Chapter L: Introduction: The object of the following essay is to give, as far as (6)

TREATMENT.--The main point is to thoroughly remove the parasite. This is best effected by the use of warm water and the syringe, carefully picking off any small portion that may remain by the forceps or curette. My practice is then to fill up the external canal with alcohol, allowing it to remain a few moments, and then to carefully dry the canal by the aid of styptic cotton. This procedure may have to be repeated every second day for a number of times until the growth is entirely destroyed. Wreden recommends the use of the hypochlorate of lime in the strength of one or two grains to the ounce of water, the salt to be freshly dissolved in water at each application. The condition of the middle ear and the integument of the external canal is to be considered after the removal of this growth, and treated as indicated by the state of the case.

2. INSECTS IN THE EXTERNAL AUDITORY CANAL.--Cases of this character occur frequently during the summer season to persons who by lying on the ground give insects an opportunity to crawl into the external canal. The common house-fly also affects an entrance into the canal quite often; also during the summer it is not uncommon to find grubs or larvæ in the canals of patients suffering from suppurative inflammation of the middle ear resulting from the deposit by insects of their eggs in the moist coverings of the canal. The movements of insects in the sensitive {816} external ear cause great pain to the patient, and their removal is sometimes difficult. For instance, the grub is provided with two hooks, by means of which it adheres tenaciously to the skin, so that it may be necessary to remove each one separately with the forceps. The quickest method of removal, as a rule, is to wash out the insect by the use of warm water and a syringe; and if this is not at hand the insect can be drowned by filling the canal with water, olive oil, or some demulcent liquid.

OTHER VARIETIES OF FOREIGN BODIES, such as grains of corn, beans, peas, cherry-stones, beads, buttons, pieces of slate-pencil, are found in the external canal, and the symptoms that are present arise partly from the presence of the body, but more frequently from the irritation produced by attempts at removal.

SUBJECTIVE SYMPTOMS.--Difficulty of hearing, often due to the foreign body filling up the external canal and thus excluding all sound-vibrations. Tinnitus aurium and vertigo are often present, and caused by pressure of the body on the tympanic membrane with resulting abnormal labyrinthine pressure; also a variety of reflex conditions are noted as a result of the presence of a foreign body in the external canal, such as coughing and vomiting, partial paralysis, etc.

OBJECTIVE SYMPTOMS.--The appearance of the external canal will depend greatly upon the amount of pressure that the foreign body has exerted. For instance, a body loosely lying in the canal will irritate but little; on the contrary, a hard body like a cherry-stone firmly impacted in the canal will quickly cause a severe inflammation.

DIAGNOSIS.--As a rule, the foreign body can be readily seen with the aid of the mirror and speculum, unless the canal has become swollen to such an extent as to hide the body from sight. Probing and such-like procedures are not advisable.

TREATMENT.--The question comes up if it is good practice to make an attempt at immediate removal of a foreign body if the external canal is in a condition of acute inflammation. Unless grave head symptoms are present it is often good practice to delay, and reduce the inflammation by proper treatment, and then remove the foreign body. In other words, there is more risk by a forcible removal during a stage of acute inflammation than to permit the foreign body to remain until the inflammatory stage is past. Numbers of cases are on record where foreign bodies have remained for years in the external canal without causing serious sequelæ. Also, be sure a foreign body really exists in the canal, as it is not uncommon for patients to come with the statement that such is the case, and yet no foreign body has been discovered.

The majority of foreign bodies can be removed by the use of the syringe and warm water. The impacted bodies--and particularly those having a hard, smooth surface--present the greatest difficulties. A good plan is to try first the syringe and warm water, and if not successful try with a toothed angular forceps to grasp the body. If, as is often the case, it is found that the forceps slips off the body, then the curved blunt hook is to be used. This can be passed by the body and then turned on its axis, so that the hook is firmly placed behind it, and then a slow upward movement will often dislodge the body. On some occasions I have used two hooks, holding the body between them, and thus dragging it out. It is also better to desist after a fair trial until a succeeding day, rather {817} than make excessive efforts at removal, which will often cause violent inflammation to follow. After the body is dislodged examine the condition of the tympanic membrane, as this is often found to be perforated by the foreign body.

Diseases of the Middle Ear.

ANATOMY.--The cavity of the middle ear is of small dimensions: antero-posterior diameter, 13 mm.; vertical diameter at the anterior part, 5.8 mm.; vertical diameter at the posterior part, 15 mm.; transverse diameter at the anterior part, 3-4.5 mm.; transverse diameter at the opposite drumhead, 2 mm. (Von Tröltsch). It is situated in the petrous portion of the temporal bone and surrounded by bony walls, with the exception of the opening covered by tympanic membrane and the opening of the Eustachian tube, having a mucous periosteal covering, very thin, transparent, and colorless. This membrane covers not only the tympanic cavity, but is reflected over the chain of small bones and tendons of the tensor tympani and stapedius muscles. It is essentially a mucous membrane, and may be considered a continuation of the naso-pharyngeal mucous membrane reflected through the Eustachian tube to the middle-ear cavity; also subject to the same pathological changes as other mucous membranes.

The tympanic cavity normally is an air-filled cavity, and allows of free vibration of the tympanic membrane and its ossicles, as well as the membrane covering the oval and round foramina; and it is readily understood that any interference with the vibration of this sound-conducting apparatus will at once affect the hearing.

