CHAPTER XVII. THE CONSEQUENCES OF CHEONIC SUPPURATION OF THE (Part 3)

the tympanum, with symptoms of more than usual cerebral irritation. From this disagi-eeable complication he has entirely recovered under Dr. Agnew's care. His general health being impaired, he went abroad, and while in London consulted Mr. Toynbee, who used bougies, hoping to dilate the canal ; but, according to Mr. C.'s statements, they caused much pain and accomplished nothing. Through Dr. Agnew's courtesy, I again saw the patient in the spring of 1865, and found that the growths had so much increased that only a small probe could be passed between them, and the hearing more impaired. The patient could still, however, hear the watch tick, but only when laid on the auricle. The patient whose case is here given, died about two years after, of inflammation of the membranes of the brain, induced by suppuration in the cavity of the tympanum, the pus not being able to find an outlet on account of the presence of exostoses. Dr. Agnew exhibited the brain and temporal bones before the New York Pathological Society. The history of the other ear of this unfortunate patient will be found in the section on caries and necrosis. Case II. — A gentleman, set. 40, whom I saw but once, in June, 1864. He states that he had a " running " from his right ear for a number of years. For some two or three years past he had observed that the ear was stopped up. He was accustomed to remove the accumulating discharge by thrusting in a match armed with cotton. There is seen a bony growth arising from the posterior wall of the meatus, and involving the whole caliber of the canal, except a space large enough to admit an ordinary sized silver probe. Through this opening a slight amount of purulent discharge, constantly makes its way. There was some hypersemia of the pharynx, and there was a small ulcer on one of the tonsils. The patient was in excellent general health, was rather a free liver, and said he had constitutional syphilis ; but no good evidence of its existence now existed. The patient had never had rheumatism or gout. Case III. — Mr. S., aet. 25, Conn. February 6, 1865 (a patient sent to me by Dr. Alfred North, of Waterbury, Ct ). — When the patient was three or four years of age he had scarlet fever, at which time his ears began to discharge, and they 406 EXOSTOSES — CASES. have continued to do bo at intervals ever since, with attacks of pain in the ears, which sometimes lasted for weeks, and prevented him from any occupation foi the time. Eight years ago his ears were examined and polypi discovered, one of which was removed by caustics. The attacks of pain have continued to occur, the discharge continues, and his hearing is become more and more im- paired. He is just now suffering from acute pain referred to the left ear. He hears the watch about one inch from each ear. In the right meatus there is seen a bony growth reaching nearly out of the orifice of the external meatus, and arising from the posterior wall. The space between the growth and the anterior and upper wall is about large enough to admit of the introduction of a camel's hair brush. In the left meatus, there is seen a gelatinous granulation, also reaching nearly out to the orifice of the meatus. On blowing air into the cavity of the tympanum, by means of the Eusta- chian catheter, air and fluid are heard making their exit into the external meatus ; but the blocking up of this passage prevents their emergence. On the right side pus may be seen in the orifice between the bony growth and the wall of the meatus. The confinement of the fluid in the middle ear accounts for the pain in the left side, and the indication of treatment was to secure its free exit. This was done by removing the gelatinous growth by torsion, the patient being ether- ized, and rendering the Eustachian tubes permeable by the use of the well- known means — the catheter and Politzer's method. The granulation was found to have its origin from a general bony expansion of the meatus. This growth had no one growth of attachment, but involved all the sides of the meatus, somewhat more expanded externally, giving the bony canal rather a funnel-shaped appearance. The bone was roughened. The pain in the ear disappeared as soon as these means for securing an outlet to the pus, con- stantly secreted from the cavity of the tympanum, and passing through the perforated membrana tympani, had been taken, and the hearing was so much improved that the watch was heard about four inches from the left auricle. He remained, under treatment for a few days, and then returned to Waterbury, and has been under the careful and able observation of Dr. North, who has applied remedies of various kinds to the left meatus, the patient keeping the Eustachian tubes permeable by means of gargles and Politzer's apparatus. The last time I saw the patient was in October of this year (1865), when the following note was made : " He had had no attack of pain in the ear since the first date. There is still a considerable discharge of pus from each ear. He hears ordinary conversation well, and the watch ten inches from his left ear, and two inches on the right : a gain of one inch and nine inches respectively." The bony growth on the right side has not increased any, and that on the left is now smooth, and has a somewhat glistening appearance. June, 1868 — Pa- tient still remains free from any disturbing symptoms. Dr. North writes me, March 25, 1873, that " the patient's general health is good. He hears ordinal conversation readily, and Dr. North's watch 8$ inches from the left auricle and 1|- from the right. The bony growth has a smooth, shiny appearance, and only admits the passage of an ordinary sized probe. The discharge from the ear is slight and of a watery nature. He has EXOSTOSES — CASES. 