To prevent a return of the affection, it is important not only to protect the patient from cold winds and other shocks to his auditory or general economy, to rectify pathological conditions in the nose and naso-pharynx, but to build up the general health by all the means at our command. This latter is usually neglected, with the result that the ear never approximately regains its normal state, and therefore remains as a constant menace to health and happiness.

If the treatment of an acute suppurative otitis be neglected or faulty, exacerbations and the chronic conditions are prone to occur-especially in lowered constitutional states and with the diseases which go with these, notably tuberculosis, syphilis, anæmia, marasmus; and chronic suppurative otitis may develop without reactive phenomena in these diseases.

In a series of over one hundred cases I found that with but few exceptions all patients with chronic running ears gave a positive reaction to the tests of Calmette or von Pirquet; whereas in acute cases the percentage was small, and as a rule only those who gave tuberculosis histories or went on to exacerbations or complications reacted positively.*

These facts eloquently emphasize the necessity for general constitutional treatment in acute or chronic ear disease.

As in acute, so also in chronic suppuration must we establish and maintain adequate drainage and remove all granulations, polypoid growths, or other obstructions to the usually profuse, purulent, and putrid discharges.

Bone caries cannot be definitely diagnosed

macroscopically by the character of the discharge, as the most foul and irritating discharges often speedily lose their odor and cease, and those that are scanty and thin often occur with necrotic processes. The detection of exposed bone by means of the probe, the unabated continuance of the suppuration in spite of faithful and intelligent treatment for several weeks, the recurrence of granulations, polypi, or the presence of cholesteatoma in inaccessible recesses, all point to the uselessness of non-operative measures, as the trouble lies beyond the reach of these.

Our treatment is subject to many modifications, depending on the quantity and quality of the discharge, the location and size of the perforation, the condition of the Eustachian tube, external auditory canal, and surrounding structures, and the patient's general health. Remember that the secretion is always septic, and therefore liable to set up complications in the temporal bone and abutting dura, and that we are justified in performing the major operations if we are unsuccessful in arresting the suppuration

* Amer. Journal of Obstetrics, Vol. lviii, No. 2, 1908.

and reducing the inflammatory infiltration of the middle ear structures within a reasonable time.

With the exception of bone caries, retained caseous purulent secretions in inaccessible pockets in the tympanic cavity, petrous, or mastoid portions of the temporal bone, the causes of chronic otorrhorea are, in the great majority of cases, removable; and even small areas of denuded or dead bone may become covered with granulations, epidermatize and heal, if we assist them in their fight for recovery.

There are numerous methods and medicinal substances for combatting the disease-all of which have their uses and limitations, according to the varying types and stages that present.

Though I deprecate the use of powders on account of their tendency to block drainage, they are of value in selected cases if cautiously used and thoroughly removed before repeating the insufflation. Antiseptic solutions seem to exercise a beneficial influence on the purulent processes by their anti-bacterial, anti-putrefactive, and anti-decomposition actions, and the choice of these depends largely upon individual preference. I usually use hot boric acid and salt solution or bichloride of mercury in strengths of of chemical irritation I wish to exert on the infrom 1-10,000 to 1-1000, according to the degree filtrating round cell degeneration in order to further its destruction and absorption.

Caustics are useful for their influence on the

circulation and nourishment of the tissues, and the marked reaction they produce. If exuberant granulations occur about the perforation or in the canal or middle ear, they should be removed

by 10 per cent. trichlor-acetic acid, ortho-chlorophenol, or other caustic, but they are seldom troublesome if the disease has been properly treated.

Alcoholic and glycerol solutions are valuable, for their antiseptic, irritating, astringent, and hydrolytic actions.

Solutions for introduction into the ear should not be cold, and I prefer them about 115 degrees F., which is well tolerated by the patient and adds to the action of the medication the stimulating, astringent, and dissolving powers of hot solutions, and besides the few drops remaining after the irrigation quickly evaporate, and we thereby overcome one of the chief objections to solutions-their tendency to remain and further soak the already water-logged tissues.

There are many rational methods of treating suppurative otitis media, but success depends not so much on the method as on the mode and thoroughness of its employment.

