OTITIS INTERMITTENS; OR, "MALARIAL OTITIS."

WITH OBSERVATIONS ON THE USE OF QUININE IN DISEASES OF THE EAR.

BY LAURENCE TURNBULL, M.D.,

PENNSYLVANIA.

In a report of two hundred and ninety-one cases of diseases of the ear, published in 1873, there will be found "intermittent otitis," at that time a rare affection, and first brought to the writer's notice in the case of a physician, Dr. Harden, of Berlin, reported by Dr. Weber-Liel, of Berlin, in 1871, and cured by full doses of quinine.

We were aware that excessive doses of quinine would in some rare cases produce temporary deafness of twenty-four hours' duration, and we were also familiar with its use, associated with morphia, in the chill accompanying otitis interna, and in otalgia, but had never before employed it as in the case we are about to relate until 1873.

CASE I. "Otitis Intermittens."-Miss M. H., aged twenty-one, Philadelphia, daughter of wealthy parents, fair, delicate skin, small in stature, and not robust. On father's side tendency to phthisis; mother stout, suffers from a heart affection, and irritation of brain. She is the eldest child, has had what the mother calls a running from left ear for a long time, and has been under the care of four different physicians. The running would almost cease for a time, but after exposure would return. She came under the writer's care in January, 1871, and continued under careful and constant treatment until July, when she was discharged well, and has continued so up to this date, March, 1881.

The following were her symptoms and the condition of the

Transactions of the Medical Society of the State of Pennsylvania, 1873.

ears. On examination the surface of the meatus was found studded with minute abscesses, some of them open, others in a swollen state with apices containing a minute portion of pus. If they were large they gave her considerable pain until discharging, they left the meatus slightly red and swollen. The membrana tympani of the left ear was opaque, the right normal. Hearing distance for low ticking watch on left side only; right side. Discharge stains the pillow, and has some odor, which is very annoying to the patient. Finding some slight dulness on percussion under one of the clavicles, and also being informed that cod-liver oil had checked the discharge, I recommended its continuance with extract of malt, nourishing animal diet with occasional use of iodide of iron in pills, directing a wash of solution of sulphate of zinc, glycerin, and carbolic acid, with the use of Politzer's air douche. In three weeks the hearing distance improved to 14, but no decrease in the discharge. She complains of more pain, therefore directed morphia to be added to the zinc injection, employing Clark's ear douche twice a day to wash out the meatus, which duty was carefully attended to by her mother. Feb. 28, no discharge for several days. Found the cod-liver oil was disturbing the stomach, directed small doses of strychnia with compound syrup of hypophosphites and sherry wine. This she took for some time with great advantage.

She continued about the same during the months of March and April, at the end of which she went to Annapolis, Maryland, a place she had been accustomed to visit for several years. On her return she had a slight chill every second day, and an increase in the discharge from the ear. I at once took the hint, and gave her full doses of quinine, with entire relief to the chills, and also checking the otitis. The hearing of the left ear was very much improved, and has continued so up to the present time.

We republish this case as an example of many we have had since, to show we were one of the earliest in this country to take advantage of the hint of our good friend "Weber-Liel" in the treatment of such cases. Ever since we had such success in the above and other cases, resort has always been had to the quinæ sulphas in all obstinate cases of this disease. We prefer the original term, intermittent otitis, to the one which it has

recently received by Dr. H. Hotz,' of "malarial otitis," as this same term is applicable to a form of disease of the ear the result of emanations from sewer gas, foul drains, and other unsanitary conditions; the symptoms were first described by Dr. Cassells, of Glasgow, as follows: Severe pain in head and ears, which were acutely inflamed, with congested membrana tympani, which were relieved by freely incising each membrana tympani, giving free exit to clear serous fluid, which continued to drain away for several days. At the end of three weeks, and without further special treatment, no quinine need be employed, the cases recovered, but with the removal of the cause, which existed in a house in which the escape of sewer gas into it was from two of the water closets. This condition is to be found not only in the city, but in the country where many houses are built without the smallest regard to the drainage of the site upon which they are built; moisture is drawn from the undrained soil. In the intermittent or "malarial otitis" Dr. Hotz dwells upon what he considers a peculiar symptom noticed, namely, "a remarkable intolerance of any application in the ear, and a strange disproportion between the objective changes observed in the auditory canal and middle ear, and the degree and extent of the subjective symptoms. The patients showed great nervous prostration and were suffering from pain in the ear and head of such violence as we usually find associated only with acute suppurative inflammation. Weber-Liel's observations were first confirmed by us, and subsequently by Voltolini.3

Both varieties of the disease were referred by Weber-Liel to malarial neuralgia of the third branch of the fifth or trifacial nerve, the otalgia being a malarial neuralgia pure and simple, the otitis being an inflammatory affection, the expression of a vaso-motor trophic neurosis accompanying or produced by the neuralgic affection. After the irritating influence of the malarial poison in the first fever has ended in a severe paroxysm of pain, simultaneously existing in all the branches of the trifacial and neighboring nerves, the malaria is shown for a considerable time longer in the form of a vaso-motor neurosis, as the effect of which there is injection of the tympanic blood vessels and a collection of muco-purulent secretion in the tympanum.