407 no pain in either ear. Any increase of the impairment of hearing is always relieved by an application of tincture of iodine to the bony growths." Case IV.— Woman, set. 27, at the New York Eye and Ear Infirmary. No reliable history could be obtained from the patient as to her ears, except that she had been occasionally hard of hearing for some years. She was quite sure that she never had had a discharge from the ears ; was in good general health, and had always been so. She could hear the watch two feet from the left auricle, and twelve inches from the right. The left membrana tympaui showed evidences of previous inflammatory action, there being thickening of its mucous and fibrous layers. There is a bony enlargement of the posterior wall of the right meatus, so large as to prevent any view of the membrana tympani. The patient was seen but a few times, not continuing under treat- ment. Case V. — Mr. W., aet. 23, a patient sent to me by Professor Fordyce Barker, of this city. Had scarlet fever when young, and since that time has suffered from purulent discharge from the ear, and has been quite deaf. General health is excellent. No gouty, rheumatic, or other diathesis. Hears ordinary conversation very near at hand with very great difficulty. The watch is heard when pressed upon right meatus ; not at all on left. A gelatinous polypus was found attached to the hypertropic posterior wall of the auditory canal. It was removed by torsion, and nitric acid applied to its roots. On left side there is a pedunculated bony growth, arising from the posterior wall, nearly occlud- ing caliber of canal. Naso-pharyngeal catarrh. June, 1868— Patient has been under observation since first date. Now hears conversation much better ; watch at a distance varying from one to two inches on right side. Secretion of pus, which when patient was first seen was profuse, is now slight. Growths remain the same. Case VI.— Miss , set. 25. March, 1873. I was asked by Dr. E. G. Lor- ing to assist him in the examination, under ether, of a case of tumor blocking up the external auditory canal, with a view to its removal if practicable. The tumor was so sensitive to the touch of a probe, that no thorough examination could be made. The patient was about twenty-five years of age, and had suf- fered a great deal from what she called rheumatism of the back, but which seemed to have been neuralgia. She was rather small and delicate, but in fair general health. She was placed under the influence of ether, and a thorough examination was made by Dr. Loring, Dr. Pardee, and myself. The tumor arose from the posterior portion of the osseous canal of the right ear, and nearly occluded the passage. There was a minute opening between it and the anterior wall, through which a No. 2 Bowman's probe could be passed into the cavity of the tympanum. The tumor was of bone, and covered by a movable integument, which was red and very sensitive. On passing the probe into the minute opening that has been mentioned, it could be passed under the growth, and when pressed upon the growth was seen to move slightly. The history of the case was, that there were frequent attacks of pain in the ear, without discharge, until the patient was eleven years old, since which 408 MASTOID DISEASE. time there Las been no true " ear-ache," and no discharge, although the parts are tender, and there is a great feeling of fulness in the ear. The watch is not heard at all on the affected side. The tuning-fork is heard better than in the other ear, which is normal. The examination, during the anaesthetic state, of the tumor by the probe, caused it to be very sensitive when the patient recovered from the ether. The aural douche was used to quiet the pain. The patient was advised to continue to use the douche ; but inasmuch as there was no pus in the tympanic cavity, and the removal of the growth seemed to involve considerable danger from periostitis, any further treatment was delayed until urgent symptoms should arise. May 8, 1873 — There is considerable pain in the depth of the ear, and Dr. Loringand I advise, that some operative means be taken to remove the growth. The history of this case indicates that there was originally a suppurative action, for we can hardly believe that very severe pain occurred so frequently as was stated, until the patient was eleven years old, with no suppuration. The exostosis, which probably then began, has been growing ever since, until it has reached the present limits, where it seri- ously threatens the future of the patient. MASTOID DISEASE. As we have seen, in considering the diseases of the middle ear, and in discussing its anatomy, the mastoid process is neces- sarily involved in any severe inflammation of this part of the organ of hearing. This may also be the case in an acute or chronic inflammation of the auditory canal, for the mastoid process opens into this part also. Yet there is a form of mastoid inflammation which assumes such importance, and overshadows the inflammatory action in other parts to such a degree, that it demands an especial study, and especial treatment. The usual treatment of an acute inflammation of the external and middle ear soon causes the symptoms of the inflammation of the lining membrane of the mastoid cavities to subside ; but when the mastoid process is involved in the course of a chronic suppurative process, the ordinary treat- ment will not avail. More prompt and decisive means are usually required. Under such circumstances, diseases of the mastoid often assume such proportions of severity and danger, that we are justified in speaking of mastoid disease as a com- MASTOID PERIOSTITIS. 