Briefly stated, we may use, locally, heat, counter-irritation, dry cleansing and draining, irrigations, antiseptics, hydrolytics, astringents, suction cupping, depletion; and all of these have their advantages and disadvantages, one of the

142

latter being the inability to bring them to bear on the diseased tissues without trauma, discomfort or pain to the patient. Especially is this the case with infants, children, and nervous individuals.

To overcome most of the difficulties of nonoperative treatment, I use my suction bell douche, as it enables me to combine in one method all the local measures just mentioned, and to add many beneficial influences otherwise unobtainable. Anyone with ordinary intelligence can be easily instructed in its use, and except for possible asinine stupidity or the use of caustics-it is foolproof. The apparatus may be employed without disturbing the patient, so long as the ear to be treated is within reach, and in children if the head is held between the two hands, one of which steadies the glass bell, perfect control is obtained, and no damage or wetting occurs.

The negative pressure depends upon the length of the drainage tube, and the force of the irrigating stream upon the height of the fluid supply-bag. The suction and nozzle pressures approximate 222 mm. of mercury for each foot of water fall in the drainage and supply-tubes, respectively. I find that two feet above the heal is about right for the supply-bag, and two and one-half feet for the length of the drainage tube. If it is desired to obtain in and about the ear a hot poultice action, pinch the outlet tube and allow the hot fluid to accumulate inside of the bell until the latter is one-half to two-thirds filled, when, on releasing the outlet tube, the suction will be resumed, and the solution will remain in the bell as long as the rim is closely approximated to the skin about the auricle, and the fluid continues to fill the supply-tube. If no suction is desired, allow a few hairs to remain beneath the rim of the douche, or elevate the distal end of the drainage tube. Dizziness is seldom noted during this douching, but if complained of, move the head far forward, lower the supply-bag, or place the ear under treatment in such a position. that its canal will fill with fluid, and thus provide a buffer for the jet and lessen its impact.

After a few applications, as the patient experiences relief and comfort, the treatment is not only quietly tolerated but often anticipated with pleasure. The negative pressure is of advantage aside from the hyperæmia engendered because it prevents the water-logging of the tissues and actually enables us to obtain the advantages of both the dry and irrigation treatments, with none of their disadvantages. It relieves the tension throughout the middle ear and communicating

cavities, draws the exudate with its toxins and bacteria to the surface, allows fresh blood and all that this entails to reach the field of conflict, and as far as I have observed exerts no deleterious action if used in connection with irrigation to wash away those elements drawn to the foreground, and the stench from their decomposition.

The local effects of the fluid can reach only

JOURNAL OF MEDICINE

to the innermost part of the canal, unless there is an abnormally large perforation, or unless the douche is used alternately for suction and for condensation. This is accomplished by alternately releasing and compressing the drainage tube while holding the cup firmly against the head. The pressure will force the fluid in the canal into the middle ear to an extent depending on the height of the supply-bag, and if the Eustachian tube is permeable, fluid may be forced through it into the naso-pharynx. This latter procedure I often make use of in both acute and chronic cases, and after unsuccessful mastoid operations. It is impossible to thus enter the mastoid cells if the head is inclined forward, as the air pocket in the cells and antrum prevents the entrance of fluid in this direction. releasing the drainage tube, suction is re-established, and the fluid forced into the middle ear is withdrawn, having bathed the tissues during its entrance and exit.

On

To better break up tenacious or inspissated masses in the middle ear or canal, I employ hydrogen peroxide before each suction douching. In some cases, Politzeration or catheterization is of service to help clear the tube and tympanum, but I endeavor to avoid the use of these measures, except in the presence of the partial vaccum existing during suction irrigation, as even the theoretical objections to inflation are overcome by this method, for any matter blown into the ear will readily find exit through the road offering the least resistance the external auditory canal, and the fluid draining therefrom.

The maintenance of a patent tympanic membrane opening without repeated incisions is often difficult under the older methods of treatment, and likewise the avoidance of adhesions between the drum and the inner tympanic wall, and while it is unthinkable that we can remove connective tissue bands or prevent their formation, if the two surfaces between which they occur are immediately or mediately joined together, we can lessen the tendency to and the effects of adhesions by prompt, free and maintained drainage, removal of the exudate, and the keeping of the surfaces in question as far apart as possible. These results the suction irrigation tends to accomplish.

