of suspected frontal sinusitis. which appear amongst our statistics
nose
casualties
and
following
:?
Gunshot wounds of the face,
B.
Results of shell concussion ears.
little less
say without hesitation that them, as in every case a complete I
A.
and external
by
a
the fact that
sinus
consulted in
war
comprise
enlistment.
be accounted for
missing
examination of the
The
civilian clinic the
almost
with males.
a case
skiagrams
work,
great. complete absence of malignant cases small percentage of tuberculous. This discrepancy be expected on account of the age limit and the an
and this
any
a
our
and concise.
not
are
chest examination
it is not
complete
cases
the statistics with those of
We have is
cards with
those used at the
as
and these have minimised
and made the records of the
Comparing
principle
printed
jaws
on
and
ears.
the middle internal
41
EXPERIENCES AT A BASE HOSPITAL.
The neurasthenic
C.
which is
fairly
We have
complication functional aphonia,
common.
a
great
preponderance
suppuration, possibly due to
the
of cases of middle-ear
difficulty in eliminating
such
fully at the medical examination for enlistment, had ha\e this complaint 50 per cent, of those examined with it when they joined. of the It may be of interest to summarise our experience be divided results of shell concussion on the ears. They may as
cases
into the
following groups
:?
Otitis externa without
1.
implication of
the middle
estimate, but
percentage of these cases is hard to undoubtedly some are due to this cause. 2. Rupture of the membrana tympani. Of these three sub-groups may be mentioned The
(c)
:
without infection of the middle
(rt) Perforation (&) Perforation
ca>.
ear.
with infection.
Perforation
complicated
with
nerve
deafness.
With regard to the rupture, we have found that practically of the form is the kidney shape, with the apex
pathognomic
the handle of the malleus at the hilum. In
one case
I have
perforations, the smaller rather postero-superior quadrant, and one
seen two
being situated in the some small indicating it to have been due to direct violence, of the foreign body having been driven through as a result explosion.
The
larger
Infection is,
as
would be
above.
type described expected, fairly common owing
one was
of the
carried in either from is outside or from the meatus, which under war conditions with but Nerve deafness is uncommon
to the fact that
anything
the
force is taken It is
of dirt
are
aseptic.
perforation, internal
particles
ear
simple explanation being that the concussing
by
the membrane and its
in most
possible
rupture
saves the
cases.
that in the
perforation
cases
there is
a-
CAPTAIN J.
42
rapid
P.
I.
reflex action of the tensor
HARTY
tympani tightening
the
of the concussion is borne in
membrane, and the brunt
this way. It has been, however, our experience that nerve ?deafness without perforation is often associated with an
atrophic
condition of the membrana
tympani.
Nerve
3. deafness. This has been classified into two
sub-groups
:?
concussion.
(a) Auditory (b) Labyrinthine hemorrhage. We have not had the opportunity as
the main differences
seem
of
investigating these,
to be that the former will at all
partially recover after some months, while the latter is permanent. 4. Nerve deafness superimposed upon ears, either in a state of chronic suppuration, or with dried-up perforations, the results of earlier suppuration. events
We have had
a
fair number of these, and in the absence of
influence of the membrane the internal
the
protecting naturally suffers.
Subluxation
5.
of
the
stapes.
Two instances of the above have where there with
a
was a
inflation
markedly
negative Rinne,
combined with
clear
a
by means
come
under
indrawn membrane
and
a
history
our
of concussion.
Concussion
A
1
"the
.
nerve
a
cases :?
Internal Ears.
..
.
.
perforation
.
3 15
com-
deafness1
Subluxation on the left side and included in the above.
right
single
31
perforation without infection perforation with infection perforation without infection
bined with
side
of the Eustachian catheter cured these,
Nerve deafness Concussion
notice
on one
normal bone conduction
positive Rinne and perfect hearing resulting. Subjoined here are the statistics of these Shell Concussion Effects on the Middle and Concussion
ear
5 with
nerve
deafness
on
43
EXPERIENCES AT A BASE HOSPITAL.
Concussion perforation with infection combined with
nerve
Concussion chronic
&
deafness
nerve
deafness
suppurative
superimposed
on
old 10
otitis media
1
Subluxation of the stapes
83 Included in the above
illustrating Two
these
are two
types. up together.
men came
rather
On
ears,
non-infected and without any
perforations
nerve
cases
the first, he
examining
found to have the characteristic
was
interesting
in both His
involvement. him five
days history was that a trench mortar had burst but the first, near was man The second standing previously. near
he
was
buried by the explosion, and had
when he
was
free another trench mortar
to be
dug
exploded
Just
out.
and buried
second time, and sad to relate on extricating himself third burst quite close. This man on the right side had
him
a
a a
perforation, evidently produced by the first explosion, and a pronounced nerve deafness superimposed by the later explosions. On his left side he had
characteristic
concussion
?escaped
a
a
with
negligible
amount of
nerve
involvement and
subluxation of the stapes cured by inflation. With
regard
to the sinusitis cases, our
of the
explorations
maxillary and sphenoidal sinuses have been made by the suction syringe method of Watson-Williams, which has proved reliable. The actual number of explorations made has been
:?
Sinus. 75 13
Maxillary antra Sphenoidal
Negative
Result.
Result.
32
43 8
....
5
Sinus operations have been
advisable,
Positive
and if necessary the
performed
cases
where
thought
to
England
transferred
CAPTAIN
44 for
a
J. P.
I.