Its arterial blood is supplied from the middle meningeal, stylo-mastoid, ascendant pharyngeal, posterior auricular, tympanic, and internal carotid arteries. These freely anastomose with each other. The veins pass internally through minute openings of the petrosal squamous fissure to the veins of the dura mater, and thence into the superior petrosal sinus, and also externally into the venous ring surrounding the tympanic membrane, and also to the veins of the meatus (Schwartze). This is important to bear in mind, as furnishing an easy passage for the extension of middle-ear inflammation to the brain membranes.

The nerves forming the tympanic plexus are as follows: The mucous membrane is supplied by the tympanic plexus, formed from the tympanic branch of the petrous ganglion of the glosso-pharyngeal nerve--from the branch of the superficial petrosal and branches of the sympathetic nerve. The otic ganglion receives fibres from the inferior maxillary nerve, from the auriculo-temporal nerve, and from the sympathetic plexus, and it is distributed to the tensor tympani and tensor palati muscles.

The mastoid cells lead directly from the tympanum. They consist of one large opening, the antrum, and the lower mastoid cells. These cells consist of a large number of varying-sized cavities, and are enclosed by a dense layer of bone. The mucous membrane lining these cells is a direct extension of the tympanic membrane, and liable to the same pathological conditions as that mucous membrane.

{818} The Eustachian tube connects the cavity of the tympanum with that of the naso-pharynx, and is mainly intended for the introduction of air into the tympanic cavity. It has a length of 35 mm., partly bone (11 mm. in length), partly cartilaginous (24 mm. in length). The pharyngeal opening is 8 mm. high and 5 mm. wide; the tympanic orifice, 5 mm. high and 3 mm. wide (Schwartze). The mucous membrane lining this canal is a continuation of that of the naso-pharynx, and affords an easy way for the transmission of disease from the naso-pharynx to the middle ear. The Eustachian tube at rest is probably closed, although this is a matter still discussed; but it is essential for normal hearing that the air-pressure exerted on the tympanic membrane through the external auditory canal should be equalized by that exerted through the Eustachian tube. This necessitates the opening of the tube from time to time for free admission of air into the tympanic cavity. This is accomplished by the action of the musculus dilator tubæ, the tensor veli palatini, and the salpino-pharyngeus muscle. In the act of swallowing the tube opens; also, if the nostrils are closed and the act of swallowing is performed, air will be pumped out of the middle ear; on the contrary, if the nostrils are open air will be forced into the middle ear.

Diseases of the middle ear can involve the superficial layers of the middle-ear mucous membrane only, and may be of a catarrhal character. Hyperæmia and swelling of the epithelial cells, with increased mucous secretion, will be found. Later on, if the inflammation assumes a higher degree, a serous fluid will be profusely poured out, with lessening of the mucous secretion. When the deeper epithelial cells are involved, then pus-cells often appear, and a suppurative process becomes established, with frequent destruction of the soft tissues of the middle ear.

These different grades of inflammation are seldom found distinct, but run one into another. A case can start as a pure catarrhal inflammation; this, after attaining its acme, may end in recovery or degenerate into a chronic catarrh; or, on the contrary, it may advance into an acute purulent inflammation with a subsequent chronic stage.

CAUSES OF INFLAMMATION OF THE MIDDLE EAR.--Change of temperature, causing a sudden cooling of the body, is a frequent cause of this disease; for instance, exposure to wind from a partly-open window, a sudden rush of cold water into the external canal, as in surf-bathing, etc. Irritating foreign bodies in the external auditory canal may also cause this disease.

But inflammation of the middle ear occurs most frequently as a sequela of diseases affecting the general body. Among these may be mentioned, in order of their relative importance--

1. Scarlet Fever.--This disease is apt to cause the purulent form of middle-ear inflammation, and often of a very grave character. The ear complication can occur during the existence of the rash or immediately after its cessation (Thomas), and may run a rapid course, causing destruction of the tympanic membrane and middle-ear ossicles. Destruction of the facial nerve in its passage through its bony canal is not infrequent. Wendt has noticed in severe cases that the periosteum of the mastoid process, also that of the squamous and petrous portions, may participate in the purulent process, and end in subsequent caries of the bone. The severity of the ear complication will largely depend upon the condition {819} of the naso-pharyngeal mucous membrane. Light attacks of scarlet fever with slight throat symptoms would most probably cause slight irritation of the middle-ear mucous membrane, while the anginose variety would cause most violent inflammatory sequelæ.

2. Measles is apt to cause the catarrhal variety of middle-ear inflammation rather than the purulent form. It occurs during and immediately after this eruption, and is a direct continuation of the naso-pharyngeal inflammation viâ the Eustachian tube. Hearing, as a rule, is diminished, due to the swollen mucous membrane of the Eustachian tube and middle ear, and also to fluid accumulations that often exist in the middle ear. Wendt[3] draws attention to the fact that chronic affections of the auditory apparatus, such as formation of adhesions between the ossicles or between the tympanic membrane and wall of the tympanum, may arise while the soft parts are in a swollen condition, and often chronic catarrhal sequelæ may be traced to this cause.

[Footnote 3: _Ziemssen_, ii. 112.]

3. Tuberculosis is often associated with the catarrhal and purulent varieties of middle-ear inflammation, having, as a rule, a subacute course, the patient's attention sometimes only being drawn to his ear by the escape of pus from the middle ear into the external canal, the medium of communication being the mucous membrane of the pharynx viâ the Eustachian tube. Wendt[4] states that as yet the presence of tubercles has not been authenticated, although the clinical observations of rapid destruction, especially of the tympanic membrane, would seem to indicate it.