I am convinced that the treatment outlined has many advantages over the older methods, not because it utilizes any new theory or drug, but because it combines in one procedure all those remedial actions which we know to be beneficial,

and enables the patient to obtain, without annoyance-simply, safely, and efficiently-regular

home treatment for his disease.

Acute cases regularly progress without complications to a satisfactory recovery, and in the great majority of chronic cases a cure may be obtained without resorting to major operative

measures.

(PARACENTESIS).

Paracentesis is employed principally for the purpose of evacuating the purulent contents of the tympanum, the ultimate object being to relieve pain, limit the extent of the infection, shorten the course of the disease, and prevent complications.

Indications.-Paracentesis of the drum membrane is indicated in acute purulent otitis media when attended with intense redness and bulging of the drum membrane, in whole or in part. With these objective symptoms there are coexisting pain and fever, the latter being more marked in young children. The syndrome above described, viz., bulging of the drum membrane, intense aural pain and fever, is invariably of sufficient import to warrant this operation. In infants bulging is a later manifestation than in adults.

Occasionally the purulent process may have continued for some days without rupture, especially in infants, in which event the intense redness gradually assumes a yellowish color, due to attenuation of the membrane and the accumulation of purulent exudate in the tympanic cavity. An early paracentesis, when performed under strict aseptic precautions is preferable to a delayed spontaneous rupture. It is a safe rule to open the drum membrane as soon as the diagnosis of purulent tympanitis becomes positive.

A clean-cut incision in the drum membrane (and by this I do not mean a puncture) immediately relieves pressure, establishes drainage, and the subsequent healing of the wound takes place with but little damage and no scar tissue. Nature's opening is usually a small, jagged hole, the borders of which are more or less necrosed, which, as healing takes place, is prone to result in scars, and considerable deposits of new connective tissue in the drum membrane.

Paracentesis is also indicated for enlarging

*Read before the Medical Society of the State of New York at Albany, N. Y., January 26, 1909.

perforations which already exist, providing they are too small or are unfavorably located for purposes of drainage. A pin-hole perforation in the presence of an extensive intra-tympanic purulent process affords insufficient drainage. These small perforations are usually accompanied by a sensation of throbbing or pain in the ear or mastoid. region. They do not entirely relieve the bulging of the membrane, especially at the site of the opening. In enlarging the pin-hole perforation it is often necessary to cut both upwards and downwards, in order to establish drainage both of the tympanic and attic region.

The operation should be performed with a long, slender-handled, small-bladed scalpel, and, if possible, under nitrous oxide anesthesia, inasmuch as the procedure is attended with severe pain. The general direction of the incision should extend upwards and downwards. It may be curvilinear or straight, according to the requirements of the individual case, freely opening the drum membrane throughout its entire extent. The old-time spear-shaped lancet should be discarded for this operation.

Before operating, the external auditory canal and drum membrane should be carefully cleansed by prolonged douching with a warm bichloride solution 1-3000, and dried with sterile cotton, in order to prevent, as far as possible, the invasion of new bacteria from without.

Immediately following the incision, similar douching may be continued until all secretions and clots are removed. The patient should remain in bed until the more acute symptoms have subsided. The canal might be lighty tamponed with sterile gauze, to be changed as often as it becomes soaked with secretion, and the suction douche employed according to the methods outlined in the previous paper.

Value. The operation releases pent-up pus from the tympanic cavity, and thereby retards the tendency to bacterial invasion of contiguous structure, establishes free drainage of inflammatory exudate, shortens the course of the disease, and lessens the danger of mastoiditis, intracranial and labyrinthine complications. These results come chiefly from the rapid removal of the inflammatory products from the tympanic cavity, which otherwise might be forced under pressure through the aditus into the mastoid

antrum.

Removal of Aural Polypi.-Coming to intratympanic operations the most frequent procedure is the removal of polyps of granulation tissue. The presence of polyps or granulation masses in the tympanic cavity and external auditory canal almost invariably indicates a chronic purulent process in the tympanic cavity and its adnexa. The most common attendant symptom is otorrhea.

