Owing to the prevalence of the grippe since 1889, the list of ear troubles has been swelled. The habit of diving or ducking the head while bathing is re

RATIVE OTITIS MEDIA.

BY J. H. M'CASSY, M.A., M.D,

DAYTON, 0.

Purulent otitis media should receive the best skill and attention of the general practitioner as well as that of the aural surgeon. Judging from the large number of deaf mutes and persons with perforated drums, defective hearing and with suppuration of the middle ear, one is forced to say that either patients or physicians are derelict in their duty toward these cases. Suppuration in the middle ear shows a deathrate of 2 per cent., and is nearly as fatal a disease as typhoid fever. Every laudable effort should be put forth to remove the fountain of danger, for no one can tell the moment a slight cold may precipitate a fatal mastoiditis, meningitis or septicemia. Persons having foul and menacing discharge of pus, emanating, more or less constantly, from their ears, should leave no stone unturned to have it stopped, else they voluntarily slumber over a volcano. Away with that superstition, existing among many of the laity, that running from the ear is beneficial to its victim, giving vent to poisonous matter, which, if checked, might cause other diseases! The longer you dally with suppuration of the middle ear the greater will be the loss of hearing, and even life itself.

CAUSATION.

During the winter and spring, when sudden changes occur in the temperature, children frequently have earaches, which are the forerunners of otorrhea.

in the middle ear. Even hunting-dogs that dive have otitis media and become deaf. Scarlet fever, measles, whoopingcough, diphtheria, naso-pharyngeal catarrh, dentition, phthisis, etc., stand in causal relation to suppuration in the middle ear. The germs pass from the throat to the ear through the Eustachian tube.

TREATMENT.

As in all other branches of surgery, great diversity of opinion exists as to the treatment of these cases. There are physicians who are so radical and impatient that they scarcely wait for the results of antiseptic treatment for one month until they remove the ossicles and tympanum. There are others who go to the opposite extreme, are slow, and rely upon nature to separate the sequestra and do its own curetting, and as a result they have frequently to affix their signature to a death-certificate of such patients. Good discrimination and sound surgical judgment are necessary at this time, in order to adopt a happy medium between the two extremes. In most cases of prolonged and rebellious suppuration in the middle ear, it will likely be found that the ossicles will be in a state of caries or necrosis. The incus will generally be the first attacked, then the malleus, and finally the stapes, with the exception of the head, which is rarely affected. Every case should be given a fair trial with the antiseptic treatment; if this fails, it is then our duty to remove the necrotic membrane, with its carious ossicles. This will give free drainage and permit the proper

application of medicine. Rapid repro- | duction of the membrana tympani after thorough removal is unusual. Caries or necrosis in the tympanum should be dealt with in the same manner as in other parts of the body. It is bad practice to pack the external auditory canal with powders and cotton and imprison decomposing material.

The following are the prevailing types of suppurative inflammation of the middle ear:

1. Acute otitis media purulenta. 2. Chronic otitis media purulenta without caries or necrosis.

3. Chronic otitis media purulenta

with caries and necrosis.

CASE I.

In March, 1889, Master D., aged ten years, who was just recovering from the grippe, had mucous râles scattered through his bronchial tubes and a good deal of naso-pharyngeal catarrh. For several days he complained of fulness in his left ear, tinnitus and impairment of hearing, being able only to hear the watch on its being pressed against his ear. His temperature ranged from 100° to 102° and his pulse rate was 120 per minute. His appetite was poor, his tongue coated, and bowels constipated. At the end of the fourth day the pain in his ear and head, which radiated to the angle of the jaw and to the pharynx along the Eustachian tube, was so severe as to leave no doubt that the middle ear was seriously involved. Inspection showed the membrana tympani hyperemic at first; later it became lustreless and opaque. The long handle of the malleus was obscured from congestion, and the white point of the short process was the only visible landmark. The membrane became sodden and bulging, rupture was threatend, and, to avoid which, a paracentesis in the posterior and inferior segment was made. Inoffensive, whitish, creamy pus flowed freely from the ear. The fever and pain were controlled by calomel purge, phenacetin, Dover's powders, and a cold pack on the left side of the head. The ear was syringed out twice or thrice daily with warm soda or sublimate solution (the latter 1 to 10,000). After

cleansing the ear a few drops of warm solution of boric acid and sulphate of zinc, fifteen grains of the former to one grain of the latter to the ounce, were dropped into the ear. The external auditory meatus was closed with cotton. was practiced once Politzerization daily to keep the Eustachian tube open and equalize the air pressure in the ear. The discharge of pus ceased in one month, then the preforation closed. After this a dry dressing, consisting of boric acid or aristol, was used.

