THE TREATMENT OF ACUTE OTITIS MEDIA.

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BY PROFESSOR BEZOLD, MUNICH.

Translated by Dr. ARNOLD KNAPP.

S the acute inflammatory processes of the middle ear are variously classified in the different text-books, it seems proper to first give an exact definition of the morbid processes with which we have to deal. Most authors distinguish three principal groups:

Acute middle-ear catarrh ;

The simple acute inflammation of the middle ear, otitis media acuta simplex, also called tympanitis acuta simplex; The acute purulent otitis media or acute purulent tympanitis.

The subdivisions into croupous and diphtheritic otitis media, myringo-tympanitis, and acute desquamative otitis can be disregarded.

A sharp distinction between these three main groups cannot be made either from an etiological or from a pathological standpoint. They are, in other words, different grades of the same morbid process.

The character of the secretion formed in the middle ear serves as a useful criterion to separate a catarrhal from the more truly inflammatory type. The fluid in the former is serous, while in the latter it is sero-purulent or mucopurulent. The two varieties of the more inflammatory type, the simplex and the purulenta, differ only in degree.

A distinct clinical picture is presented by that disease of the middle ear which depends upon simple occlusion of the Eustachian tube, whether the occlusion be acute or of

some standing. This tubal catarrh is sharply defined by its pathognomonic otoscopic picture, and by the immediate return of the hearing after removal of the tubal occlusion. The secretion, at first serous then later more viscid though transparent, may be regarded as a transudate ex vacuo.

The separation of this clinical picture from the other inflammatory processes was made from its clinical picture and functional findings, even before bacteriology had shown that this morbid process is entirely different from the middleear inflammation originating from infectious disease.

The examinations of Zaufal, Hasslauer, and others have shown that the mucous membrane of the normal tympanic cavity is not entirely free from pathogenic organisms. Scheibe and Brieger have examined the exudate in cases of tubal catarrh, and have always found it sterile; Kanthack, however, arrived at the opposite result. It is plain why cases with a collection of serum in the middle ear prove to be more sterile than the normal empty tympanum. Whatever few pathogenic germs were present were acted upon not only by the normally functionating, ciliated epithelium but also by the bactericidal action of the serum and thus rendered sterile. This process is therefore clinically, as well as etiologically and pathologically from the absence of organisms, distinctly to be separated from the truly inflammatory otitides.

Pathogenic organisms are always present in the acute otitis simplex and purulenta.

The attempt to divide the middle-ear inflammations according to the various kinds of organisms found has been generally given up, and the following facts have remained: In thrombo-phlebitis, streptococci are usually found to be present, while the pneumococcus is rarely followed by sinus thrombosis. The kind of organism does not seem to have any especial relation to the severity of the process, whether the simple or the purulent form of otitis. It may be stated that the streptococci were found present in the mildest forms of otitis after measles and after scarlet-fever, where the ear has been found affected in all the cases of children coming to autopsy, though clinically the ear disease was

not marked. This organism is regarded as especially deleterious by some authors. The various general diseases, excepting tuberculosis, whose course is apt to be complicated by otitis, do not give us any clue to divide these two varieties. The most severe as well as the mildest affections of the ear occur in scarlet-fever.

Nevertheless, it seems necessary to distinguish between these two forms clinically, as they differ in the intensity of the inflammatory symptoms and the frequency of accompanying complications. The kind of secretion in both cases is in the beginning sero-purulent, in the severer forms sanguinolent, and later more purulent. The same varieties of pathogenic germs found in the middle ear are present in the mild as well as in the severe inflammations.

The degree of extension of the suppurating process in the various cavities of the middle ear is not characteristic. No acute inflammatory process can be said to limit itself to the tympanum or to any circumscribed area, as pathological examinations have shown that even in cases where the clinical symptoms have been but little marked, as, for instance, in measles, the suppuration was found not only in the tympanum but in the antrum and mastoid cells. A fibrinous exudate may form in the beginning, at various parts of the mucous membrane.

