CHAPTER XVII. THE CONSEQUENCES OF CHEONIC SUPPURATION OF THE (Part 6)

of opening the mastoid, beginning with Arneman. Drs. Weir, Laight, and Buck of this city, Drs. Newton of Brooklyn, and North of Waterbury, Conn., are among the surgeons who have operated since 1870, and this sound sur- gical procedure may be said to be fairly established in the profession. Twenty-six of the thirty-four cases reported by Buck resulted in recovery. CASES/ It would be easy to insert very many cases of trephination of the mastoid that are now to be found in the literature of otology, but in adherence to the plan of this work, a few are selected which will clearly exhibit the symptoms of caries of the mastoid, and the clinical facts of those cases for which perforation of the process is performed. Cash I.— Otitis Suppurativa Media— Caries of Mastoid— Incision through Periosteum — Removal of Sequestrum through External Auditory Canal- Recovery. This was tinder my care at the Manhattan Eye and Ear Hospital, and has already been reported by Dr. C. I. Pardee,* but chiefly with reference to its being a case of otitis media, caused by the use of the nasal douche. I saw this patient, who was a man of about thirty-five years of age, soon after the inflam- mation of the ears had occurred, which was about nine months before he pre- sented himself at the hospital in October, 1889. He was then suffering from a suppurative inflammation of the middle ear, but the amount of pus discharged through the perforation in the membrana tympani was slight. There was considerable swelling of the mucous membrane of the cavity of the tympanum, and the hearing was greatly impaired. He could not hear a watch at all. He was under my care for this suppuration of the ears for eight weeks, when he disappeared, and I next saw him, as just stated, some nine months after, at the hospital, when I found his condition had become worse, and that it was alarming. He complained greatly of pain in the head, which prevented him from pursuing his avocation, which was that of a plumber. The auditory * New York Medical Gazette, vol. vi., No. 23. 42 G MASTOID CARIES— CASES. canal of the left side was filled with granulations, the mastoid process was red, tender, and painful. Just in front of the meatus there was an abscess, and a small fistulous opening just above the same part. The hearing on that side, as tested by the watch and voice, was completely gone. On the other side, the ear was in substantially the same condition as when I first saw him. I immediately made incisions down to the bone, rather against the patient's will, just behind, above, and in front of the attachment of the auricle. I found no dead or exposed bone, but quite a large amount of pus was evacuated. The patient immediately began to improve. In a few days Dr. Pardee removed a piece of the mastoid structure through the auditory canal, the pain in the head disappeared, the suppuration from the mastoid ceased, the granulations were removed from the canal, and the patient resumed his occupation. The notes of the following case, except so far as they relate to matters observed by myself, were furnished me by Dr. Hubbard, of Bridgeport, through whom I saw the patient. Case II. — Sub-acute Aural Catarrh — Membrana Tympani intact — Suppura- tion in Mastoid Cells — Opening of Mastoid Process— Death. Dr. Hubbard was consulted in December, 1869, " by W. E. S., set. 38, by profession a mechanic, with good physical development and unexceptionable habits, on account of a severe influenza, from which he was suffering, and which was at that time epidemic in this city (Bridgeport). His mother and one sister, I have reason to believe, died of tubercular inflammation. Hitherto he had suffered no severe illness since the ordinary diseases of childhood, from all of which he made perfect recoveries. The attack of influenza was charac- terized by severe irritation of the whole respiratory system, with marked impairment of the special senses of taste and smell. The auditory apparatus was not at first, however, specially implicated. I prescribed for his 'cold' several times during the acute stage, as an office patient. But he at those visits made no mention of any trouble about his ears. Later he reported that he had lost his cough, but complained of catarrh of the fauces and nasal pas- sages, for which I prescribed the nasal douche, and gargles made stimulant and astringent by alum, chlorate of potash, chlorate of sodium, tannin, etc. To the use of these he ascribed considerable improvement. I then lost sight of him until about the first of April, 1870, when he consulted me on account of an annoying tinnitus affecting only the right ear. At the same time he reported that he had occasionally, for several weeks immediately preceding, suffered moderate hemicrauia of the affected side. Inspection showed marked enlargement of the mastoid process, which he declared had been at no time the seat of pain, and yielded no suffering under firm pressure. Specular exam- ination showed a moderate degree of congestion of the membrana tympani, and by Politzer's method the Eustachian passage was found to be pervious. The middle ear was occasionally inflated, however, and warm water injections to the meatus externus ordered daily at bedtime, and a blister directed to be applied over the mastoid process. At the same time I continued constitutional reatment by quinine, iron, and strychnia, as he had been the subject some MASTOID CARIES — CASES. 