CHAPTER XVII. THE CONSEQUENCES OF CHEONIC SUPPURATION OF THE (Part 8)

well. The aperture through which the sequestrum passed had closed. The dis- charge of pus was moderate and the general health of the child was good. Wilde,* Agnew,t Gruber,| and Yoltolini § have reported cases of the extraction through the external meatus of the whole of the internal ear, during the life of the patient. "Wilde's case occurred in the practice of Sir Philip Crampton. The patient was a young lady, who, after the most urgent symptoms of inflammation of the brain, with paralysis of the face, arm and leg, and total loss of hearing of one side, recovered from the head symptoms and paralysis of the extremities after a copious discharge of pus from the ear. " One day Sir Philip perceiving a portion of loose bone lying deep in the cavity of the meatus, drew out the whole of the cochlea and semi- circular canals." Dr. Agnew's case occurred in a patient who suffered from exostosis consequent upon chronic suppuration of the oppo- site ear, and who afterward died of brain disease dependent * Text-Book, p. 37. \ Von Troltsck on the Ear, American Edition, % Lehrbuch, p. 543. § Monatssclirift fur Okrenkeilkunde, Jakrgang IV., p. 84. 438 NECROSIS OF INTERNAL EAR. upon retention of pus by the exostosis. The case as regards the exostosis will be found on page 404 of this work. The patient was a gentleman of thirty-eight years of age,* who had suffered from chronic suppurative inflammation of the middle ear for the greater part of thirty-two years. Three years before the patient came under Dr. Agnew's observation, after a severe exacerbation of the aural inflammation, com- plete loss of hearing occurred in the ear, and paralysis of the facial nerve of that side. Granulations continued to recur constantly. On the 16th of April, 1862, the patient was in a deplorable condition ; he had suffered for months from pain in the ear, loss of sleep, loss of appetite and dizziness. The concha was swelled and extremely tender ; a pear-shaped polypus, of fibrous character, which was kept bathed in very fetid pus, projected from the meatus. Dr. Agnew placed the patient under the influence of chloroform, and removed the polypoid mass by means of Wilde's snare. In attempting to get the snare about the base of the polypus, he encountered a solid body in the middle ear, which proved to be the ne- crosed internal ear. An incision was then made into the audi- tory canal, in order to enable the forceps to grasp the seques- trum. Dr. Agnew's report says : " Having got the body in the grasp of the" forceps, a slight rocking motion, with trac- tion, enabled me to extract it." The whole of the internal ear — vestibule, semicircular canal, and cochlea — were found to be removed." This patient lived four years after this, and never had any painful symptoms from that side of the head after- ward. Gruber's case occurred in a child thirteen years of age. Both cochlese were exfoliated, and yet the patient recovered, with no facial paralysis — an evidence that the cavity of the tympanum was left in a comparatively sound condition. Voltolini'sf case was one that occurred in the practice of Dr. A. Jacobi, of Berlin. The whole labyrinth was removed from the ear of a child that is still living. The substance of the cochlea was not fully united with the surrounding bony substance of the petrous bone, which, as Voltolini remarks, is * American Medical Times, vol. vi., p. 183. f Monatsschrift fur Ohrenheilkunde, Jahrgang IV., p. 84. CARIES AND NECIIOSIS. 439 evidence that the disease dates back to an early period in the life of the child. Toynbee* reported four cases of necrosis of the cochlea and vestibule, in which the parts had been exfoliated during life. One of them is Wilde's case, already quoted. The pa- tients were adults, with the exception of one, a child of seven years old. The following engravings illustrate the ravages which chronic suppuration makes upon the bony tissue of the ear. They were made from photographs of the bones, and are from the collection of Dr. C. E. Hackley, who kindly allowed this use of them. :<,■ m Left Temporal Bone, from Case I. Exterior view, zhoiving the external meatus, a,, from which the anterior wall has been removed, as has also the inner wall of the middle ear. b. The mastoid process. Inner Surface of the same Specimen, showing c. The vestibule, d. d. The windings of the cochlea, which have been exposed by saw- ing away portion of the bone. e. The tympanum, communicating with f. the mastoid cells, which have been by chipping away a thin layer of I History. — Case I. (Figs. 85 and 86). — Left temporal bone from a man who had phthisis, and died suddenly of pneumo- thorax, August, 1866. His hearing distance was nothing for the watch, nor could he distinguish words, though he seemed Arcliiv fur Okrenkeilkunde, Bd. I., p. 113. 