In either case the same mode of treatment, whether abortive, curative, or preventive, is in vogue with all who accept this view of the origin and infectiousness of furuncles, and that consists in the destruction of the cocci by the use of topical application. Although digressive, there may be mentioned, of these, kalium sulphuratum +21, corrosive sublimate +22, carbolic oil +23, sublimate alcohol +24, aluminium aceticum +25, boric acid is alcohol +26, carbolic acid glycerine +27, menthol in petrolol +28 +29, menthol in alcohol +30, and menthol in sweet oil +31, +32.
Coming to the middle ear, we find the roles played by bacteria, according to recent views, to be exceedingly important, and the amount of minute and exact knowledge concerning them which is already acquired may well be a matter of surprise.
Briefly stated, it is held that bacteria may find entrance to the middle ear +33 either by way of the Eustachian tube, the blood circulation, the lymphatics, the membrana tympani +34, or the fissura petro-squamosa, and that their presence may induce either excessive secretion of mucus, plastic changes, or the formation of pus. It is held by some that in the tympanic cavity may always be found a small number of bacteria +35, which remain harmless and quickly perish under ordinary conditions, but which may be aroused to activity and a virulent development under circumstances which favor.
It has been experimentally demonstrated that such is the condition of the interior of the Eustachian tube +36, but all authorities agree that the most probable source of infecting germs in the tympanum is through the tube from the naso-pharynx.
In otitis media suppurativa, which, of all forms of middle- ear inflammation, is the most important in this relation, and which has been the most carefully investigated, there have been found in the secretions +37 the streptococcus pyogenes +38, the pneumococcus of Fraenkel, the pneumobacillus of Friedlander, and the staphylococcus pyogenes +39. The first named is found the most frequently and in the most severe cases, which may be complicated with mastoiditis, purulent meningitis +40, cerebral abscess, phlebitis, thrombosis, or pyaemia. This, it will be remembered, is the same microbe that produces puerperal fever and erysipelas.
In mastoid inflammation this streptococcus is almost exclusively found +41, while its presence has been demonstrated upon the cerebral meninges +42 in a case of caries of the temporal bone, and in the labyrinth +43, in fatal cases from diphtheria and measles. It is also this coccus which is present in the destructive otorrhoea of scarletina. A less severe and more rapid form of inflammation, both as to development and resolution, is thought to be induced by the pneumococcus. In connection with these four microorganisms, the tubercle bacillus is found not infrequently +45 +46 while the most recent discovery has been the presence of the bacillus pyocyaneus +47. The presence and true character of these various bacteria has been verified, time and again, by the inoculation of mice, guinea pigs, and rabbits with cultures.
One suppurative case which underwent examination presented an especially interesting sequel. Re-examination eight weeks later, the discharge having continued, showed that the diplococcus, which was first present, had disappeared, but had been replaced by the staphylococcus pyogenes albus. This condition is called by the observer +25 a “secondary infection,” and it is argued that, in the same way, a tertiary might occur, and it is argued that, in the same way, a tertiary might occur, and this process be, perhaps, a cause of the long duration of many suppurative cases, and explain their marked tendency to become chronic.
In the middle-ear suppuration of influenza there has been discovered +48, in addition on the streptococcus, the diplococcus pneumoniae and the staphylococcus, a bacillus of peculiar form +49, which could not be made to grow upon the usual nutrient material, and which is considered to be the influenza bacillus +50.
As to the practical importance of these new discoveries, which have been so laboriously made, they teach us certainly the necessity of the most absolute cleanliness and antisepsis in our manipulation of aural cases, and especially in the care of instruments, which are used from one patient to another.
Beyond this, as a means of prognosis or as a guide to treatment, very different estimates are half of the value of our present knowledge of these bacteria. It is thought by some that the fact of the presence of a given microbe, whether it be regarded as the primary cause of the diseased condition or not +40, will determine the after progress of the disease in fixed channels; 37 while others believe that the finding of a certain coccus in the secretions can give no aid in the prognosis of aural disease, since the same microbe will at one time occasion only slight local effects and at other times serious general disturbances +38, and since, indeed, inflammatory processes differing as much as the catarrhal and the suppurative are due to identically the same micro-organism +51.
It is more than probable that the present store of knowledge is only a step toward the ultimate benefit which may accrue to otology from the science of bacteriology, and it is hoped that this will eventually reward the zeal of the workers in this obscure field.
DISCUSSION.
FRANCIS B. KELLOGG, M.D., of Tacoma: It is with considerable trepidation that I undertake the discussion of a paper which I have never seen. This unfortunate omission was unavoidable- sickness having prevented its completion in time for a preliminary transcontinental journey. If, Therefore, my observations seem to relate to the subject in general rather than to the paper in question, this circumstance will serve at once as explanation and excuse.
They are, in the main, extracts from notes recently taken in Politzer’s clinic in Vienna.
1. Perforation of the Membrana Schrapuelli-This form of perforations peculiarly subject to invasions of masses of exfoliated epidermic cells or cholesteatomata. These cells are thrown off from the skin of the auditory canal, and by some occult process emigrate towards and through this opening into the attic of the tympanum. Loaded with septic germs, they become in this location a source of no small danger to the life of the patient, since, if neglected, they are liable to set up necrosis of the thin, bony roof of the attic, which alone separates the latter from the brain.
To dislodge and remove these masses from the tympanum is evidently, therefore, a matter of great importance. it is also one of no small difficulty. With the exception of the measure to be described, Hartman’s canula offers the most effective means of accomplishing this end. It is open, however, to the objection that, except in large perforations, the canula itself offers an obstruction to the escape of the masses. The desirability of vis a tergo is evident, and presents a strong argument in favor of the following procedure: a large-sized catheter is inserted, its presence in the tube demonstrated by the air-bag and otoscope; after which the patient’s head is tipped towards the affected side, and he is given a pus-basin to hold under the ear.
He is directed to open his mouth widely, and to make (during the injection) short, sharp respirations, with the accent upon the expiratory sound, making as much noise as possible with the breath. It is impossible to do this without closing the naso-pharyngeal passage, thus preventing the escape of water into the throat. A large syringe, full of warm boiled water, is now forced through the catheter and tube into the middle ear. It is necessary to use considerable force, as much water unavoidably escapes about the point of the catheter, which fits only loosely into the mouth of the Eustachian tube. Enough water, however, enters the tympanum so that it is seen to drop from the external ear into the basin.
The passage if even a few drops in this way is exceedingly effective, bringing away masses of epithelial debris, and softening that left behind so that it may be removed at a subsequent sitting. Nor is this procedure effective alone for the removal of cholesteatomata. According to Politzer, cases of chronic middle ear suppuration which have resisted all other treatment, have yielded to injections of boiled water alone when applied in this manner.
In adopting this treatment there is a single phenomenon for which it is necessary to be prepared, viz., vertigo. It is caused by the pressure of the water in the middle ear upon the oval window, and through this upon the labyrinthine fluid. With a clear appreciation o fits cause, its relief is prompt and brilliant. The proper instrument for this purpose is an air-bag fitted with a rubber tube about a foot long, terminating in an ear-piece. The patient must be watched for symptoms of vertigo, as they will sometimes be so affected as to be unable to speak for a moment, and first show the affection by unsteadiness in the chair. Upon the first complaint or evidence of dizziness, exhaust the air-bag, insert the ear-piece air-tight into the canal, and exert suction upon the drum. The relief is magical.