427 time previously of malarial infection. Under tins course the apparent conges- tion of the membrana tympani disappeared, but the tinnitus was in no degree diminished. At this stage of the case, having met, as well as I was able, till rational indications, leaving to me only an empirical course, I advised him to consult Professor Roosa, and he advised me to renew the blister to the mas- toid region, also to apply a leech to the tragus, and repeat it after a stated interval, after which he requested to see him again." My notes, on seeing the patient, are :— Hearing distance, right side, 2", tested with a watch that should be heard 3' ; membrana tympani opaque ; no light spot ; handle of malleus injected. A very feeble current of air passes into the Eustachian tube. Patient complains of a very annoying buzzing soimd in his ear. There is a very slight want of symmetry in the mastoid, no pain referred, to it, no tenderness in any part of it ; no pain in the ear. Two leeches ordered to the tragus and a blister to the mastoid. One week later I again saw the patient ; the symptoms were the same. He had had some pain in the ear one night since his visit. I injected steam into the middle ear, and sug- gested that leeches be again applied. (I again copy Dr. Hubbard's notes.) " These measures were faithfully carried out, but with no good results. The time having come for another visit to Dr. Ptoosa, the patient called at my office, when examination revealed fluctuation at the summit of the mastoid process, indicating, however, a small quantity of fluid, and attended, as it seemed to me, with too little pain to be explained by the theory of a perios- titis. I thereupon advised him to postpone his visit to New York, and poul- tice the tumor for twenty-four hours, and then report again. At his next visit I found the swelling and fluctuation slightly increased, and I freely incised the integuments to the bone, liberating about half a drachm of thick, healthy- looking pus without disagreeable odor. I then probed the wound, expecting to find denuded bone, but I failed to detect a greater degree of roughness than is peculiar to that portion of the cranium. I advised him to keep the wound open and favor the discharge by poulticing. The discharge for the succeeding few days was little, but resulted in a marked diminution of the tinnitus and a corresponding sense of relief to the patient. He now failed to report to me for about a week, and meanwhile, from lack of attention, the incision healed, and when he presented himself again there was a re-accumulation of pus in much greater quantity than previously. This I evacuated, and found it of the same character as before. Thereafter the wound was kept open and the tinnitus ceased, and the patient declared to me and others that he was ' a new man.' From this time my regular attendance ceased until May 12, 1870, when I was recalled and obtained the following history . He had continued in his improved condition until the evening previous, which he was passing in social enjoyment with his family and a brother who was paying him a visit, and, when laughing violently at some burst of humor, he stopped suddenly and exclaimed : ' There, I guess I have laughed too hard, for I have made my head ache.' No further reference was made to his suffering until he had retired to his room at bedtime, when he informed his wife that he was suffering from an intense frontal headache ; he also complained of rigors, and passed an uneasy, sleepless night. Notwithstanding a resort to several domestic remedies, 428 MASTOID CARIES — CASES. May 13, I found the patient still suffering from pain through the forehead and temples ; pulse 70, regular, and with steady rhythm ; tongue brawny, a thin white fur upon it ; intellect clear ; skin unusually open, and feeling like the third stage of a paroxysm of intermittent fever, which I confess 1 was disposed to consider it, inasmuch as he had previously suffered from that disease. I did not consider the symptoms sufficiently clear to indicate anti-periodic treat- ment, and I therefore temporized by giving the following palliative (a mixture of morph., aconite, and camphor water). May 14th, found him no better. Skin still open ; pulse 08, with slight unsteadiness of rhythm, coating still more inflammatory ; headache the same ; urine rather copious ; intellect in the morning clear, but once had requested an imaginary window-frame to be removed from his bed ; pupil unaffected, no intolerance of light or sound ; temper cheerful. I abandoned the malarial theory, and expressed myself to the friends as apprehensive of basilar meningitis, consecutive to subacute inflammation of the mastoid cells. Ordered an active cathartic, and 3 ss bro- mide of potassium, combined with the iodide. May 14th, p.m. — Visited him in consultation with my partner, Dr. D. H. Nash. No relief; on the contrary, an increase of the cerebral disturbances, occasionally delusions and illusions of mind, and mostly of the ludicrous sort ; pulse slow and somewhat staggering ; no pain in the ear or its surroundings ; bowels had moved freely two or three times ; urine still copious ; has had no sleep. Continue the bromide of potas- sium mixture, apply large blister to the nape of the neck, and give gr. xx hydrate of chloral, and repeat in four hours if necessary. 15th — Had slept about two hours; general condition no better; decidedly humorous in his behavior ; double vision, without apparent strabismus, could not read ; pulse 00, more irregular ; had less pain in the head, or at least he said less about it. Continued same line of treatment, with addition of gr. ij calomel once in four hours. Blister acted thoroughly. 