440 CARIES OF TEMPORAL BONE. to hear the sound of the voice. He was very much debilitated when he entered the New York Hospital, consequently no thorough examination was made of his ears. He had profuse discharge from both ears, and polypi on both sides. On the left side, the post-mortem examination showed polypus attached in the middle ear and extending forwards into the meatus, and backwards into the mastoid cells ; membrana tympani gone ; stapes only one of ossicles present; membrane of fenestra rotunda gone. Left lemporal Bone, sawed through External Meatus, Middle Ear, and Cochlea. The pieces are turned to one side, showing— a. Mastoid process. t>, t>. External meatus, ending in c, the middle ear. At cl there ivas an opening downwards through the bony meatus, and at e an opening upwards, by which there was a free communication with f, the mastoid cells, which were separated from the interior of the cranium by a very thin layer of bone at g. h, h, show the cochlea sawed through. Case II. (Fig. 87). — Left temporal bone from , who entered the New York Hospital August, 1866, with great fever and pain in the left ear ; had been sick two days. His disease ran much the course of typhoid fever, without marked head symptoms other than the acute pain in the ear (which only existed the first two days). When a child he had discharge from the ear and post-aural abscess and disease of mastoid process. On the autopsy, pus was found under the dura mater and in mastoid cells ; the whole temporal bone was gone from the infiltration of pus through it ; the membrana tympani was completely destroyed ; the base of the stapes was the only CAEIES OF TEMPOEAL BONE. 441 part of tlie ossicula remaining ; there was an opening from the outer part of the bony meatus upwards into a cavity which also had an opening outwardly. Bight Temporal Bone, from Case V-, showing the Cranial Surface of the Bone. At a the bone was very thin, and broke away when the dura mater was removed ; the bone was much hollowed out about t>, the middle ear. Case V. (Fig. 88).— August 18, 1868.— H. O. applied at New York Eye and Ear Infirmary, on account of pain in right ear, saying he had a " kernel " (was ?) removed from his ear two years previously, by one of the surgeons of that institution. The right membrana tympani was found injected, right Eu- stachian tube obstructed. H. D. — Eight ear, pressed ; Left, il- Applications of warm water, with occasional leeching, were ordered. After some time the walls of the meatus swelled so that the walls of the membrana tympani could not be seen. Under varying treatment the state of the case was sometimes better, sometimes worse, till March, 1869. During his attendance the patient twice stopped coming, thinking he was well, when he complained of pain over the right side of the head, starting from the ear. Expecting meningitis, he was taken as an in-patient at the Infirmary, April 1st, 1869, treated again with leeches, cold to head, bro- mide" of potash, and tonics. About May 1st, 1869, he showed occasional delirium, and contraction of the muscles of the nape of the neck ; had retention of urine ; pulse 110-130 ; temperature 102°. Died May 10th. No discharge from ear for thirty-six hours preceding death. On autopsy, twelve hours after death, we found the brain slightly congested ; the right optic nerve (which went to an atrophied eye) was atro- 442 CARIES AND NECROSIS— PROGNOSIS. phied both before and behind commissure ; the meninges of the base of the cerebellum, and upper part of the spinal cord, were covered with lymph and bathed in sero-pus (about two oz.) ; right auditory nerve very red ; periosteum over the posterior part of the right temporal bone was very easily detached ; the bone under it was greenish, infiltrated with pus ; the passage from the middle ear to the mastoid cells was much enlarged, with only a thin wall of bone between it and the brain. On detaching the pericranium this wall was broken through. Membrana tympani entirely gone ; the promontory was rough- ened ; the stapes was the only one of the ossicles left in position. Prognosis. — The prognosis of caries and necrosis of the temporal bone depends upon several factors. To a marked de- gree it is influenced by the age of the patient. Young children will throw off quite large portions of the bone, and yet come off with their lives, while older persons will usually succumb to one of the many consequences, such as pyaemia, hemorrhage, abscess, which may result from death of bone in this part of the body. The situation also of the dead bone will influence the prognosis of caries to a marked degree. Caries of the mastoid, especially when occurring in young children, is very often recovered from. Caries and necrosis of the walls of the middle ear is of course the most dangerous of all that may occur, especially caries of the upper and lower wall. It has been seen that the whole internal or labyrinth wall may be destroyed, and the contents of the external ear be exfoliated, and yet the patient recover. In these cases the necrosed internal ear seems to have passed through a sound tympanic cavity. The prognosis of caries and necrosis of the temporal bone is, however, always grave under any circumstances, and no life can be said to be what the life insurance companies call a p good risk, if a chronic suppurative process has gone on to this extent. The ossicula auditus may be thrown off with com- parative impunity, as we see by cases all about us; yet even these cases, unless the suppuration has entirely ceased, belong to a class of cases of whose results we must always CAEIES AND NECROSIS — TREATMENT. 443 stand in dread. Until the parts have healed, and some kind of a neo-plastic membrana tympani has formed, we are not safe in giving a decidedly favorable prognosis. Treatment. — It is impossible to give any specific rales for treating caries and necrosis of the bony parts of the ear. Each case must be judged by itself, under the general rules of treatment that have been given as appropriate for chronic suppuration ; the chief of these rules, I may venture to repeat, are a thorough removal of the accumulating pus before it has time to produce its corroding and destructive effects, and careful attention to the general health and habits of the pa- tient. Gruber* mentions one means of treating caries of the tem- poral bone, in which I have no experience, but of which he gives a favorable report, in some cases where the severe pain was not relieved by local antiphlogistic and anodyne treatment. This is