THE MEDICAL AND SURGICAL TREATMENT OF SUPPURATIVE AFFECTIONS OF THE

MIDDLE EAR.

CORNELIUS WILLIAMS, M.D., ST. PAUL, MINN.

Before entering on the discussion of the treatment of suppurative diseases of the middle ear, it would perhaps be as well to say a few words as to the diagnosis in such cases. This is not entirely superfluous either, for it is possible to make mistakes in diagnosticating the condition actually existing in ear diseases, and in this connection I am reminded of an incident of some twenty years ago, bearing upon this point. It was at a meeting of a medical society not far to the southward of this city, and the author of this paper was present, when during a short period when nothing of interest was presenting, a gentleman present arose and proceeded to discant upon the very simple nature of ear diseases in general, but especially upon the easy diagnosis and the facility of treatment of a running ear. In passing it may be said that very experienced aural surgeons have called attention to the fact that a differential diagnosis is not always made as between an otitis media and a furuncular inflammation of the external auditory canal, and I may as well say here that the treatment of an otitis media, as outlined by the gentleman mentioned, could never cure the disease in question, but that I doubt not that many cases might get well under such treatment or indeed, in spite of it. The same may also be said of a similar treatment, the method of dropping medicated solutions into the ear, used by many general practitioners and aural surgeons. In the matter of the medical treatment of an acute otitis much can really be lone. Let us suppose that an otoscopic examination has revealed the existence of an acute inflammation of the middle car and that there is a reddened drum membrane, that it is swollen, that there may be partial displacement of the mem

brane outward, that there is heat and pain in the middle ear, and all this attended by a certain amount of constitutional disturbance. What are the best means of combating this condition without resorting to a major surgical interference? First, the patient should be put to bed, and very thoroughly purged by calomel and salines. He should be quickly brought under the influence of opium, giving it in whatever form that may be elected, in doses sufficient to entirely quiet the pain. The external auditory canal must be thoroughly cleansed with soap and water and then alcohol and water, lastly bichloride and finally sterile water. A steady gentle stream of warm sterile water may then be allowed to flow into the canal, completely filling it, and this can be kept up with a suitable apparatus for many hours, if need be, with but little danger of inducing a furuncular condition of the skin lining the canal, which condition is the bete noir of the surgeon in the treatment of affections of the middle ear. Further, a Leiter's coil, or simpler, an ice bag applied to the mastoid region, over a folded towel, is both grateful and exceedingly useful. The ice bag must be kept on for five or six hours continuously and then allowed to gradually get warmed before its removal, to avoid sudden change of temperature of the skin. The ice bag and the warm douche may be used simultaneously.

In a certain number of cases this treatment will result in aborting the inflammation, and if in spite of it, the morbid process should go on to suppuration, that process is much modified. If, however, the patient should not be seen by the physician until after the formation of pus, why then I know of no course to pursue, which more quickly relieves the distressing features of an acute inflammation of the middle ear, than that described above, even should the membrane have already perforated. The perforation must be enlarged so as to give free exit to pus. I have found the free use of salicylic acid in many cases, to be followed by excellent results, indeed, I am convinced that there is a condition often present, which is practically identical with that which prevails in acute rheumatism, and I seldom fail to bring the patient under the influence of the salicylates as soon as possible.

But let us suppose that the more acute stage of the disease has passed, and that the patient suffers from an established suppuration of the middle ear, what then shall be done? It should be borne in mind that there is a great swelling of the mucous membrane of the middle ear, and that the perforation is a small one, often pouting outward, and that the introduction of substances of whatever nature from without into the middle ear is extremely difficult of accomplishment, if it can be done at all, and do little good; then why should we attempt it? It has been advised to empty the middle ear by Valsalva's process, or by Politzer's inflation, both of very doubtful utility, for the manifest reason that these methods are very apt to force pus into the antrum as well as through the perforation. Washing through the eustachian tube is difficult and not safe. Aspiration into the external canal, or through the eustachian tube, though not dangerous, is not to be recommended because of the greater congestion which is thus produced.