1 Archives of Otology (vol. ix. No. 3).

2 Edinburgh Medical Journal, April, 1878.

3 Monatsschrift für Ohrenheilkunde, Nos. 5 and 7, 1878.

The symptoms and course of the ear disease are thus given by Weber-Liel: Generally, although not always, there has been a preceding angina or naso-pharyngeal catarrh, when towards evening or in the night there is a chill, perhaps so slight that it is scarcely noticed; this is followed by a feeling of fulness and roaring in the ears, and sometimes by vertigo and pressure in the head. The patient passes a restless night, with profuse perspiration, but on the next day is perfectly well, and the ear symptoms have passed off. Forty-eight hours or so after there is another chill, with shooting pains in the ears, deafness, and increased subjective noises; an examination of the ears often shows in this stage an exudation in the tympanum. As the stage of perspiration comes on after the chill, the patient falls asleep, to awake perfectly well, except that the subjective noises continue. If the exudation of the tympanum has ruptured through the drum membrane, the discharge, which was perhaps profuse during the night, ceases by morning, and all pain is relieved. Tenderness of the tragus, which was marked during the attack, is also relieved. Thus the attacks continue, following the quotidien or tertian type, with intervals of perfect freedom from all general symptoms, although the local symptoms in the ears increase in severity, and the intermissions, so far as the ear is concerned, become less and less marked, till finally · the ear symptoms are a constant irritation. Usually but one ear is affected. The mastoid cells may gradually become involved and be filled with pus. Local treatment, even paracentesis of the drum membrane or perforation of the mastoid cells, affords only temporary relief to the constantly recurring attacks of pain. Neither the air douche, warm or cold applications, or morphine injections prevent the recurrence of the nightly pains. Quinine alone in a large dose gives relief, and the earlier it is prescribed the more thorough and rapid is its action. In these cases Weber-Liel asserts that he has found the spleen enlarged and tender. If the disease has continued for a long time, as it sometimes does even for months, till the local changes in the ear have become thoroughly developed, the quinine then is of no value. In all cases of subjective noises and tympanal catarrh, dependent upon malaria, large doses of quinine diminish the noises and deafness, he says, while in the common forms of the disease the same medication has the effect of increasing these symptoms very decidedly. Weber-Liel has seen affections of

the meatus, especially furuncles, showing a decided intermittent character, and has healed them rapidly by quinine; in these cases he thinks the disease is the expression also of a vaso-motor trophic neurosis, the result of a neurosis in the course of the trifacial nerve. Voltolini described several cases which showed a similar intermittent character, and which were only relieved by quinine. He also protests against the common method of giving quinine in large doses at once, but prefers to prescribe one or two grains every second hour; by this method he claims to have met with brilliant results. In obstinate cases of malarial disease he considers that the quinine should be taken for a long time; not, however, in frequent doses after the acute symptoms have been relieved, but three or four times in the day, and this to be continued for some three months.

Dr. J. Orne Green' describes a case of otitis intermittens in a female patient who suffered regularly every evening from feverish symptoms, pain in the face, teeth, and head, and especially in the region of the ear. These neuralgic symptoms, which affected only one-half of the head, were accompanied with an inflammation and discharge from the ear on the same side. After a few hours the patient fell into a perspiration and the symptoms disappeared. There was no malarial fever in the neighborhood, but the sanitary condition of the dwelling proved very unfavorable. All the symptoms improved by a change of residence on the part of the patient.

It is somewhat remarkable that quiniæ sulphas has been employed successfully in almost all affections of the ear in the prevention and relief of acute otitis externa media, or interna, and still holds its own as the sole remedy in the most distressing form of disease of the ear termed "Ménier disease," or what is more correct, Ménier's class of symptoms in which auditory nerve vertigo is one of the most important symptoms. It is stated in a recent work on the ear, on p. 152, eighteenth line from the bottom of the page: "Finally, in children the internal administration of quinine sometimes gives rise to an acute or subacute inflammation of the middle ear." Yet in these very cases reported, there already existed before the quinine was administered, "a slight tendency to nasopharyngeal (and prob

1 Boston Med. and Surg. Journal, April, 1879.

2 Diagnosis and Treatment of Ear Disease, by Albert H. Buck, M.D.: Wm. Wood & Co., New York.