409 plication requiring especial notice and treatment. Perhaps it is a complication or consequence of chronic suppuration in the middle ear, only second in gravity to an extension of the inflammation to that portion of the dura mater covering and running into the tympanic cavity. The diseases of the mastoid that may arise as a conse- quence of a chronic inflammation of the middle ear may be divided into the following varieties : 1. Inflammation of the periosteum. 2. Caries and chronic suppuration. It is true, as has been already indicated, that the first form often arises in the course of an acute catarrh, and that it perhaps always exists to a more or less extent in this dis- ease ; but it is no less true that a chronic suppurative process that has been going on quietly for years perhaps, will suddenly become an acute inflammation of the mucous membrane and periosteum of the part, and require especial and prompt treat- ment. The mucous membrane lining the mastoid cells is so closely connected to the bone, that, like the mucous membrane of the cavity of the tympanum, it is essentially a periosteum. Caries and necrosis are of course the same affections that occur so frequently in other parts of the middle ear, and from the same cause — imperfect removal of the pus that has been forming. Sclerosis and hyperostosis of the bone has also been con- sidered as a separate morbid condition by Agnew* and A. H. Buek,f but as admitted by the latter author, the cases are not yet numerous enough to allow us to make a positive diagnosis of this disease from clinical facts. We are, perhaps, justified, in this practical treatise, in classifying this class of cases under the head of periostitis. Symptoms. — The symptoms of mastoid periostitis are usu- ally sufficiently striking to arrest the attention of the medical adviser so soon as they occur. During the course of an acute or chronic suppurative pro- cess in the middle ear, the patient begins to complain of great * Transactions of the American Otolo<?ical Society. f Archives of Ophthalmology and Otology, vol. iii, STo 1. 410 MASTOID PERIOSTITIS — TREATMENT. pain behind the ear, the mastoid process becomes red, tender, and swelled. This is the usual course, although at times the ' pain is not referred especially to the mastoid, even when it is evidently involved, as shown by the redness or tender- ness of the part. The pain is usually of the severest kind, preventing the patient from sleep and from his usual occupa- tions, although he may not be confined to the house. The early diagnosis of this affection is by no means an unimportant matter. A delay in the recognition of the true state of things allows of the extension of the disease to the brain through some of the numerous foramina which transmit the minute branches of the middle meningeal artery. Pus may also be carried into the circulation through the mastoid vein which passes to the lateral sinus. Professor Alfred 0. Post, of this city, who was one of the first physicians in this country to give diseases of the ear the same attention that was paid to other parts of the body, has seen several cases where disease of the brain and death have resulted from the non-recognition of mastoid disease. Many neglected cases run their course, however, with great suffering to the patient, and with much loss of function, with- out destroying life. This is proven by the frequency with which mastoid cicatrices are seen in our aural cliniques. The history of such patients usually shows that they have had a narrow escape, but that nature has at last given relief by an external opening through which the pus and dead bone made their way. Treatment. — The treatment of mastoid congestion and peri- ostitis is very simple. An incision should be made through the integument and periosteum down to the bone. The inci- sion should be from below upward, lest the knife should slip and pass into the tissues of the neck. The opening should not be a puncture, but a cut of from three-quarters to an inch i and a half long, or even longer, according to the age of the sub- ject. The incision should be parallel to the attachment of the auricle. Even if the posterior auricular artery be wounded, the bleeding can be readily arrested by pressure or torsion. I have never found any alarming hemorrhage. A free escape of MASTOID PERIOSTITIS — TREATMENT. 411 blood is desirable. The surgeon who has not made this inci- sion in cases of mastoid periostitis will, perhaps, be surprised at the depth of the tissues when they have become infiltrated from an inflammatory action of some days standing. I have sometimes been amazed at the depth to which the scalpel entered, especially when pus has formed. Pus will not be found in the majority of the cases, but the indications for an early, free, and deep incision are imperative when we find red- ness, tenderness, and swelling of the mastoid process in con- nection with an inflammatory process in the ear. It should be remarked, however, that there are some inno- cent cases of mastoid disease that may occur in the course of an acute catarrh — cases that will not demand the incision that has been described. Young children, especially children of stru- mous habit, at times suffer from an infiltration of the tissues of the mastoid, which may, if carefully watched, be allowed a little more delay than the same class of affections occurring in an older subject. There is a phlegmonous inflammation of this part occurring in young subjects, which does not go on so rapidly or painfully as a periostitis. Still, in