the wound is dry. When the discharge remains offensive, which is very rare, it is better to depend on accurate tamponing than on syringing. Attempts have been made to close the wound by a complete suture and to let it heal under a blood-scab. Although this may often be successful in the hands of a thoroughly competent surgeon, it involves considerable risk. It is proper, however, in the case of an incomplete operation in which the antrum is not reached. When the diminished discharge does not require a voluminous dressing, a serviceable form of band

age is the one shown in Fig. 134, which is kept from becoming distorted by the insertion of whalebone at its two edges, while the bands of tape prevent it from slipping.

The mortality of mastoid operations is below 8 per cent. in recent years; in some published series of cases even very far below this figure or nearly zero. The majority

of deaths are due to the extension of neglected disease, and only a small proportion of the accidents can be ascribed to the operation. The mortality of mastoiditis without operation is not known, but must be very high.

CHAPTER XLII.

CHRONIC PURULENT OTITIS MEDIA.

372. Chronic suppuration of the middle ear is the sequel of acute inflammation. When the acute symptoms -the pain and the feeling of stuffiness-have subsided, and when the amount of discharge has become about uniform for a number of weeks, the disease can be called chronic and no spontaneous change in the condition can then be expected except in the course of long periods of time. The main symptom is the discharge. This is rarely profuse, generally scant, and sometimes so minimal that it dries in the form of crusts which the patient mistakes for wax. It is always purulent, but when copious, it is apt to be mucopurulent. With rare exceptions the discharge is offensive in smell-characteristically fetid. The rare exceptions are, on the one hand, occasional instances of copious thin mucopurulent fluid; on the other hand, a very scant discharge which dries in the form of minute crusts. The odor of the discharge should always be noted by mopping the meatus with a small pledget of cotton, as its persistence or yielding under treatment indicates the type of the disease and determines the prognosis. When the discharge is so scant that it cannot be seen in the meatus, it should be looked for by mopping with cotton. Even if this test fails, suppurative otitis should not be excluded in suspected cases until the search. for small flakes of pus is negative in the water with which the ear has been syringed.

The impairment of the hearing is very variable and depends principally on the destructiveness of the inflammation during the acute period. The deafness may be so slight that the patient is not aware of it. On the other

hand, the ear may be deaf for all practical purposes. The deafness does not depend so much on the perforation of the membrana tympani as on the adhesions in the attic, or between membrana tympani or ossicles and the internal tympanic wall. Noises and stuffiness are rarely mentioned. Dizziness is not common, but when present indicates active disease, usually in the attic (or, in severe instances, caries of the labyrinth).

373. Chronic purulent otitis may remain absolutely stationary, or may spontaneously heal temporarily or permanently or may present transient subacute exacerbations.

In the course of time and under favorable environment an otitis which has remained chronic for a long period. may finally heal without intervention. But this is not common. The vicious advice so often given by physicians of a former period to let an otorrhea alone was not founded on correct observations. When a chronic purulent otitis has healed, either spontaneously or in consequence of treatment, relapses may be expected under certain conditions. These are mainly the persistence of nasopharyngeal lesions which caused the disease in the first place, especially adenoid vegetations, and less frequently the purulent rhinitis of children. Occasional instances are observed in which a discharge from the ear is started with every severe cold, subsiding afterward even without aid. Independently of nasopharyngeal lesions relapses occur, besides, in a noticeable proportion of patients apparently cured of ear suppuration complicated with cholesteatoma or caries of bone. Whenever a purulent otitis has healed, leaving a permanent perforation of the drumhead, a subsequent attack of purulent infection of that ear begins always in a mild subacute manner and rarely with any intense acute symptoms.

The most serious cases of chronic purulent otitis are those occasionally subject to subacute exacerbations. These are mainly the class which I shall describe as the type of purulent otitis with retention of pus. The

aggravations vary very much in severity and danger. On the whole, however, their danger to life is much greater than that of primary acute inflammations of a hitherto normal ear. The majority of instances of pyemia and of intracerebral complications due to otitis occur in the course of subacute exacerbations of the chronic disease. Various estimates have shown that about to 1⁄2 per cent. of all deaths are due to ear disease, mainly in the chronic form (in European statistics). These statistics, however, are not absolutely trustworthy. It is worth noting that many life-insurance companies refuse applicants with chronic purulent otitis.

In

374. The liability of an acute suppurative otitis to become chronic depends on the severity of the infection and on the age of the patient. In very young children it is only the severe otitis of scarlet fever or diphtheria which is likely to become chronic, or perhaps a frequently recurrent inflammation due to adenoids. adults, on the other hand, the healing of an otitis without medical aid occurs only in the mildest forms of inflammation. The direct cause of chronicity is mainly the stagnation of pus with secondary infection from the meatus. In the discharge of the chronic disease the original parasites are not necessarily present. The pneumococcus has, as a rule, disappeared, and has been replaced by streptococci and staphylococci. The fetid odor is due to the coexistence of putrefactive bacilli. The change of an acute otitis into the chronic form indicates inefficient treatment. I am pleased to have noted the gradual diminution in the proportion of chronic purulent otitis presenting itself for treatment in the course of my practice, undoubtedly due to the better training of physicians in otology. It must be admitted, however, that some cases cannot be prevented from becoming chronic, except by opening the mastoid.

375. Instead of an unsystematized description of the appearances and lesions in chronic purulent otitis the author prefers to classify the disease under several heads,

with details regarding pathology and treatment sub

divided correspondingly.

We can distinguish clinically between

A. Simple chronic purulent otitis;

B. Purulent otitis with retention of pus-(with or

without complications).

In the first type of the disease the suppurating areas are accessible, and the fetor of the discharge is readily removed by cleanliness. In the second type there is retention of pus coming from inaccessible spaces, and the secondary infection which has caused the odor cannot be controlled by syringing. The distinction is based on pathologic grounds, but it can in some instances be recognized only by the therapeutic test. In describing chronic purulent otitis we must furthermore take into account the absence or the presence of complications-viz., polypi, bone disease, and cholesteatoma.

376. In simple uncomplicated chronic suppurative otitis the perforation of the drumhead seen after cleansing is usually of moderate size, sometimes round, sometimes

FIG. 135.-Large kidney-shaped perforation in membrana tympani in chronic purulent otitis; drumhead thickened, cloudy, and retracted; manubrium only partly visible; tympanic mucous membrane congested.

FIG. 136.-Perforation in lower part of membrana tympani in chronic purulent otitis; membrana tympani is thickened and opaque; the mucous membrane of the inner tympanic wall appears dark red through the perforation.

oval, sometimes bean-shaped, and anywhere in the membrana proper (Figs. 135 and 136-compare Figs. 10 and II, Plate II.). It is not common to see the small, pin-hole-shaped perforations found early during acute suppuration. On the other hand, the total drum