There is really left, then, but one course to pursue, and that is worth more than all others put together. Frequent and complete cleansing of the external canal under thorough illumination gives more relief than any other procedure which can be adopted, for the reason that it best conduces to free drainage. The instillation of medicated solutions, or the insufflation of powders, in my experience, do no good and are sometimes harmful. Surgical measures are, after all, our chief reliance in the treatment of suppurative conditions of the middle ear, whether acute or chronic. Much has been written concerning the value of free incision of the drum mem · brane as a preventive of inflammation of the mastoid. I have done it often and I believe that it does some good, certainly it is sound surgery to relieve the pressure and to secure drainage in acute effusions in the tympanum, but I doubt if the operation on the drum membrane plays the prophylactic rôle which it has been credited with. The extension or not, of a morbid process from the tympanic space to the mastoid is entirely a matter of the bacillus which we have to deal with and the conditions which prevail at the time of its invasion. At some times and with some persons mastoid complications are

almost sure of occurrence if the middle ear is affected at all, whatever the bacillus. Some bacilli, however, would seem to be much more active than others; the streptococcus, the pneumococcus and staphylococcus, in order, are oftenest found in severe and rapidly produced mastoiditis. It is not at all infrequent to have a simultaneous infection of middle ear and mastoid; a mastoiditis without perforation of the drum membrane is often seen and demands immediate action. With some surgeons no time is spent in waiting, but the mastoid is opened as soon as microscopical examination shows the presence of the streptococcus. It will be in place here to speak of incisions of the membrana tympani. You have all seen the little lanceshaped needle which is called paracentesis knife. It would better not be used. Operations on the tympanic membrane should never be done except under an anesthetic, and then a very small, sharp bistoury is the best instrument. The cut should not involve the posterior wall of the tympanum and is preferably made in the posterior and inferior quadrant of the membrana tympani, and should include the skin and periosteum of the canal as well. There are certain dangers incurred in thrusting a knife through the drum membrane. The patient may move or the physician may go further than he has intended, with the result that the facial nerve may be cut, the internal carotid or the jugular vein may be wounded, and death has resulted from such a misadventure. It is true enough that the anatomical peculiarity, which makes such accidents possible, is present in only a small percentage of cases, yet there is this danger, and it should not be lost sight of.

If there is a mastoiditis the mastoid antrum should be opened. There are cases in which the mastoid is affected and probably there is a pus formation in the antrum and cells and which gets well, apparently, without operation. Such cases have been published and I have seen a few of them myself, but they are rare. The bacillus of infection in such instances is probably not very virulent. The fact that some cases do get well if left alone can not be a sufficient argument as against the utility of an early operation. An early operation, as soon as the diagnosis is assured in fact, has very much to commend

it. Not the least in importance is the fact that it effectually and absolutely cures the disease, with the least damage to the organ of hearing of any other form of treatment, and on that account alone would be justifiable in every severe case of suppuration of the middle ear, even if there were no implication of the mastoid at all. How important a consideration this is, may be best appreciated when we survey the results which ensue in consequence of delayed operation; as seen in the thousands of running ears, ears with permanent perforations with or without constant discharge, and the consequent loss of hearing, and the ever menace to life which these cases present. I wish to qualify my statement as to the curative effect of the mastoid operation in this far only. The operation must be thoroughly done and in a surgical manner. Mastoidectomy which stops with the mere opening of one or more of the more or less superficial cells, and which stops short of the antrum, can not be called a thorough operation, and while it often arrests the disease to all appearances, as often fails in that even. Further, the opening of the antrum alone frequently leaves diseased portions of the bone, even collections of pus in the more distant parts of the process, which may give rise later to serious disturbance. To show the beneficent effect of a thoroughly-done mastoid operation I will cite two cases, operated upon by me on Monday and Tuesday of last week the one a boy of nine, with a streptococcus infection, had had but little discharge from ear at any time; his temperature was 105° when he was placed on the operating table, there was great nervous irritation as shown by twitching of various groups of muscles, etc. There was pus in the cells and antrum; temperature 99.5° when carried to his room. The wound is nearly entirely closed to-day, membrana tympani nearly normal in appearance; the discharge stopped two days after operation. Second case a child of twenty-six months, with great edema over mastoid, which had come on over night, high temperature. There was pus in quantity in the antrum. All discharge from the ear has ceased several days ago and the wound is rapidly closing. In the one case, the baby, an operation would be indicated to most surgeons, but many such