This tissue is adventitious and should be removed or otherwise destroyed. When accompanied by offensive discharge and by extensive bone necrosis some form of operation must be

employed which will not only remove the polyps, but exenterate the necrosed tissue as well. A simple method of removing large polyps is by means of a small aural snare. By this procedure the projecting portion of the mass is easily cut away. The remaining base is then cauterized, preferably with a bead of chromic acid fused upon the end of a probe. The latter alone is usually sufficient for the destruction of small granulation masses. In this manner the obstructing lesion is removed, but, unfortunately, inasmuch as these growths result from an underlying necrotic process, the proliferations are prone to recur, and recurrence is usually rapid.

Recurrent proliferations of aural polyps in cases wherein all improved methods of local treatment have been faithfully carried out during the interval, indicates a chronic purulent process with bone necrosis which involves the spaces which are accessory to the tympanic cavity proper, for the cure of which the radical mastoid operation becomes imperative.

It will thus be seen that while the results of removal by snare or destruction with escharotics are favorable in the simple cases wherein the disease is confined to the borders of the drum membrane, perforations or portions of the tympanic walls, the results are unfavorable and almost invariably attended with recurrence when the necrosis is extensive, deep-seated or located in the adnexa, the latter cases always requiring the more radical procedures in order to effect a

cure.

It occasionally happens that the large polypoid masses which project into the external auditory canal spring directly from the exposed dura mater or lateral sinus, in which event their forcible removal is attended with considerable danger to the meninges.

OSSICULECTOMY.

Ossiculectomy, or the intra-tympanic operation is an operation by which the drum membrane and ossicles are removed, together with the curettment of granulations and such diseased portions of the tympanic walls, the attic with its outer wall, and the annular ring as may be reached through the external meatus. This operation is employed as a means of curing chronic purulent otitis media by the removal of diseased tissue and the promotion of drainage, and for rendering the tympanic walls more accessible to local treatment. It is an intermediary between the non-operative method of treatment and the radical mastoid operation.

Indications. The intra-tympanic operation is indicated: (1) When a purulent inflammatory process in the middle ear does not respond to local measures of treatment in cases wherein the diseased process is chiefly confined to the drum membrane, ossicles and the tympanic walls. (2) After recurrence of polypoid proliferations, unless such recurrence is associated with evidences of extensive necrosis in the aditus, mas

toid antrum or labyrinth, clinical evidences of which are continued discharge with foul odor; perforations in Schrapnel's membrane, or along the upper posterior walls of the tympanic membrane; pain in the mastoid region; vertigo, nausea and vomiting. (3) As a preliminary to the radical operation, either on patients who never have given evidences of complicating symptoms, and in whom it is hoped that improved drainage and subsequent persistent local treatment will effect a cure of the disease; or in patients who demand a preliminary operation rather than submit to the more formidable procedure as a last resort. Proportionately the number is not large.

The Results.-In my own experience the results have been favorable in a considerable proportion of all cases operated upon. In carefully selected cases or localized chronic otorrhea with large perforations in the drum membrane proper, and who furnish no history of recurrent mastoiditis, the results have been good, complete recovery being the rule. By recovery is meant a

cessation of otorrhea.

The removal of the tissues above mentioned improves the drainage from the tympanic cavity, attic and the mastoid antrum. Hence even though the otorrhea may continue, the establishment of drainage tends to lessen the complicating dangers of the disease.

The operation is not wholly without danger. The facial nerve, denuded of its bony covering in the region of the labyrinthine (mesial) wall of the tympanum, may be injured during the operation, with resultant facial paralysis. Deliscences over the jugular bulb sometimes lead to injury of the blood vessels at these points with serious consequences. Curettment of polypoid proliferations from the parietal surface of the dura in cases where the tegmen has become destroyed by necrosis, has been known to cause serious meningeal involvement.

The chorda tympani nerve which runs in the posterior fold of the drum membrane is often severed with resultant derangement of taste on the corresponding side of the tongue. This injury is negligible.

THE SIMPLE MASTOID OPERATION.

Indications. A simple mastoid operation is indicated wherever a purulent inflammatory process has invaded the mastoid. antrum and mastoid cells with the following evidences:

(1) Pain over the mastoid region. The pain is deep seated and continuous, and radiates over the entire side of the cranium. The facial expression is that of anxiety and suffering.

(2) Tenderness on pressure over the mastoid cortex. The localizing points of tenderness are found over the mastoid antrum, the mastoid tip, along the zygoma and about the entrance of the mastoid emissary vein. Tenderness is sometimes entirely absent.

