CHAPTER XV. ACUTE SUPPUKATION OF THE MIDDLE EAR. (Part 1)

CHAPTER XV. ACUTE SUPPUKATION OF THE MIDDLE EAR. Acute suppuration of the middle ear commonly occurs as a direct and recognized consequence of an acute catarrh of the same part. A catarrhal process is unchecked, and passes on to a suppurative one. In some cases, however, the catarrhal inflammation is unobserved — we cannot, however, say that it does not occur — and the first intimation of any morbid action given by the ear is a discharge of pus from the auditory canal. I have seen several cases where the patients have assured me that the first idea that they had of trouble in the ear, was the moistening of the canal from the flowing out of the pus. An examination of the ear in such cases has always revealed a perforation of the membrana tympani. We probably never see a discharge of pus from the surface of the auditory canal, with- out previous intimation, by pain or swelling, that an inflamma- tion of the part had occurred. It is my belief, however, that the cases of sudden and painless perforation of the membrana tympani are nearly always preceded by some premonitory symptoms, such as pharyngitis, feelings of fulness in the ear, impairment of hearing, etc. ; but that the failure to notice them is usually to be attributed to carelessness in observation, and to be regarded as another indication of the common indif- ference to an inflammation of the ear, that is not positively painful. Then, again, there are cases where pain is felt long before the pus is discharged, but where it is mistakenly referred to some other part of the body. Neuralgia of the head, is a diagnosis often incorrectly made for the first stages of acute catarrh of the middle ear. It is not to be denied, however, that there are cases of ACUTE SUPPURATION OP THE MIDDLE EAR. 351 acute suppuration of the middle ear, where the initial symp- toms of swelling of the lining membrane of the Eustachian tube and cavity of the tympanum are so quickly passed over, in a few hours, or even minutes, as to be practically unrecog- nizable. Such a course of the disease is frequently observed in phthisis pulmonalis, where a membrana tj'mpani will some- times break down from an accumulation of mucus behind it, and go on to suppuration without a trace of pain. The usual origin of acute suppuration is, however, a violent one. The severe pain of acute catarrh is unrelieved, pus is formed in the cavity of the tympanum, the lining of the mas- toid cells is very much distended, the outer surface of the pro- cess becomes red, tender, and painful, the head throbs, and the whole system is seriously disturbed. In young persons delirium occurs, and in all subjects, there is general febrile excitement, and the condition of the patient is one of intense suffering. There is probably no more severe pain to which the human sys- tem is liable, than that due to the distension of the little space called the cavity of the tympanum by mucus, serum, or pus. Symptoms. — The symptoms, then, of this disease are usu- ally pain in the ear and head, constitutional disturbance in the way of febrile action, with impairment of hearing, and tinni- tus. The membrana tympani also exhibits marked changes in appearance. But the pain may be entirely absent, as we have seen, and yet the inflammatory process, because it is sudden in its origin, be fairly entitled to the adjective acute. The cases of the painless form of acute inflammation, in persons suffering from phthisis pulmonalis before alluded to, are not as amen- able to treatment as the more acute cases. I suppose this fact is partly to be attributed to the failure in the general nutrition, and also to the contiguity of a diseased mucous membrane, which is constantly acting as an exciting cause of trouble in the pharynx and Eustachian tube. The membrana tympani has usually lost its naturally trans- parent appearance in a case of acute suppuration. It has a boggy, sodden, or swelled appearance, and has none of its nor- 352 ACUTE SUPPURATION. inal distinguishing marks in the way of light spot and handle of the malleus. Yet this is not always the case. I have seen cases where the transparency of the drum membrane was almost unimpaired, and the accumulated pus and mucus which were bulging it out, could be seen through it. In one case, that of a young lady, I found pus not only in the cavity of the tym- panum, but also between the mucous and fibrous layer of the drum-head. The pus moved when the head was moved. She recovered, with perfect hearing power, and a sound membrana tympani, without an artificial or spontaneous per- foration of the drum-head. The treatment resorted to was the use of leeches, a gargle, and Politzer's method. There was considerable pain at the outset, but not the intense pain which is usually one of the characteristics of acute suppura- tion. The patient visited my ofiice daily during the whole course of the disease, which occurred in the mild weather of spring. It is possible that some cases of so-called abscesses of the membrana tympani, should be regarded as examples of limited suppuration in the tympanic cavity. I have not as yet seen any cases, where it seemed to me that an abscess was confined to the layers of the drum-head, without any communication with the cavity of the tympanum or the external auditory canal. It should be added, that the osseous portion of the bony canal is often found to be very much inflamed, in conjunction with the symptoms in the membrana tympani, the cavity of the tympa- num, and the mastoid cells. I. may be pardoned for reminding the student, that it is often impossible to draw the line between the affections of the three parts of the ear. Their anatomical connections show that they must of necessity run into each other, however distinctly they may be separated in their ori- gin. It is rather a predominance than an exclusive localiza- tion of symptoms in a part, that gives rise to an exact classifi- cation of disease. For example, an otitis media, in a young child, may very readily and rapidly pass on to an otitis in- terna, or inflammation of the labyrinth, and give us much difficulty in deciding which was the original affection. Causes. — The causes of acute suppuration of the middle CAUSES OF ACUTE SUPPURATION. 