[Footnote 4: _Ibid._, vii. 77.]

4. Retro-nasal catarrh is a frequent cause of middle-ear inflammation, the disease being communicated along the mucous membrane of the Eustachian tube. All degrees of inflammation are found, the catarrhal variety being the most frequent, while acute nasal catarrh is a cause of a large number of ear complications. Chronic retro-nasal catarrh is apt to cause a chronic middle-ear catarrh, that progresses insidiously, and almost unnoticed by the patient until the deafness begins to interfere with the ordinary affairs of life.

5. Scrofulosis causes most frequently the catarrhal form of middle-ear inflammation; and this is a direct continuation of the catarrhal affections of the naso-pharyngeal mucous membrane viâ the Eustachian tube. Birch-Hirschfeld[5] asserts that scrofulosis is the cause of the largest number of those cases in which weakening or destruction of the function of hearing has occurred during childhood; also, that the large number of scrofulous individuals found in deaf-and-dumb asylums is explained in this way; and that after the scrofulosis is cured the deafness remains as a result of permanent pathological middle-ear changes produced by the former disease.

[Footnote 5: _Ibid._, xvi. 794.]

6. Smallpox may cause several varieties of middle-ear hyperæmia, and frequently also a hemorrhagic catarrhal process is met with. Not seldom is found a suppurative inflammation, with extensive destruction of the soft tissues and ossicles, with permanent subsequent deafness. There is probably no reason to doubt that a pustule itself can develop in the middle-ear mucous membrane, just as is found in the cornea, and cause an acute inflammatory process; but, as a rule, the middle-ear mucous membrane is secondarily involved as a consequence of inflammatory process existing in the naso-pharyngeal mucous membrane.

{820} 7. Diphtheria is a cause of middle-ear inflammation. Wendt[6] states that in a fifth of the entire number of cases of croup and diphtheria; and in two-fifths of those cases in which the naso-pharyngeal space participated, but in no case without immediate connection with the corresponding affections of this space, he found an extension of the specific process into the middle ear. In some cases the tubal prominences were covered with membrane terminating at their orifices; in other cases a membranous cast of the cartilaginous portion of the tube was found. As a rule, the pathological changes noted were hyperæmia of the mucous membrane of the middle ear and catarrhal and purulent inflammation.

[Footnote 6: _Ziemssen_, vii. 71.]

8. Syphilis causes most frequently the catarrhal variety of middle-ear inflammation; the purulent variety is also met with, but much less frequently, the disease of the naso-pharyngeal mucous membrane determining largely the grade of inflammation. Hereditary syphilis may cause this complication, as well as the primary disease, but not so frequently. Hutchinson has observed some cases of deafness in which the disease was situated either in the labyrinth or auditory nerve, the middle ear being healthy. Also, deafness may be caused by syphilitic affections of the external auditory canal, causing obstructions to sound-vibrations passing through it.

9. Typhoid fever may cause either the catarrhal or purulent form of middle-ear inflammation. For instance, Hoffmann[7] found fourteen cases of deep-seated disturbance of the faucial mucous membrane; he also met with perforation of the tympanic membrane four times--twice in connection with caries of the mastoid process.

[Footnote 7: _Ibid._, i. p. 159.]

It is easy to understand why middle-ear complications should complicate such a disease as typhoid fever, where the mucous membranes generally are the favorite seat of inflammation. Disease of the internal ear and auditory nerve are not uncommon after typhoid fever.

10. Bright's disease is a cause of hemorrhage into the middle ear. Schwartze reports in the year 1869 the case[8] of a young man who suffered from albuminuria with retinal hemorrhages; also, enlargement of the liver and spleen existed. He suddenly complained of pain in the right ear. The tympanic membrane was of a red color and devoid of concavity. Three days later an abundant serous discharge existed, with a small blood-coagulum, the patient dying a few days later of the kidney disease. Examination showed a hemorrhagic inflammation of the mucous membrane of the right tympanic cavity, which was also found filled with a bloody purulent fluid. The left tympanic cavity also was found filled with a similar fluid. A number of other similar cases are reported.

[Footnote 8: _Archiv für Ohren Heilkunde_, Bd. iv. p. 12.]

11. Whooping cough has been noted in several cases to have caused hemorrhage into the middle ear, with perforation of the tympanic membrane, with subsequent partial deafness.

The two principal types of acute middle-ear inflammation are the catarrhal and purulent; and these up to a certain stage have similar symptoms, but when pus has formed it gives rise to conditions that must be described as peculiar to purulent inflammation alone.

{821} Acute Catarrh of the Middle Ear.

This may be described as acute catarrh of the mucous membrane lining the middle-ear cavity. The prominent symptoms are as follows:

1. Pain.--This is, as a rule, of the most violent character. It is described as a boring or tearing pain situated in the ear itself, and often extending over the entire temporal region: any muscular exertion like swallowing or sneezing causes increase of it. The external ear becomes swollen, and so exquisitely tender to the touch that the least pressure over the tragus causes the patient to flinch very markedly. The pain tends to increase during the night up to the early morning hours, and to lessen during the day. The immediate effect of a middle-ear inflammation is to render the entire region of that side of the face tender, so that any movement of the jaws or neck becomes painful. It is also not uncommon to find the sympathetic glands of the neck becoming enlarged and tender, and they may go on to suppuration. The adult will complain most vigorously of the pain, so that there will be no difficulty in locating it; but in the infant or young child the greatest difficulty may be experienced in determining its precise seat, owing to its inability to express in language its suffering. Two points may be mentioned as aids in the diagnosis: (_a_) the cry of a young child suffering from an acute inflammation of the middle ear has a peculiar shrill, continuous character, an intermission sufficient only to inspire being noticed; (_b_) pressure over the tragus of an inflamed middle ear will cause a quick shrinking away of the little sufferer, thus showing the seat of the disease.