15th, p.m. — Condition little changed. Prognosis to family — fatal result, qualified by suggestion of possible relief from trephining mastoid process. May 10, a.m. — Patient worse ; suggested the counsel of Dr. Roosa ; treatment the same. Met him at 9 p.m., with Dr. Nash. Agreed to diagnosis of meningitis, with probable origin from mastoid cells. Determined on free explorative incision upon the mastoid process, and use of trephine if developments indicated it. Accordingly Dr. Roosa made an incision one inch and a half long, parallel with the attachment of the auricle (about one half-inch posterior), down to the bone, permitting thorough exam- ination with the finger as well as with the probe. This means, however, failed on the part of either of us to discover either necrosis or a denuded state of the bone. After a long search, and when the search and further proce- dure were about to be abandoned, the probe (in the hands of Dr. Hubbard, R. ) — Bowman's No. 1 — caught in a little depression, and by considerable pressure passed the external table of the cranium, into the interior of the mastoid por- tion of the temporal bone, to the depth of one and a half inch, without other resistance than that afforded by the external table. The orifice was now enlarged sufficiently to favor the escape of any pus that might be in the depths of the bone, an opening three-eighths of an inch in diameter, but no great quantity of pus escaped (just a trace, R.). Subsequent examination with the probe revealed a cavity of considerable size, caused by the breaking down of MASTOID CAPJES — CASES. 429 the mastoid cells. (The incision was carefully syringed with tepid water, and the opening plugged with lint, R.) 17th — I first observed dilatation of the pupils, with gradually increasing drowsiness, attended by delirium. This condition continued, with occasional aggravations, until the 19th, when the patient passed slowly into a state of profound coma, and he died without con- vulsions, at 2 o'clock A.M., May 20. No post-mortem examination could be obtained." I have only to add a few words to the history thus so graphically given by Dr. Hubbard. On the evening of the operation, or the third and last time I saw the patient, I examined the case as carefully as possible, and I found the membrana tympani intact and translucent, no congestion whatever. There was no bulging in any part of its surface. The patient, who recognized me perfectly, and showed that his memory was unimpaired, heard my watch about six inches from the ear — a decided improvement upon the hearing power on the two occasions when I had previously seen him. There was absolutely no tenderness in any part of the mastoid. Eesides a very minute openiug near the superior boundary of the process, which was scabbed over, there seemed to me to be no abnormal appearance in this part, and I examined it very carefully. On probing this minute opening, which was the trace of Dr. Hubbard's incision of some weeks before, there was no escape of pus. So doubtful did the case seem to me, even with the history of the abscesses which had been opened, that I hardly expected that the free incision which I made would reveal anything abnormal. There are several points in this case which distinguish it from any that I have seen, or that I have been able to find reported. I. — There never was a suppuration of the membrana tym- pani. A primary inflammation of the mastoid cells or their lining membrane, or of the periosteum in this region, is very rare, as is a middle ear inflammation in which the mastoid becomes involved, without suppuration in the cavity of the tympanum. I have seen one case, however, in which the use of the nasal douche caused an inflammation of the mastoid of one side, without suppuration in any part of the ear, while in the other, suppuration of the membrana tympani occurred. Bat the mastoid inflammation was quickly overcome by the use of leeches. II. — Until the formation of the abscess, there were no marked symptoms indicating the true seat of the disease. The symptoms were rather those of a chronic inflammation of the middle ear, that is to say, tinnitus, fulness, and occa- sionally slight pain. Certain it is, there was none of the 430 MASTOID CARIES— CASES. agonizing distracting pain of which patients with periostitis usually complain. III. — The interval of apparent recovery after the evacua- tion of the pus. In reviewing the case, the conclusion seems to me inevita- ble that we had from the beginning to do with a subacute inflammation of the mastoid portion of the middle ear, and which smouldered until the blazing up in the abscess opened by Dr. Hubbard. The origin of this was, of course, the coryza, or cold in the head. It was perhaps an inflammation of the mastoid and tympanic cavity which extended less rapidly than usual to the periosteum and tissues lying upon it, and it was on this account a concealed and dangerous foe. According to a theory of mine the second attack was essentially a new process attacking the former seat of disease, or locus minoris resistentice — " the weak spot," as patients say, induced by some exciting cause that is unknown. The integrity of the nerve, up to a late period, is shown by the amount of hearing power exhibited on the evening that the perforation of the bone was made. Dr. C. K. Agnew reports a case which has been alluded to in the account of caries of the mastoid, an outline of which, made up from Dr. Agnew's report, is herewith presented. Case III. — Acute Otitis Media — Mastoid Periostitis — Opening of Mastoid by a Gimlet — Subsequent Trephining — Hyperostosis of Mastoid Cells — Re- covery. Miss X, in middle life, caught cold and a sore throat, after exposure in the country on the 26th of August, 1864. Immediately after she was seized with violent pain in the right side of the head and corresponding ear. On Septem- ber 5, a swelling began in the mastoid region, the severe pain from the ear having continued until that time. On the 30th of September, the pain