353 ear are the same as those that have been enumerated in the chapter on acute catarrh. The chief one is, exposure to cold — inflammation of the naso-pharyngeal mucous membrane being the usual starting point. The violent use of the posterior nares syringe in an acute or sub-acute catarrh, will also in very rare cases set up acute suppuration in the tympanic cavity ; at least I have seen it do so in one case, which was the following : A physician, aged 27, had suffered for years from chronic naso-pharyngeal catarrh. During the winter of 1872, he was attacked with acute coryza and pharyngitis. He had once used the nasal douche for a similar attack, and it caused such severe symp- toms that he was obliged to desist from it. I was in the habit of using the naso-pharyngeal syringe for him at irreg- ular intervals, in order to relieve the chronic naso-pharyn- gitis from which he suffered. On visiting him one afternoon, when he was suffering from the acute attack, his nostrils felt so full of secretion that he requested me to use the naso- pharyngeal syringe, which I did, injecting a lukewarm solution of chlorate of potash. The bulb of the instrument caused some gagging as it came in contact with the swelled wall of the pharynx. In an hour or two he was attacked with acute aural catarrh of the left side, which, in spite of the most energetic treatment by means of leeches, went on to suppuration before morning. Under appropriate treatment the patient recovered, with a sound drum-head, and with the hearing power as great as before the attack. The fact has already been mentioned that sea-bathing sometimes becomes a cause of acute catarrh. In the same manner, want of caution in protecting the side of the head from the force of the waves, or the canal from the entrance of water, may produce acute suppuration. Scarlet fever, measles, diphtheria, tonsilitis, bronchitis, pneumonia, and whooping-cough, play an important part in the production of acute aural disease, and usually, the suppu- rative form is the one first recognized, although, as has been said, there is probably almost always an unobserved stage of the milder variety of inflammation. Injuries of the side of the head, and of the membrana tvni- 23 354 ACUTE SUPPURATION— COURSE. pani, are causes of acute suppuration of the middle ear of a very severe nature. This subject, has, however, been discussed in the chapter on Injuries of the Menibrana Tympani. Course. — The course of acute suppuration is usually violent until perforation of the drum membrane occurs ; when it opens — at times with quite a loud explosion — relief to the severe pain is usually experienced. If no measures are taken to remove the accumulated pus, and to check its formation, the impair- ment of hearing will continue, although the pain and tinnitus may be relieved, and we shall soon have a case of chronic suppuration of the middle ear, and the patient be liable to all the fearful consequences of this disease. In rare cases, pus may escape, however, into the Eustachian tube, and the case go on to resolution with no perforation of the drum-head. This is more apt to occur in children than in adults. In the worst event of all, the suppuration may extend into the brain or the circulation. It may pass through the thin, and sometimes porous lamella of bone which forms the roof of the cavity of the tympanum, or it may go beneath into the jugular vein, and thus produce blood poisoning or pyaemia. It may also extend to the labyrinth. The mastoid process is of course always more or less involved hi acute suppuration, or even in acute catarrh. Its cells form, as the anatomy shows us, an integral part of the middle ear. Disease of the mastoid process is also a danger- ous complication ; but for a full discussion of the subject, I beg to refer the reader to the consequences of chronic sup- puration. Under appropriate treatment, however, the secretion of pus usually soon ceases, the membrane closes up, the hearing is restored, and scarcely a trace is seen either in the anatom- ical structure or the functions of the organ, of the disease which has raged so violently. "With a want of logical reasoning that is remarkable, some practitioners invite suppuration of the drum-head, in every case of acute catarrh, or "pain in the ear," and then declare, that nothing can be done for the hearing when the membrana tympani is once perforated. Our aim should always be to ACUTE SUPPURATION — TREATMENT. 