HARTY
continuance of treatment, but
returned to
operations exception,
been
fair number have been The intranasal
direct from here.
duty, cured, have
a
performed
frontal sinus
in
all
cases
with
one
in the late
stage where the osteomyelitis of the frontal bone had already started. This was treated by the external method with obliteration of the sinus, but unfortunately proved fatal owing to rapid extension of the osteomyelitis with infection of the meninges, etc. a
seen
anterior wall had necrosed and
The endonasal method of Watson-Williams used for very after
the frontal sinus, and
entering satisfactory, enabling short
a
The
period
statistics
of
our
us to return some cases to
duty
out.
daily washings a large number obstruction, especially
show
for nasal
has been
results have been
of
operations-
those due to
performed septal deflections. In this war clear nasal passages are absolutely essential, as when a man is wearing his gas helmet he is solely dependent on his nasal respiration. The history most frequently is that the man is unable to wear the gas helmet, or when he has it on that he is incapable of performing any active movement. I am including short notes
might
on a
few
cases
which I think
be of interest.
1.?Sergt. G. W. This man complained of pain in the left ear, especially after being on the rifle range. On examination he was found to have a small scar just in front of the left tragus, which he said was due to the removal of an accessory auricle in childhood. Otoscopy revealed a small horn-like ecchondrosis growing from the anterior meatal wall which curved inwards and almost touched the membrane. A patch Case
of hemorrhage was seen on the membrane at what must have been the point of contact during any excessive excursion of tfr? conducting mechanism. The ecchondrosis was successfully removed by the meatal route and the man returned to duty. On Case 2.?Lance-Corpl. M. Admitted here May ist. April 25th a trench mortar burst close to him, and a fragment was driven through the left side of the bridge of his nose,fracturing
Plate II.
Fig.
-
i,
Case 2.?Lateral
skiagram.
Nose to
right.
Viv
'w ftlW
9 '
i
..
wm
1
-
..
2.?Antero-posterior skiagram showing the shrapnel 2.?-Antero-posterior fragment in the right sphenoido-pituitary sphenoido-pitnitary region.
Fig. 2, Case
?'-
EXPERIENCES AT A BASE HOSPITAL.
45
the left nasal bone and making a distinct window. His mental condition was good, but lie was suffering from a ptosis of the right eye, and on more careful examination he was found to have right-sided complete ophthalmoplegia with anaesthesia oyer the distribution of the frontal nerve. Skiagram, prints of which
be attached, showed the irregular shaped foreign body to situated in the region of the pituitary fossa. On May 4th, under general anaesthesia and using Killian's long speculum, the missile
are
found to have tracked across the nose perforating the uppsr portion of the septum; it then passed through the right sphenoidal sinus, and the foreign body could be seen through a hole in the posterior wall of the sinus. Attempts to remove it with forceps and also with the magnet were unsuccessful. Hay 5th another attempt was made, and this time the aperture in the posterior sinus wall was carefully enlarged, and a rightangle seeker passed so as to curve behind the foreign body, .which was thus dislodged, and after some difficulty, owing to the depth, seized with a pair of nasal packing forceps and extracted. The dura mater on careful inspection seemed to be intact. The cavity was swabbed out with collosol argentum, and subsequently spraying with the same fluid frequently employed. The patient, although never feeling very bad, said he was much better, and a slight headache he had previously was
disappeared.
Captain Pringle examined the eye condition for me, and agreed with the ophthalmoplegia diagnosis. The fracture had evidently run into the sphenoidal fissure and implicated all the nerves. He still had at this later date, May 22nd, almost complete loss of all ocular movements. Paralysis of accommodation with a dilated pupil. "
Ptosis.
for
The vision is not impaired beyond what by the loss of accommodation. Visual fields full.
can
be accounted
Discs normal. Vessels normal.
movement of the globe is due to the external Whether this indicates the initial stage of recovery starting in the sixth nerve time alone will show, but Captain Hngle thinks the prognosis is bad. on The patient has been able to get about for some days, and ay 22nd I freshened up the edges and brought them together, closing the entrance wound.
The rectus.
slight
,
Case 3.?Private B. Shrapnel ball in right maxillary antrum. This man was seen on January 28th. He was orbit. wounded on January 10th, the ball entering the right at nucleation of the on January nth was
globe
performed
CAPTAIN J.
46
P. I. HARTY
the C.C.S. Admitted here February 7th. The skiagram show? clearly the size and position of the ball. Rhinoscopy revealed a perfectly clean and roomy right nasal cavity, but no sign of the foreign body. After careful localisation by stereoscopic radiology, operation was undertaken on February 13th. Under general anaesthesia an intranasal entrance to the antrum was made, and a little finger introduced could feel the foreign body partially fixed in the roof. It was easily dislodged, but owing to its size extraction was difficult, so the patient was taken into the X-ray room, and a forceps having been passed in, with the help of the screen it
was an easy matter to seize the ball and extract it, although the combined girth necessitated a strong pull when passing through the anterior naris. Recovery was very rapid, no temperature, and the antrum perfectly clean after a few washings out. The patient was sent to England on February 18th. Skiagram print attached.
This case, unfortunately, had Case 4.?Private M. termination. Admitted here April 30th.
fatal
a
struck by a rifle bullet in His eye was removed at the C.C.S. He came down with a tube inserted along the track of The tube was taken out and a glycerine and saline the bullet.
the
History.?-On April 27th left infraorbital region.
of Observation
Dates
he
was
r
I 36
8