2. Loss of Hearing Power.--This depends partly on a lessening of the vibratory power of the conducting apparatus, partly due to a thickened tympanic membrane, and also to the fact that the mucous membrane covering the middle ear and chain of small bones becomes swollen, and so clogs their movements. Again, the tympanum may be filled with a mucous or muco-serous fluid, instead of being an air-chamber, as in the normal condition, so that vibrations of the conducting apparatus may cease entirely, while at the same time increase of intra-labyrinthine pressure takes place. A tuning-fork placed on the incisor teeth or on the forehead is heard more distinctly on the deaf side, due to the sound-vibrations being retarded in their outward passage through the diseased middle ear; also, the voice of the patient is heard by himself with increased resonance, due to the same cause (retarded sound-vibrations), and the patient unconsciously lowers the voice below its normal tone.

3. Giddiness is not uncommon, due partly to increase of labyrinthine pressure, and in some cases to a sympathetic irritation and congestion of the vessels of the basilar brain membrane. Fever is always to be looked for in acute middle-ear disease.

4. Noises in the ear (tinnitus aurium), resembling the noise produced by the escape of steam or the singing of crickets, etc., are common, and are due to a variety of causes. For instance, a large number of these noises (according to Theobold's theory) depend upon muscle and blood-vessel movements, causing vibrations that in a normal condition pass out through the external auditory canal without being noticed; but if their outward passage is impeded by obstructions existing in the middle ear, like thickened tissue or the existence of fluids, as mucus or pus, or by {822} obstructions in the external auditory canal itself, such as impacted cerumen, etc., then these vibrations are thrown back and impress for a second time the auditory nerve-endings, and thus become noticeable sounds. (A familiar example is to shut the external auditory canal by closing the meatus: a tidal noise is at once noticed.) A crackling noise is often caused by air entering the middle ear and bubbling up through the confined fluids.

OBJECTIVE SYMPTOMS.--The tympanic membrane is at first slightly injected, particularly along the manubrium and the anterior and posterior folds; but as the inflammation advances the entire membrane becomes intensely injected and red. The cone of light is either very small or may be entirely absent, due to the membrane having lost its high reflective power. At this stage exudations into the middle ear frequently show themselves, and if of sufficient quantity may cause an outward bulging of the membrane: frequently the tympanic membrane at its lower third becomes less transparent, and in some cases fluid collections show a dark border-line stretching across the tympanic membrane, and movable by change of position of the head.

DIAGNOSIS.--This disease can be hardly mistaken: the only difficulty that can arise is whether the case is one of simple acute catarrh or is one of commencing purulent inflammation, as the symptoms are identical in each up to the formation and escape of pus, when no doubt can arise.

TREATMENT.--This must be directed against the acute inflammation that exists, then as quickly as possible to restore the mucous membrane to its normal condition and return to the sound-conducting apparatus its normal vibrating power.

Local bleeding is to be considered among the most important remedies, and therefore is taken first. This is best done by the use of the Swedish leech, applied to the tragus, as at this point the blood is most easily drawn from the tympanic cavity, in number from one to three; and if the taking of a larger quantity of blood is desired, this can be accomplished by encouraging the after-bleeding by hot fomentations. When great pain exists, when the auricle is tender and pressure on the tragus produces marked increase of pain, the application of a leech is indicated. In children it is best to refrain from the use of leeches.

The use of heat and moisture is most valuable. An effective method of application is as follows: Place the head of the patient in a horizontal position, with the affected ear turned upward, and fill the external auditory canal with water at the temperature, say, of 100° Fahr. Place quickly over the auricle towels that have been dipped in very hot water and wrung out as dry as possible, and over these a large flannel pad. This makes an excellent dressing, and one retaining the heat and moisture for a length of time. When it cools repeat the same proceeding until relief is obtained, when a large dry cotton pad can take the place of the previous dressing. Patients suffering from acute catarrh of the middle ear should be confined to the house, and, still better, to bed. All physical exercise aggravates this disease, and a suitable anodyne may be given to procure sleep if it be found necessary. Paracentesis of the tympanic membrane is sometimes indicated in those cases where the membrane shows distinct bulging and perforation is clearly close at hand; also in some cases where, notwithstanding previous treatment, the pain still {823} continues with great severity. This operation is best done by incising the posterior half of the membrane by means of a broad paracentesis needle. The incision should be made at a point midway between the periphery of the membrane and the handle of the hammer, and on the dividing-line of the upper and lower posterior quadrants, the cut to be made downward. Paracentesis of the membrane is to be done while the head of the patient is well supported and the membrane illuminated by means of a light reflected from the head-mirror. Immediately after the operation wet hot flannels should be applied to the ear to relieve the pain.