The severe forms are characterized by unusually free discharge. A perforation in these cases occurs early. This usually takes place through the drum-membrane or through any dehiscent area in the bony cells, either on the external mastoid surface, on its lower surface extending under the muscles, or on the internal or dural surface. If these preformed defects in the bony walls are well marked, the perforation through the drum-membrane need not take place. This is not unusual if the pus breaks through the lower inferior mastoid surface and gravitates down the neck.

The opening in the drum-membrane must be made if this membrane be very red, swollen, and prominent. If on the following day the ear is dry, the secretion is scanty and the case a mild one. If free discharge follows the paracentesis

for a number of days or weeks, the severe form is present. This holds good in cases with spontaneous perforation. After the presence of this opening our treatment becomes modified, and the possibility of re-infection from the ear canal is present. Hence the division into a perforative and non-perforative form of acute otitis is justifiable. Transitory discharge may take place through a thin scar or atrophic drum, and these cases should be classed with the simple variety.

Acute otitis media gives a straightforward clinical pic ture when it occurs in a healthy individual after nasal or naso-pharyngeal trouble; the influenzal type is more or less similar. The class of otitis following severe general diseases runs a somewhat different course; the prototype on the one hand is the scarlet-fever otitis, on the other hand the phthisical. These are influenced by the intoxication and disturbance of nutrition from which the body suffers. Acute otitis media in other cases after the appearance of a perforation gives a more or less constant clinical picture.

The perforation if spontaneous is very small, and recognizable by the inflammatory changes in the surrounding area, and appears as a flat pyramidal prominence from which a drop of pus exudes.

The determination of the exact site of the perforation is important for proper treatment. According to some textbooks this site is most frequently in the lower anterior quadrant. In my experience the upper and lower posterior quadrants are more frequently selected, and never in the limbus but in the thin intermediate zone or near the umbo. I have never observed an acute perforation in Shrapnell's membrane.

A marginal perforation, multiple perforations, and a rapidly growing perforation in the lower anterior quadrant point to a constitutional trouble, principally tuberculosis. In the presence of a thin scar, a genuine acute otitis may be accompanied by a large perforation. I have only observed a perforation in Shrapnell's membrane in chronic suppurations. The acute perforations have a great tendency to diminish as soon as the discharge is less; a yellowish flat prominence

like a smallpox pustule appears, and disappears in a few days. If the suppurations last some time, secondary changes take place about the perforation site, the prominence grows, and a polypoid growth appears at the apex. I consider this a perfectly normal tissue reaction on the part of a healthy organism. If this does not take place, and the opening tends to enlarge, prognosis and treatment are affected.

In the regular course of an uncomplicated suppurative otitis media, even if it lasts a year, the perforation closes if the individual is otherwise healthy and we disregard the rare cases where a large perforation appears in a scar. The hearing returns to the normal even if the purulent process has lasted for a long time, and no complications have been present, especially no perforation into the labyrinth during the time of suppuration.

The only thing which seems to make the course of a genuine otitis media atypical is the unusually different duration of the disease. It is especially important for us to estimate the reasons for this atypical prolongation of the disease.

The overwhelming influence which bacteriology at present exerts on all clinical views has resulted in considering a marked virulence of the bacteria to be responsible for the protracted cases, as it seems that the kind of bacteria has no distinct influence on the duration. For this supposition. no convincing animal experimentation has been furnished.

My observations of operative cases and autopsy-findings have shown me that an anatomical peculiarity which I described ten years ago in the handbook of Schwartze may explain to a great extent the unequal duration of acute purulent otitis. This is the unusual difference in the size and distribution of the pneumatic cells. In cases which were operated upon, and where the suppurative process had existed for one or several months, or had led to death through a complication, it was noticeable that the empyema was found localized to pneumatic cells which were considerably larger than the normal. This same state of affairs was present even though the perforation in the drum membrane no longer existed or never had been present, and where the