CASE II.

Chronic Suppuration of the Middle Ear without Caries or Necrosis.

Mrs. T., aged forty years, was referred to the writer by Dr. Taylor, in April, 1896. The patient was just recovering from acute tonsillitis and She suffered from acute bronchitis. which intense pain in her left ear, radiated to the occipital and frontal regions. She also had tinnitus and impairment of hearing. The membrane was reddened and bulging. It seemed that suppuration was threatening. Small doses of calomel kept the bowels and kidneys acting freely. Phenacetin controlled the fever and headache, and cold packs, alternating with warm ones, were applied to the ear. Politzerization, practiced twice daily, kept the Eustachian tube patulous, through which the serous fluid of the incipient otitis media drained. doubtedly an attack of otitis media arrested in the serous stage. Then special attention was given to the otorrhea of her right ear. She never had measles, but at the age of ten she had had scarlet fever, and since that time taking cold would precipitate earache and otorrhea several times a year. She always wore a plug of cotton in this ear for "protection." She could only hear the watch on its being pressed against her ear. She could not hear an ordinary conversation with her right ear. She had occasional attacks of tinnitus and vertigo. The vibrating tuning-fork placed on her vertex was heard quite well in the right ear. The posterior two-thirds of the membrana tympani was gone; the ossicles were

This was un

visible and intact; granulations were abundant and the discharge was foul. The "perforation whistle" was elicited on inflation.

Treatment. The ear was cleansed twice daily with warm water that had boiled, containing a little boric acid, permanganate of potassium, or corrosive sublimate. The granulations were touched every few days carefully with saturated solution of chromic acid or a 4 to an 8 per cent. solution of nitrate of silver. This soon removed all the granulations in sight. Still, the discharge did not cease. Alcohol was instilled into the ear, but this caused so much pain and vertigo, that it was abandoned. The saturated boric acid solution containing one grain of sulphate of zinc to the ounce was used after each cleansing for a few weeks, but the discharge did not entirely cease. Then several drops of an.8 per cent. solution of nitrate of silver were put into the ear with a dropper and allowed to remain in for a few minutes, the head being turned in various directions to permit the drops to pass well into the ear and even down the Eustachian tube. The ear was then syringed out, commencing as the patient raised her head to the erect position. The patient said she could feel the medicine come into her throat. Under this treatment suppuration ceased in four weeks, with satisfactory improvement to the hearing.

CASE III.

Chronic Otitis Media with Caries and Necrosis of the Ossicles and the Wall of the Tympanum.

Mr. D., aged twenty-five years, having a good family history, had had a purulent discharge from his left ear for ten years, the origin of which is unknown. Half of the drum membrane was gone. The handle of the malleus was almost destroyed through necrosis; the osseous ring was roughened by caries. He suffered a great deal from earache, tinnitus, and vertigo. The watch pressed against his ear could not be heard. There was a discharge of offensive pus from his ear.

Treatment. The treatment described in Case II, with the addition

ལ་

of tr. iodine and a 50 per cent. solution of trichloracetic acid, was used for two months, as the patient preferred to try the effects of thorough antiseptic treatment before submitting to an operation. Local treatment failed to check the discharge. Under general anesthesia the rest of the drum and the necrosed incus and malleus, with some granulations from the attic, were removed, and the osseous ring was curetted. The ear was cleansed twice daily with saturated boric solution, then dried and closed with pledgets of cotton. The discharge ceased in four weeks, and has not returned. The watch can now be heard at a distance of six inches.

REMARKS.

The sublimate solution should not be used very strong nor very frequently, because it is irritating; besides, it may pass down the Eustachian tube into the throat and cause poisoning. Powder should not be blown into the ear, especially if the perforation is small and high up, because it may lodge in some inaccessible crevice, form into crusts and cause irritation. Peroxide of hydrogen is an unstable drug, and is often a positive irritant. It decomposes on heating, which necessitates its employment at the temperature of the surrounding atmosphere. The writer rarely uses it in the ear except as a test for pus. A saturated solution of trichloracetic acid carefully applied will act like a charm in removing granulations, but is more liable to be followed by adhesions than a solution of chromic acid or nitrate of silver.

It is a notable fact that suppuration is abundant in wounds during or following the grippe. It is difficult to get fresh wounds to unite by first intention, because the germ of la grippe is a pus-producer. In Case I pus-formation was abundant and difficult to control.

Acute otitis media is oftener of microbic origin than any other disease of the ear. The germ goes from the naso-pharynx to the ear through the Eustachian tube.

In the great majority of cases of an acute inflammation of the middle ear sufficient depletion can be secured by