The condition of the pharyngeal and nasal mucous membrane should be thoroughly attended to, as from this source a large number of cases of acute middle-ear catarrh have their origin. Nitrate-of-silver solutions are often of great service as a local application to the naso-pharynx. Tannic acid makes a good astringent gargle, and is more particularly adapted to those cases where a pure astringent effect is needed. Chlorate of potash is an excellent gargle, and often proves of great service. It may not be out of place to state that the use of alcohol and tobacco tends to keep up an irritated condition of the naso-pharyngeal mucous membrane, and they should be dispensed with. As part of the treatment inflations of the middle ear are used to aid in the removal of abnormal secretions from the tympanic cavity and to restore the sound-conducting apparatus to its normal condition. This can be thoroughly carried out by the Politzer proceeding. This consists in forcing air (by compressing a rubber hand-bag, Politzer's air-bag, so called) through the lower nasal passage up the Eustachian tube, and so into the middle ear. The patient holds a small quantity of water in the mouth. The nasal end of the tubing connected with the air-bag is placed in one of the lower nasal passages, and the nose tightly closed over it. The patient is then told to swallow, and at the same moment the air-bag is forcibly compressed, and the air is thus compelled to travel along the nasal passage and up the Eustachian tube into the middle ear. The act of swallowing causes the soft palate to be forcibly pressed up against the posterior pharyngeal wall, and at the same time causes the Eustachian tube orifice to open widely. A column of air thus used will expel large accumulations of mucus from the Eustachian tube, and to some extent from the middle-ear cavity, and at the same time the thorough distension of this cavity throws into motion the tympanic membrane and chain of small bones--a most desirable proceeding. In acute conditions the inflation should be made only after all pain has ceased, and then at first very gently; but in a short time a thorough inflation two or three times repeated, say every two or three days, is most beneficial. The inflation of the middle ear by the use of the Eustachian catheter is a more irritating procedure, and does not accomplish the purpose any more completely than the Politzer method. Therefore the latter is to be preferred in adults, while in children it is the only available method that can be used.

Chronic Catarrh of the Middle Ear.

Various classifications of this disease have been made by different authors: I prefer the division that Buck has used in his textbook. The following summary will give an idea of it:

{824} Chronic catarrh is a name that has been given to a class of cases where deafness and tinnitus are prominent symptoms, and where no suppurative action in the middle ear has existed at any previous time, and where the internal ear is supposed to be in a healthy condition. In some of these cases there will be found a marked hypertrophy of the mucous membrane, and sometimes of the submucous connective tissue, accompanied with excess of secretion, with the same condition existing in the naso-pharyngeal membrane. The tympanic membrane often becomes sunken, and therefore strongly concave outwardly. The short process of the malleus is very prominent, and the handle of the malleus, by being drawn forcibly backward, becomes apparently shortened (foreshortening of the malleus handle, so called).

The membrane loses its vibratory power to some extent, and the cone of light is either very small or is entirely absent. The color of the membrane changes to a more or less opaque white, with often a line of vascularity along the manubrium, or it may assume the color of ground glass; white calcareous deposits are not seldom met with; marked evidences of catarrhal inflammation exist in the naso-pharynx, such as increase of mucoid secretion, with enlargements of the tonsils, and often granular pharyngitis may be found. The mucous membrane of the Eustachian tube is often involved in the process: marked swelling of its mucoid tissue, with the tube filled with secretions, prevents free entrance of air into the middle-ear cavity. In the nasal mucous membrane, beyond the ordinary catarrhal conditions, polypoid formations are common; also thickening of the mucoid and submucoid tissues prevents the free passage of air.

In another class of cases coming under the head of chronic catarrh of the middle ear a very different set of symptoms from the class first described are noticeable. In these cases perhaps catarrhal symptoms have at one time existed, but have completely passed away, and the mucous membrane not only of the tympanic cavity, but also of the pharynx and Eustachian tube, has undergone a fibroid degeneration, causing destruction of the glandular elements and ending in an atrophied mucous membrane (the so-called proliferous degeneration of some authors). The tympanic membrane in these cases is abnormally thin and very transparent, sometimes much sunken, no doubt due to connective-tissue adhesions in the middle-ear cavity. The external auditory canal is devoid of cerumen and hair; also the same change in the mucous membrane of the naso-pharynx and Eustachian tube gives a smooth, transparent appearance to their surface. In this class of cases in post-mortem examinations there have been found the stapes firmly ankylosed to the margin of the fenestra ovalis; the chain of small bones firmly ankylosed; fibroid adhesions in the mastoid cells; and adhesions between the tympanic membrane and the labyrinthine wall.

CAUSES.--A percentage of cases result from a previous acute middle-ear catarrh. Others apparently originate as a chronic condition and slowly advance. Beyond all doubt, a large percentage are inherited, as the same disease can be traced back through several generations, where signs of the disease were noted in early youth, with slow advance as years go on. It is also a matter of interest to note that these cases are apt to show sensible advance in women at the birth of a child.

{825} PROGNOSIS, as a rule, bad, both as to the possibility of preventing increase of deafness and of doing away with tinnitus--a most annoying factor.

TREATMENT is successful in proportion to the catarrhal symptoms that exist, and which are to be treated on the general plan laid down for catarrhal inflammation. A great number of these cases call for a tonic plan of treatment, such as iron tonics, cod-liver oil, etc.

Local treatment consists in inflations of the middle ear by the Politzer method. In those cases where a thin, sunken membrane exists care should be observed not to use undue pressure, lest a rupture of the membrane result. In those cases where tinnitus aurium is a prominent factor a few drops of ether placed in the Politzer bag cause a more stimulating effect from the inflation than the use of pure air, and is sometimes of service in lessening this annoyance. It is an important part of the treatment that the general health should be in the most vigorous possible condition.

Acute Purulent Inflammation of the Middle Ear.