(3) Drooping of the postero-superior canal

wall, and bulging of the drum membrane, which does not diminish as a result of paracentesis.

(4) Fever. The rise in temperature is not characteristic, but is more marked in infants and young children.

(5) Discharge. The discharge may be simply excessive with a tendency to increase rather than diminish; it may be of virulent type, or a sudden cessation of discharge may take place with simultaneous increase of mastoid pain. A prolonged profuse aural discharge which resists. all approved measures of local treatment, including paracentesis, is considered by many otologists to furnish sufficient indication for the performance of the simple mastoid operation. Some recent experiences have led me to believe that, given an acute purulent otitic inflammation with fetid odor wherein it has been demonstrated that the invasion has been one of the more virulent types of pathogenic bacteria and in patients of weakened vitality, if the discharge manifests no tendency to abate after six or eight weeks, a mastoid operation must be seriously considered. In the majority of cases of this type occurring in my practice extensive disease of the mastoid cells has been found.

(6) Sub-periosteal post-auricular swelling, with or without superficial abscess.

(7) The operation is imperative in the presence of symptoms of intra-cranial complications or of purulent labyrinthinitis.

(8) The advent of facial paralysis. This complication invariably indicates the necessity for an immediate mastoid operation, on account of the intimate relationship which exists between the facial canal and the labyrinth.

(9) Blood examinations in conjunction with other symptoms of mastoiditis are of great diagnostic value. A high leucocytosis and polynuclear percentage indicates the presence of infection in some portion of the body.

In addition to the above-mentioned indications. it may be stated that on account of the manifest danger of serious complications, the mastoid operation is a life-saving measure, and although it is performed primarily in the interest of the life of the individual, there are secondary considerations which materially enhance its value, and, as a consequence, are worthy of note at this point.

The mastoid operation in acute mastoiditis quickly terminates a purulent necrotic process which otherwise might become chronic and attended with all the train of deleterious and dangerous results which accompany this troublesome affection. To mention them is sufficient: (1) Necrosis of bony areas which are closely related to vital structures. (2) The prolonged and constant danger of serious labyrinthine and intercranial complications. (3) Loss of hearing.

It will thus be seen that even though a patient suffering from acute mastoiditis might recover from the acute symptoms without loss of life,

The time for operative interference is ever dependent upon a satisfactory diagnosis of the presence of destructive purulent inflammation in the mastoid cells. Just when the exact time has arrived may not be measured by days or hours, but the simple mastoid operation should be performed in acute purulent inflammation which involves the mastoid cells, whenever a permanent remission of symptoms has not been effected either by drainage through the drum membrane, rest in bed, or the employment of local measures such as have been described in a previous paper.

Much has been written in favor of a so-called early, simple, mastoid operation, and if by this is meant operation as soon as it can positively be demonstrated that a purulent inflammatory process has invaded the mastoid cells, which is too virulent and too extensive to offer any hope of spontaneous cure either by drainage or absorption, then the early operation is to be recommended.

On the contrary, it is not wise to operate immediately upon every patient who has tenderness on pressure over the mastoid antrum, during the first three or four days of the attack, for the reason that in the milder cases, it is quite possible for drainage through the aditus, combined with local absorption, to effect a cure without operation, and, further, it is deemed safer in the interest of the patient to operate after Nature has thrown out some protective limitations to the disease within the mastoid cells.

There are some dangerous indications which call for immediate operation, whatever the concomitant symptoms may be, and among these

are:

(a) An acute mastoiditis occurring in an ear which is the seat of chronic purulent otorrhea.

(b) Upon the advent of symptoms of labyrinthinitis, the chief of which are nausea, vertigo and nystagmus.

(c) The appearance of facial paralysis.

(d) The appearance of symptoms of intracranial involvement.

Without entering into a description of the operation, it may be stated that the simple mastoid operation, when properly performed, should extend to the limitations of the disease itself, and this usually calls for the removal of the mastoid cortex, the complete exenteration of all mastoid cells, especially the large cells at the tip, those posterior to the sigmoid flexure, in the zygoma and the curettment of all granulations and necrosed areas and the establishment of post-aural drainage of the mastoid cells and the aditus.

The simple mastoid operation, when skilfully performed and previous to the advent of serious