355 prevent or limit suppuration in the ear, but if it do occur, and even if a large portion of the drum-head be swept away, we may usually, if the ossicula be left, by prompt, energetic, and patient treatment, restore it, and with it, the hearing power. It should be observed, that diffuse inflammation of the ex- ternal auditory canal is often a troublesome complication in the course of an acute aural suppuration with perforation. It is probably caused by the irritation of the pus in the audi- tory canal, and perhaps in some cases by the excessive mani- pulation for the purpose of cleansing the ear. Such a com- plication is sometimes embarrassing ; for it may prevent us from continuing the astringents which are indicated for the relief of the suppuration. Treatment. — If the case be seen in the earlier stages — that is, when the pain is still present, and the membrana tyinpani is intact — two or more leeches should be at once applied, and if the appearance of the membrana tympani indicate that it is about to rupture, or if the pain be not quickly subdued by the use of the leeches, a paracentesis of the membrana tympani should be at once performed in the most bulging portion of the membrane. If the mastoid be red, tender and swelled, it should be at once incised down to the bone, except in the case of young children, where the more yielding nature of the integument and the periosteum will admit of some delay. If the mastoid process be simply red and tender, but not swelled, the use of leeches will probably subdue the inflammation without an incision. The ear should be douched very often, say every half hour, with lukewarm or hot water, the temperature of the water be- ing determined by the patient's feelings. This procedure the patient will usually find very grateful. In case of the absence of a douche, warm water may be dropped into the ear from the sponge, a procedure as old as the time of Hippocrates. A douche may be extemporized by the syphon arrangement, of a bit of rubber tubing in &ny kind of a vessel that will contain water. At the same time, especially if the weather be cold, the patient should be kept in his room, and perhaps in bed, while pecleluvia and diaphoretics are employed. 356 ACUTE SUPPURATION — TREATMENT. If the membrana tympani have ruptured, the pus should be removed at least twice a day, by careful but thorough syriugiug. At the same time, Politzer's method of inflating the ear should be practised. This latter procedure gives no pain when carefully done, i. el, when the bulb is not too vigor- ously pressed. It at once improves the hearing, helps to cleanse the ear, and prevents the formation of adhesions in the cavity of the tympanum, and gives the patient hope and confidence. The throat should be kept free of secretion by a gargle. The chlorate of potash in a saturated solution is the one I usually use. In cases of scarlet fever, the pharynx will require the most careful and energetic treatment. The neck should be kept warm by poultices, and the pharynx be very often cleansed by the use of a nebulizer, chlorate of potash in powder placed upon the tongue, and so forth. Dr. Sexton, of this city, has found great relief in tonsilitis from the use of the warm douche upon the pharynx, by means of David- son's syringe, or rubber tubing attached to a water faucet. Relapses of pain should be combated by leeohes, warm water, and the internal administration of opium ; but opium has very little power in subduing the pain from acute aural suppuration if used without the local treatment. The admin- istration of calomel or other mercurials, the application of blisters, will not be required. The former kind of treatment is useless, while the latter aggravates the suffering of the patient. Blisters are only applicable, if at all, to chronic aural disease. If the case go on well, a physician who does not see much of this form of disease, will be astonished at the rapidity with which the suppuration is checked, and the membrana tympani restored. The impairment of hearing will be the last symp- tom to be fully relieved. The hearing power should be often accurately tested by the watch and tuning-fork in the course of the disease, in order that if possible we may not dismiss the patient until the cure is complete. The astringent that I usually use in acute suppuration is a solu- tion of sulphate of zinc, which is poured into the ear once or twice a day, after syringing. The solution should be previously ACUTE SUPPURATION — TREATMENT. 357 warmed. Should the suppuration continue unduly, the nitrate of silver may be applied in strong solutions, say from 40 to 80 grains to the ounce. This solution is brushed over the drum- head and in the edges of the perforation. In some cases it may be necessary to drop the solution into the ear, after- wards neutralizing it by syringing with a warm solution of salt and water. Indeed, it should be said once for all, that except in very rare and exceptional cases, cold fluids should not be dropped into the ear. From the nature of things, the general practitioner will see a great deal of this form of disease — if he be on the look- out for it — since it occurs so often in the course of the ex- anthemata and in connection with diseases of the respiratory organs. It will be seen that there is nothing in the treatment of this affection that will prevent the usual care of the general disease. It is a great and often fatal error to wait the subsi- dence of the general symptoms before the aural ones are alleviated. They are quite as important as the most urgent constitutional disturbances. Indeed, they are often the un- suspected cause of most of the latter. It only remains to be said that the results of treatment of this disease are very satisfactory. Of 32 cases reported by myself,"" 15 were cured, i. e., the membrana tympani was healed and the hearing powerfully restored, as tested by the watch and conversation. As has been said in another place, the old writers on diseases of the ear were not in the habit of apply- ing accurate tests as to the restoration of hearing ; so that their standard of cure is not so high as that which obtains among writers of the present day. Many of my cases of aural disease, that have been reported as improved or much im- proved,