The disease proceeds very frequently from some inflammation in the naso-pharyngeal cavity, the mucous membrane of the Eustachian tube furnishing a ready way of communication between the pharynx and middle ear.

The exanthematous diseases furnish a large proportion of these cases. Scarlet fever stands first on the list, as causing the largest number of these cases, and also those of the most serious character. Measles, smallpox, diphtheria, the different forms of fever, such as typhus and typhoid, cerebro-spinal meningitis, pneumonia, bronchitis, etc., are complicated by this form of inflammation, and the ear disease represents simply a continuation of the naso-pharyngeal inflammation which occurs so frequently in the above-mentioned diseases. Another set of causes come under the head of change of temperature, such as exposure to draughts of air and sea-bathing, where the cold water entering the external auditory canal acts directly upon the tympanic membrane. Some few cases occur as the result of injury, such as blows upon the ear or direct injuries to the tympanic membrane.

COURSE.--The same pathological conditions are to be noted here as in the acute catarrhal attack, with the difference that the inflammation goes on to a higher grade--namely, pus-formation. In this form of disease there exists marked hyperæmia and swelling, not only of the superficial but also of the deep-seated tissue, with pus-formation, and generally perforation of the tympanic membrane, with occasional ulceration and destruction of other parts of the middle ear. The neighboring cavities of the antrum and mastoid cells participate more or less, while blood-vessels penetrating the superior wall of the middle ear furnish a ready means of communication between the inflamed middle-ear tissues and the brain-membrane, so that the wonder is not that brain complications result, but that they occur so seldom.

The changes in the tympanic membrane in the first stage are marked hyperæmia and swelling of the tissue, so that it often assumes a uniform red appearance, without a trace of the malleus or cone of light. {826} Pus-formation in the middle ear is quickly followed by bulging of the tympanic membrane, due to increase of middle-ear pressure; and this in the great majority of cases is followed by perforation of the tympanic membrane, due not only to increase of pressure, but also to a destructive ulcerative process in the membrane itself. The latter process is seen in those cases of great destruction of the tympanic membrane that occurs in scarlet fever, where almost entire destruction of the membrane is often found. Perforation may occur at any part of the membrane.

SYMPTOMS AND COURSE.--These are very much the same, up to a certain point, pus-formation, as have been described under the head of Acute Catarrh--namely, the great pain, deafness, tinnitus, headache, tenderness on pressure over the tragus, increase of pain by movement of the jaw, followed often by quick relief by perforation of the membrane and escape of pus through the external auditory canal, with a subsequent subsidence of inflammation and restoration of the tympanic membrane. A moderate attack may run a course of from two to six weeks, and end in entire recovery, or it may end in a chronic suppuration with its sequelæ.

DIAGNOSIS.--It often will be difficult at the outset to know if the case is one of acute catarrh or whether it will advance to a purulent inflammation; but as the disease goes on to pus-development and subsequent drum-perforation, no doubt can exist as to its true character. The perforation can often be seen, and air may be forced through it with a whistling sound by a forcible expiration of the patient. In regard to whether complications exist, such as mastoid or brain involvement, several points can be given as aids in the diagnosis. When mastoid involvement exists, the soft tissues over it become swollen, very tender on pressure, with pain in that part of the bone; also, often swelling of the posterior upper wall of the external auditory canal, a part adjacent to the mastoid process.

In those cases where the inflammation tends toward the cranial cavity, the pain spreads over the entire side of the head, and often becomes marked in the occipital and frontal regions, and is of a peculiar lancinating character. Vertigo is also present, even if the head is in a quiet horizontal position, but greatly increased by movement of the head. The body-temperature in acute purulent inflammation in adults is not altered as a rule, but in children it is raised.

PROGNOSIS.--An uncomplicated case if properly treated will generally result in a good recovery, and often with but slight impairment of the hearing power. If allowed to run its course, it may cause serious and permanent changes in the middle ear destructive to hearing, and may end either in a chronic purulent inflammation with bone destruction or in involvement of brain membranes or brain tissue proper.

TREATMENT.--In the early stages absolutely the same treatment as recommended for acute catarrh is indicated--the use of leeches, hot-water applications, rest in bed, anodynes, etc. When pus has formed and the tympanic membrane is bulging, paracentesis is indicated (method of operation, vide p. 917), to be quickly followed by the use of hot water to relieve the pain of the operation; the gentle use of the syringe and warm water will keep the canal free of pus during the suppurative process; also the external ear is to be kept covered by a cotton pad or some other like application as long as pain and tenderness exist.

{827} In young children suffering from scarlet fever it is of the utmost importance to cleanse frequently the pharynx of its muco-purulent secretions. This can be done by means of a probang or cotton wrapped on a curved end of whalebone, and afterward some detergent wash can be used, such as a strong decoction of green tea containing alum or a solution of common salt. The muriated tincture of iron, one part to five parts of water, is an excellent local application to be applied with a camel's-hair brush. Chlorate of potash makes a valuable gargle. In young children Meigs suggests the use of a powder containing one part of chlorate of potash to six parts of sugar, and a pinch of this placed on the tongue and allowed to dissolve.

