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period of observation would permit the evolution and development of what is, at that stage, the incipient clinical picture; and thus the case would be placed in some other category than that of the otitides. How common it is to find the pneumonia developing the second day after the paracentesis which brought forth no pus from the ear, to cite only one instance from numbers of such cases.

To err is human, and the law of averages holds for mistakes as well as for any other human activity; but surely the medical practitioner who repeatedly sees such findings may be pardoned for pausing and questioning the advisability of a procedure which incises a cavity, presumably filled with purulent contents, which failed to show any signs of evacuation upon being opened. Let us agree, at least, upon one thing: Eardrums shall be opened to evacuate pus, and for no other purpose. They shall not be opened to relieve otalgia. For this other therapeutic measures are available.

The significance of the above once accorded, the next proposition is comprehensible. Again the conclusion is presented first, namely,

Repeated paracentesis not only does not prevent the development of an operative mastoiditis, but is in itself poor therapy which often results in permanent functional disability to the patient. The functional disability, the loss of hearing acuity which results from repeated attacks of acute catarrhal otitides, is too well known to need repetition. This functional disability results from the formation of intratympanic adhesions and permanent contractures in the delicate structures of the middle ear. How few stop to consider the functional disability which must result from the oft-repeated incisions into. the drum-heads of these little patients!

Cases have been met where paracentesis was performed four times in as many days upon the same patient during the recent influenza epidemic. Those guilty of this practice do not see these patients later, when, because of loss of hearing, they become handicapped in their studies or in their vocations and come to us for relief, when the onset of their loss of hearing can be traced to the traumatized middle ear which occurred in early life. The permanent perforations, the scar tissue replacements and the adhesive bands which are found are all traceable, to a great extent, to this deleterious practice of repeatedly incising the drumhead.

An incision of the membrana tympani to evacuate pus, properly performed, should 1equire no repetition; and where this practice is indulged in, where no flow of pus has eventuated, it seems to your essayist a nefarious one. A patient presents a systemic infection, runs a temperature and has reddened drums; and a physical examination is negative. The throat may be red. The drums are incised. No pus is obtained and, in a few days, the general clinical picture persisting and a subsequent examina- ́ tion revealing general negative results, the ears meanwhile having, fortunately, attempted to close, paracentesis is again performed. Meanwhile, the systemic infection continues, and thus matters go on for another few days, and the ears are again incised. It seems in some cases as if Nature eventually gratifies the persistence with which the one practicing this kind of otology seeks pus where there is none, by sooner or later presenting a secondarily infected ear; and then the case is thought to be understood. But the temperature drops because the systemic infection has run its course; and the patient emerges from the sick

room with a secondarily infected middle ear superimposed upon a body weakened by a general systemic infection; and is a proper candidate for eventual mastoid involvement.

The rôle played by the repeated paracentesis in inducing the condition is hardly comprehended, and one should really classify such a case as a traumatic mastoiditis rather than as one of the sequelae of a systemic infection. I may be pardoned for overdrawing the suppositious case so as to point the lesson more strongly, but during the last winter, case histories analogous to the hypothetical one given above have been met with oftener than one would like to acknowledge.

In regard to this proposition of repeated paracenteses, another group of cases comes under observation. These are cases on whom a paracentesis has been performed based upon well founded indications; and in the course of a week or ten days the disease in the middle ear is attempting to run its course and come to its termination. As these cases reach their terminal stage in the process of resolution, the discharge is finally becoming more scant; and then, because of some indiscretion in the child's diet or for any other extraneous reason, a slight elevation of temperature ensues with the result that, the clinical condition in the ear not being recognized as being in the stage of resolution, paracentesis is again performed upon a drum-head which is tending to close and end the chapter as far as that particular otitis was concerned: but the attending physician or pediatrician upon that case prevents, by his repeated paracenteses, natural resolution. Had he left that ear alone during this period of resolution, the drum would have closed as the pressure within the tympanic cavity came down to normal, and eventually a normal middle ear would have