the actual cautery. The iron is applied at several points over the mastoid process. After the bony slough is removed, an irritating salve may be applied to continue the counter irritation. Dr. Post, of this city, also speaks well of the actual cautery as a less painful means of treating mastoid periostitis than the incision. I have no doubt, judging from a recent experience in a case of Dr. H. O. Newton's — which I saw in consultation — where Dr. Newton trephined the mas- toid process for continuous and severe pain referred to the middle ear, but without finding dead bone, that such openings will do very much to relieve the deep-seated pain of caries that is referred to the ear and the brain. The facilities for treating chronic suppuration, since we have Politzer's method of opening the Eustachian tubes, are much greater than those enjoyed by our predecessors. We may, by the employment of this method, more thoroughly cleanse the tympanic cavity from pus than by the simple use of the syringe. In the chapter on chronic suppuration, a detailed account of the means of thoroughly cleansing the ear has already been given. * Lehrbuck, p. 552. 444 CEREBRAL ABSCESS. A patient with caries of the temporal bone should be made aware of the gravity cf his condition, so that he and his friends may be on the lookout for serious symptoms, which may be promptly treated, and that they may not fall into the error of supposing that no harm can possibly come from " a simple running from the ear." If polypi or granulations have occurred in connection with caries of the canal or tympanic cavity, they should be removed with care, lest severe hemorrhage occur, or other harm to the parts. The galvano-cautery has proved an efficient and safe means of removing such granulations,* and of causing the bone to heal. Fatal hemorrhage has occurred from caries of the bony canal, in which the internal carotid passes through the apex of the petrous portion of the temporal bone, as well as from destruction of the bony wall that separates the mastoid pro- cess from the lateral sinus, and also from the breaking down of the thin plate of bone that forms the floor of the cavity and separates it from the jugular vein. Fortunately for the lives of many patients, there is a tendency to thickening, or hyper- plasia of the bony walls of the tympanum, in some cases, and thus they are protected from the corroding effects of pus.f CEREBRAL ABSCESS. The proceedings of pathological societies and surgical records show, that abscess of the cerebrum more frequently results from disease of the middle ear than from any other sin- gle cause. Of seventy-six cases of cerebral abscess collected by Drs. Gull and Sutton,:}: twenty-five, or about one-third, were * Archiv fur Ohrenheilkunde, Bd. VI, p. 116. f Gruber, Lehrbuch, p. 543. Gruber states that Billroth has tied the com- mon carotid artery for a case of aiiral hemorrhage, which occurred not from caries, but from a congenital defect in the bony wall. The hemorrhage ceased for ten days after. After all attempts to restrain the hemorrhage were fruit- less, Billroth ligated the left carotid, and two days after the patient died from severe hemorrhage from the right ear, the nose, and mouth. A child, for whom parents would not allow the operation, died from the same cause. Koeppe reports a case of hemorrhage from the lateral sinus, through the nose and ear. This was in consequence of destruction of the bone. % Reynold's System of Medicine, vol. ii., p. 544. CEREBRAL ABSCESS. 445 directly traceable to chronic suppurative processes in the middle ear. Lebert," in his article upon this subject, con- siders that aural disease is the cause of cerebral abscess in about one-fourth of the published cases. There is usually caries in connection with the cerebral abscess, but cases have occurred in which, although the dis- ease of the ear extended to the brain, there was no death of bone. The anatomy of the cavity of the tympanum, especially of the roof, or tegmen tympani, where a process of dura mater actually extends into the tympanic cavity, and where there may normally be a gap in the bone, has taught us how easily this may occur. The cause of the extension of a sup- purative process to the brain is undoubtedly very often that which Mr. Toynbee so clearly sets forth in his chapter on this subject — that is, the non-escape of the pus externally through the membrana tympani. The perforation of the membrana tympani in acute inflammation usually prevents any such dis- aster as the passage of the pus to the brain or the circulation. Rupture of the membrana tympani is, therefore, a con- servative process, if suppuration has once been established ; for there is no other safe way of escape for the pus, except through the Eustachian tube — a means of exit which is one of the last that nature chooses. Abscess of the brain in acute disease was only once observed by Mr. Toynbee. A direct communication usually takes place between the diseased mastoid or petrous portion of the temporal bone and the brain substance through the meninges, but the dura mater and other membranes may be healthy, and even a portion of healthy brain may he between the diseased bone and the cere- bral abscess. The chronic disease of the ear may be going on very well, until some mechanical injury — exposure to cold, or the like — sets up an acute process, which extends to the brain through the delicate bony walls of the tympanic cavity, or the cancellous structure of the mastoid bone. Patients suffering from chronic suppuration of the middle ear cannot be too much guarded against blows or falls upon the ear, or against exposures to sudden changes of temperature, * Virchow's Arcliiv,