By such a plan of treatment an acute purulent case will be best carried over the acute stage, and in many instances will end in entire recovery without the necessity of local treatment; but in some cases the purulent discharge from the middle ear will continue, and it remains to consider the best local remedies for checking this discharge and when they are to be used. It is with me an absolute rule that no remedy is to be used with a view of checking a purulent discharge until absolutely all pain has passed away and no pain is caused by pressure on the tragus or over the mastoid. During the interval the local treatment will consist of cleansing the external canal from the contained pus by the use of the syringe and warm water, the canal being afterward dried by cotton on a cotton-holder. If the discharge is small in quantity, the use of cotton on a cotton-holder will be sufficient to cleanse the canal, and causes less irritation than the syringe and warm water. The frequency with which the ear is to be cleansed will depend upon the amount of the discharge, as it should be done as little as is consistent with keeping the external canal free from pus. It is also useful for the patient by the Valsalva method of self-inflation to cleanse the middle ear from the therein-contained pus just before the time of using the syringe. If this is not feasible, the Politzer method of inflation answers the same purpose. When all pain has passed away, and if the discharge still continues, it will be proper to make a local application. My favorite one is insufflation of a small quantity of finely-powdered boracic acid (a convenient rubber blower is made for this purpose). This application answers well also in chronic purulent middle-ear affections. In applying this powder a very small portion only is to be used, so that there can be no danger of blocking the discharge by the powder obstructing its passage through the middle-ear cavity. A small portion is to be placed in an insufflator and blown in, the application to be repeated every few days. I would also mention the great importance of keeping the external canal closed by a wad of absorbent cotton, which not only absorbs the pus as it slowly escapes, but also prevents the immediate contact of air with the middle-ear cavity--a most desirable aid in the cure.

Chronic Purulent Inflammation of the Middle Ear.

Urbantschitsch[9] calls attention to two distinct pathological conditions that are to be noted in this disease--the one a swelling and hypertrophy, {828} the other a thinning, of the mucous and submucous tissues. The thickening consists in an infiltration, with subsequent connective-tissue development, either in the submucous or over the free surface of the mucous membrane, causing in the first case a diffuse tissue hypertrophy; in the latter case forming a circumscribed connective-tissue formation, papillary excrescences, and nodes. The condition accompanied with thinning of the tissue is to be considered a higher grade of purulent inflammation, by which it results that a portion of the normally existing tissue disappears, and is not again reproduced, while the newly-developed inflammatory products do not advance to organization, but are thrown off in the purulent discharge. In this way can be explained why at one time, by examination through the external canal and perforated tympanic membrane, there is found a swollen connective tissue, while at another time the bone can be seen through the thinned membrane.

[Footnote 9: Vide _Textbook_, p. 351.]

CAUSES.--As a rule, it is a sequela of a previous acute attack. And it is also safe to say that a large number of chronic purulent cases are the result of bad treatment or non-treatment of the acute attack. To mention the causes of chronic suppuration is to repeat those causing the acute variety, such as diseases of the naso-pharynx resulting from scarlatina, variola, measles, typhus, tuberculosis, bronchitis, syphilis, etc.; also the external irritating causes, effect of change of temperature, as by draughts of air, cold water entering the external auditory canal, etc.

SUBJECTIVE SYMPTOMS.--Difficulty of hearing is always present. This is often caused by masses of granulations or collections of pus, filling up largely the tympanic cavity. These with a hypertrophied mucous membrane could sensibly interrupt sound-vibrations; and it will not be out of place to remark that the recovery of hearing will depend largely on what amount of change can be effected in these different conditions. Tinnitus aurium is not a constant factor; a few patients suffer from discomfort caused by pus passing down the pharynx, causing nausea.

OBJECTIVE SYMPTOMS.--More or less swelling of the external canal, while the constant passage of purulent fluids over the skin results in exfoliation of its epithelial layer and a subsequent weeping from the skin tissue. The secretion varies from an abundant discharge to a minimum of a few drops per day. It may be watery or muco-purulent, or of a thick, creamy, tenacious consistence. Odor is common, and if the bone is involved of a most disagreeable character. The perforation in the tympanic membrane may vary in size from that of a pin-head to a loss of the greater part of the entire membrane; also, the membrane is found thickened, with an occasional calcareous deposit in its fibrous layer. Granulations and polypoid growths are found in the external canal and middle-ear cavity. The mucous membrane of the naso-pharynx will show the various changes that are found associated with the different diseases that cause this complication.

DIAGNOSIS.--This is without difficulty as a rule. The discharge, the perforation that often can be seen, the whistling caused by the air being forced through the middle ear and the perforation in the tympanic membrane by the Valsalva or Politzer method of inflation, are very significant of middle-ear suppuration. The pulsation often noticed at the bottom of the external auditory canal, and which has been considered indicative of perforation, is caused by a thin surface of fluid in contact with a {829} pulsating blood-vessel, and therefore is not necessarily a sign of perforation of the tympanic membrane, as fluids are found in the external auditory canal from inflammation of its coats, and in such a case pulsation might occur; but this is but seldom the case, and the removal of the fluid would remove any doubt as to whether the fluid was a result of external-ear inflammation or caused by purulent middle-ear disease.

The course of a chronic purulent inflammation is very variable. In many cases under proper treatment healing and restoration of tissue go on rapidly. The secretion grows daily less and of a thicker consistence, and the mucous membrane of the middle ear rapidly returns to a normal condition. The perforation in the tympanic membrane becomes smaller, and often entirely closes, so that in a young person the restoration may be so complete that it is difficult to know where the seat of perforation has been. In one case in my practice in a child of ten years, where the membrane had been destroyed to at least three-fourths of its extent, a full restoration took place. In another class of cases the course is not so favorable. The tympanic membrane is largely destroyed, and is not regenerated. The chain of small bones may be either partly or entirely lost. Granulations form in the mucous membrane of the middle ear, and the bony walls of the tympanum undergo partial necrosis, the pus appearing as an acrid, irritating fluid with more or less odor. The graver complications of purulent inflammation are apt to occur in those cases of chronic purulent inflammation where there has been a stoppage of the free discharge of pus from the middle ear, causing it to collect in the antrum and mastoid cells.