resulted; but his secondary paracentesis again opening up the cavity, while the mucous membrane lining the middle ear is still thick and edematous from the infection which is just about to run its course, the infection lights up again and the structures which have just about been able to maintain themselves against the primary invasion offer a weakened resistance to the secondary attack: and from this secondary infection there eventually results a so-called surgical case of mastoiditis. Or, the purgative or other remedial agent which the wise practitioner has also administered has accomplished its purpose and the temperature drops; and this result is ascribed to the secondary paracentesis. I have met cases where Nature was crying for the privilege of healing an ear, and where injudicious interference kept it open until a "hands off" policy in regard to the ear was insisted upon, when all that was needed was two or three days' time for the ears to cure themselves. There is urgent necessity for those handling these children to recognize that an otitis has an inherent right to resolve, and that the stage of resolution should be accorded the significance it warrants and interference with resolution by secondary paracentesis avoided. You may claim that expert opinion is necessary to recognize this stage of resolution, but my contention rests herein-that those who assume the responsibility of managing such cases must either qualify themselves to comprehend this situation or seek such expert counsel.

Finally, cases are met with in which the evolution of a classical mastoiditis is in being, and frantic attempts to ward off the impending surgery on the mastoid process are made by the practitioner, whose efforts. are mainly directed toward incision and reincision of the drum-head. Far better for

the patient's future health and welfare is it to meet the situation squarely by operative intervention upon the mastoid process than to attempt to ward off the impending surgery by repeatedly incising the drum-head, with all the deleterious features pictured above as end results, to be carried thru the patient's life as a permanent handicap; for simple mastoidectomy terminates in a healed ear which is functionally active, with hearing as normal as would have been the case -all other factors being equal-had there been no mastoid operation performed.

In concluding this argument on repeated paracentesis, it is germane to the question to say that such an attempt to ward off the impending surgery on the mastoid process usually fails to accomplish the object sought, for the reasons laid down in the first proposition advanced this evening-that neither the paracentesis nor the repeated paracentesis is in itself a factor which prevents the development of a so-called surgical mastoiditis. To illustrate this last proposition, I will cite the following case history because it points the lesson, not only of the propositions which have gone before, but of one other proposition which I will discuss with you this evening. The case history follows:

On May 11, 1920, S. K., aged six years, was admitted to the Park Hospital. Three weeks previously, subsequent to an attack of measles, the child began to complain of pain in the right ear, soon followed by involvement in the left, also. Five days later, double paracenteses were performed, followed by a profuse otorrhea for two weeks, when the left ear stopped discharging. During this period, temperature elevations were high, and the left ear was again incised, but no discharge of pus was obtained. One week before admission, with temperature elevations as high as 103-104, both ears were again incised because of the absence of discharge from both middle ears. There was no complaint of pain locally. The temperature continued, ranging up to 104, for four days, when severe persistent headache was the chief complaint. The attending otologist again incised the ear-drums, obtaining a discharge which lasted about twenty-four hours, only. The temperature and cephalalgia continued, and some

edema developed about the right ear. A radiogram of the mastoid was negative.

The writer, who was called in consultation that day, found the patient septic, with chilly sensations but no pronounced chills, a temperature of 105, a slight discharge from both middle ears, a beginning Kernig and some rigidity of the neck. At this time, no other abnormality was noted. The mastoids gave no classical symptoms.

Cultures were at once taken from the ear discharges, a blood cell count was made and a blood culture taken. Till the time of the writer's visits, no laboratory aids to diagnosis had been used, and a tentative diagnosis of sinus thrombosis, which he made, was based therefore on the history of the case and its clinical picture, and was arrived at by a process of eliminating any other sources of the sepsis which, until that time, had been unaccounted for. It was extremely difficult to convince the medical attendant and the pediatrician who had been called into consultation as to the involvement of the ear. The absence of the discharge during the high range of temperature had failed to be accorded its due significance, and an expectant attitude had been adopted awaiting a more definite development of the clinical picture.

The culture from the discharge from the ears gave pure culture of pneumococcus. Following a preliminary negative report on the blood culture, the final report gave the streptococcus hemolyticus. The blood examination showed a leucocytosis of 39,000, with a differential count of 78% polynuclears, 20% small, and 2% large, mononuclears. Hemoglobin, 80% (Sahli). Red cells, 4,200,000. Color index, 0.95. No nucleated red cells.

Examination of the urine showed it to be turbid; amber in color; acid in reaction. There were heavy traces of albumin, no sugar, heavy trace of acetone, but very faint trace of diacetic acid. Microscopically, there were a few leucocytes and some pus clumps. No casts nor crystals.

The diagnosis was then conceded and the child admitted to the hospital.

The final proposition that I wish to present this evening in the light of a critique is this:

That mastoidal infections in children indicating surgical intervention may be present, and there need not be pain, either subjective or objective, as a symptom; nor need there be a high temperature accompanying the phenomena, altho in children there usually is. The differential diagnosis between acute purulent otitis media in children and this, the painless type of mastoiditis, depends on the finding of profuse, excessive discharge, and on the fact

that in acute otitis media the temperature soon drops, while in this type of mastoiditis the temperature may persist; altho in adults the temperature factor is not to be considered.

It requires no stretch of the imagination nor much argument these days for any one to recognize classical mastoiditis. The pain on pressure, the induration over the process, the sinking of the posterior meatal wall, the temperature, the discharge, the bacterial flora in the discharge and the history of the systemic infection standing in pathogenic relationship to the ear picture are all well understood and are usually promptly recognized, but the ear which has been opened once or oftener and which is discharging pus, the patient meanwhile being comfortable as far as the ear is concerned, running a temperature intermittently or steadily, very often not exceedingly high, these cases come under the group heading of the painless type of mastoiditis and are often overlooked until the stormy clinical picture of one or another of the intracranial infections makes its appearance.

Pain in the ear is due to two causes-to pressure of retained purulent secretions, or to a periostitis when the lesion has reached the outer covering of the process. In the class of cases which I am discussing, these factors are absent. A false sense of security is thereby engendered.

The lesion is, however, easily recognizable by a knowledge of its salient features. A profuse discharge from the ear, disproportionate in amount to what could reasonably be expected to come from so small a cavity as the tympanum, generally running from the external auditory canal onto the cheek, and at night, or when the patient is lying down, making a pool of pus on the pillow,

with little or no mastoid tenderness, is all that is generally present, subjectively or objectively.

In the case history cited above, the patient at first had a free flow of pus and the painless type of mastoiditis went unrecognized. Later, when the condition had run its course within the middle ears, these became dry, and the lesion which then caused the clinical picture had its seat in an infection of the blood vessels (sinus thrombosis) and the meninges.

In conclusion, the tendency these days to rely on laboratory aids to diagnosis manifests itself in some in an attempt to place diagnostic reliance upon radiographic findings. To those who think on the matter at all, the nature of the infantile bones and the absence of definite cell structure until later in life would make the conclusion inevitable that the use of the radiogram for diagnostic purposes in children is negligible in value. 51 West 73rd Street.

POSTOPERATIVE MANIFESTATIONS OF SYPHILIS; WITH CASE REPORTS.1

BY

WILLIAM SPIELBERG, M. D.,

New York City.

Case 1. S. G.-Patient is 13 years old. On June 27, 1919, he presented himself at the Ear, Nose & Throat Clinic of Beth Israel Hospital, Department of Dr. Kopetzky.

I examined the patient and found the following:

Rhinoscopic examination:-A profuse, yellow. ish, purulent discharge of marked foul odor completely filling up both nasal fossæ. On clearing away this discharge by suction, a perforation of the cartilaginous portion of the nasal septum was revealed, with the anterior border of the perpendicular plate of the ethmoid protruding forward and almost in contact with the right outer nasal wall; on slight manipulation, a large portion of the bony septum came away

Read before the Eastern Medical Society, New York City, November 12, 1920.

covered with crusts, pus and blood of intense foul odor, and found to consist of perpendicular plate and vomer, leaving a large perforation of the nasal septum involving both bony and cartilaginous portions; the remaining portion of the septum being swollen and covered by small areas of ulceration. The middle turbinates were markedly congested and bled easily to the touch of the probe, and almost touched one another thru the septal perforation. The floor was also covered by areas of ulceration and irregular swelling extending posteriorly to the soft palate.