TREATMENT.--The first indication is to cleanse as thoroughly as possible the middle-ear cavity of the muco-purulent fluid that may have collected. This is best accomplished by forcing air up the Eustachian tube and through the middle ear by either the Politzer or Valsalva method of inflation. The fluids thus forced out into the external canal can be removed by the use either of warm water and the syringe if large in amount, or by cotton on a cotton-holder if small in quantity: the latter plan is less irritating, and also completely dries the external canal. No local application ought to be made as long as any pain exists.

The local applications that my experience has shown to give the best results consist of boracic acid and iodoform. (The latter is objectionable on account of its odor.) The powder-insufflator furnishes a convenient method of applying these powders, and only small quantities should be used, so that no possible plugging of the middle ear can take place. Some authorities prefer fluid applications instead of powder. Weak solutions of sulphate of zinc, from one to four grains to the ounce, are frequently used: a few drops, warmed, are poured into the external canal and allowed to remain a short time, and then removed by a twisted tuft of cotton on a cotton-holder. Nitrate-of-silver solutions are to be used on a cotton-holder; and if a very strong solution is used it should be neutralized with salt and water.

The frequency of application of any remedy will depend upon the amount of discharge; but as the discharge lessens, so should the remedy be less frequently applied. The same rule applies to the cleansing of the ear, as I have no doubt that excessive use of the syringe often tends to re-establish and increase the discharge. In some cases, where the discharge has {830} become very small in quantity, a thick scab will form over the tympanic perforation, and restoration of the tympanic membrane will rapidly advance under such a covering, showing that it is good practice not to remove such a scab, provided pus is not thereby prevented from escaping. A cotton plug should always be worn in the external canal of a purulent ear, as it acts as an absorbent of the purulent secretions, as well as protects the middle ear from the irritating contact of the air.

The naso-pharyngeal cavities are to be considered and appropriately treated; also, a general tonic treatment is often indicated.

SEQUELÆ OF PURULENT INFLAMMATION.--I. Brain involvement, either of the meninges or its substance proper: _a_, purulent meningitis; _b_, abscess of the brain; _c_, phlebitis with thrombosis of the sinuses. II. Mastoid disease.

I. Brain Involvement.

It will be proper for a clear understanding of the subject to briefly consider the anatomy of the middle-ear cavity with reference to this complication. The middle-ear cavity is practically surrounded by bony walls, with the exception of the foramen closed by the tympanic membrane and the opening of the Eustachian tube. The roof of the middle ear is of varying thickness, and is perforated by a number of canals for the passage of blood-vessels, forming a direct communication between the circulation of the middle ear and the meninges of the brain; also, the petro-squamous suture in the earlier years of life before complete ossification has set in provides a way for spreading of the inflammatory process from the tympanum to the brain tissue; also, cases are recorded where caries has formed actual openings in this bony roof, through which pus has entered into the brain cavity. The floor of the tympanic cavity is very thin, and forms a fossa in which lies the jugular vein, so that involvement of this vein in the inflammatory process could occur by the close apposition of these parts. The anterior wall is formed in part by the carotid canal, and cases are noted where defects in this bony wall are found. Under such circumstances the coats of the artery would lie in direct contact with the middle-ear membranes. Also, it is to be noted that small twigs from the carotid artery pass through its bony canal and anastomose with vessels of the middle ear, furnishing a way for the spread of inflammation from the middle ear to the carotid artery that may result in thickening of its walls.

The superior and posterior surfaces of the petrous bone are in direct contact with the brain membranes. The posterior wail contains the passage into the mastoid cells by way of the antrum, through which middle-ear inflammations spread and involve the mastoid cell cavities, and may result in some cases in thrombosis of the transverse sinus.

The inner wall presents two weak points--the one the round foramen, covered with membrane; the other, the oval foramen, covered with the stirrup and the annular ligament. Inflammation can cause destruction of these coverings and give free access of pus through their foramina into the labyrinth, and thence through the internal auditory canal into the brain cavity. It is not difficult, therefore, with so many ways of {831} communication between the middle ear and brain cavity to have easy spread of inflammation between these two regions.

(_a_) PURULENT MENINGITIS may arise from continuance of the inflammation along the veins which penetrate the roof of the tympanic cavity in their passage from the middle ear to anastomose with the blood-vessels of the meninges, or may in rare instances be caused by pus entering the brain cavity by way of the internal ear, or it can result from caries of the petrous portion of the temporal bone.

SYMPTOMS.--Fever will be present; distressing headache; vertigo, a most significant symptom, and often present even when the head is quiet and in a horizontal position, but greatly increased by the vertical position and motion; pain of a lancinating character, shooting over the entire affected side and even down the neck; the occiput and vertex are favorite points for pain to locate. Nausea and hiccough are present. Abdomen depressed; pupils reacting to light but feebly; slow pulse; and in some cases paralytic symptoms are prominent. Post-mortem appearance: meninges congested, and lymph and pus often found at various points. Dura mater over the diseased petrous bone will be found thick, congested, and pus may be found between it and the bone. Caries of the petrous bone also is found in some cases.