Examination of the mouth and oropharynx: -Marked dental caries, tonsils and pillars absent, soft palate edematous with perforation just above and to the right of the uvula. Laryngeal examination:-Negative. Otoscopic examination:-Congestion of Shrapnel's membrane, bilateral.

These findings in a child of this age appeared to me to be unusual, and seemed to be rather the result of some general constitutional dis

ease.

The following interesting history was obtained from his mother:-One and a half years before patient presented himself at our clinic, he had his tonsils and adenoids removed for the relief of nasal obstruction and mouth breathing. No relief followed this operation; in fact, the nasal obstruction became aggravated and was accompanied by a constant muco-purulent nasal discharge, headaches and neuralgia pains at the root of the nose and face. After a lapse of seven to eight months it was thought that perhaps not enough of his adenoids had been removed or that there might have been a recurrence of the same; and patient was subjected to a second curettement of the adenoids. This was followed by complete nasal obstruction, marked nosebleeds, profuse, foul, purulent nasal discharge, severe headaches, marked restlessness and irritability and very disturbing nocturnal enuresis.

Family history:-Mother had three miscarriages. Occasionally she gets new growths of chest wall which break down, ulcerate and heal with big scars.

Wassermann tests taken of the entire family gave the following results:

Patient four plus. Mother two plus.

Father and two other children negative. Diagnosis:-From the above history and findings I made the following diagnosis:-Congenital lues with gummatous infiltration of the nasal cavities and soft palate, incited by trauma following the operation for removal of tonsils and adenoids.

Treatment:-Patient was referred for immediate and vigorous anti-syphilitic treatment in the department of Dr. Levin.

Case 2. Mrs. F.-Patient is 42 years old. Previous history is negative. Had five miscarriages. Six children alive and well.

Present history:-Nine years ago patient was accidentally hit on the nose, following which she began to suffer from intense headaches and pain at the root of the nose and face, worse at night. After two years of suffering, and not

having obtained any relief, patient applied to some New York clinic, where a minor operation was performed. Instead of being relieved, the above-named symptoms were intensely aggravated so that the patient, after a few months of more suffering, consented to a second and more radical operation, namely, a submucous resection of the nasal septum. Following this operation there was no improvement; in fact she felt worse, developed a profuse, purulent nasal discharge of intense foul odor, frequent nosebleeds, and at the end of one year following this operation, saddle-nose deformity. On June 30, 1919, this patient was referred to Dr. Kopetzky's Clinic at the B. I. H. by Dr. Levin's Clinic for Skin and Syphilis with a request for examination and diagnosis of the nose and throat condition. I examined the patient and found the following:

Rhinoscopic examination:-Revealed an extensive perforation of the nasal septum, involving the greater part of the cartilaginous and bony portions, areas of irregular swelling and ulceration of the remaining portion of septum. Atrophic rhinitis and accompanying ozena and pansinusitis as revealed by subsequent X-ray examination of the accessory sinuses.

Throat:-Examination revealed thickening of the soft palate with perforation of same to the left of the uvula.

Laryngeal examination:-Negative.

Otoscopic examination:-Retraction of both drums, light reflex absent, calcareous deposits, both drums.

Wassermann reaction:-Four plus.

Diagnosis: Tertiary syphilis with gummatous infiltration of the nasal septum and soft palate following nasal operation, with subsequent ulceration, necrosis, scar formation and contracture, resulting in saddle-nose deformity.

Treatment:-Both cases have received treatment at Dr. Levin's department and at our clinic.

Case 1.-Received mercury and salvarsan injection, following which nasal obstruction, headaches, and restlessness disappeared. The nocturnal enuresis did not subside until patient was put on extract pituitrin whole gland grains 22, twice a day, which controlled this symptom after its administration for two to three weeks.

Case 2.-Received the same treatment with resulting improvement and final disappearance of the ozena, partial closure of the soft palate, with marked improvement in the headaches. Both cases are still under treatment and observation.

Conclusions.

1. Before operating on any case of the nose or throat, make sure to rule out syphilis, which can easily be done by a careful history; and if suspicious, do not hesitate to take a Wassermann.

2. An early diagnosis is essential in these cases, so that immediate and vigorous antisyphilitic treatment can be commenced before scar formation and contracture begin.

3. Traumatization of tissues in a syph

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