SUPPURATIVE INFLAMMATION OF

THE MIDDLE EAR.

BY EUGENE SMITH, M. D., DETROIT, OPHTHALMIC AND AURAL SURGEON TO ST. MARY'S HOSPITAL, SURGEON IN CHARGE OF ST. MARY'S HOSPITAL, FREE

EYE AND EAR INFIRMARY, ETC.

It is not surprising, perhaps, that patients many times regard suppurative discharge of the ear as being of no particular importance, particularly after the pain caused by the inflammation has disappeared, because for many years such has been the opinion advanced by practitioners, who, it is more than likely, have never taken the time and trouble to study the subject, and who seem not to be aware of the fact that death not infrequently follows purulent inflammation of the middle ear.

The inflammation may be acute or chronic. The latter variety usually follows the acute form, though it occasionally is seen where acute symptoms have not been noticed. The discharge of pus is a constant symptom. The presence of blood in the discharge indicates the existence of granulations or polypi. As the suppuration increases and becomes fetid the external meatus frequently becomes excoriated and thickened; the membrana tympani is destroyed in whole or in part; the small bones may become detached and escape with the pus, and the inflammation may extend to the internal ear and produce delirium and coma. It is at this period that we observe convulsions in children, the cause of which is many times overlooked. Grave hemorrhages may be produced by lesion of the carotid artery, which is separated from the cavity of the tympanum by an exceedingly thin plate of bone at the inner wall of the cavity; the facial nerve, which is similarly situated, may be paralyzed; phlebitis of the jugular vein may follow caries of the lower wall; meningitis or cerebritis may cause death as the upper wall is always quite thin and sometimes entirely wanting, so that the meninges of the brain and the mucous membrane of the tympanum lie in contact. We may also have profuse salivation from implication of the chorda tympani nerve.

Suppurative Inflammation of the Middle Ear.

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A certain degree of ennui accompanies many cases. sionally the hearing is remarkably intact, but generally it is more or less compromised. The deafness and noises in the ear cause considerable unpleasantness, but patients do not appear to worry themselves over it till the disgusting odor which usually exists in chronic cases makes their existence almost unendurable, at least to their friends, and the patient is an object of disgust to all who come near him. It is no wonder that many sufferers from this affection become morose.

An exact and careful exploration is of the highest importance. Without it it is impossible to diagnosticate or intelligently treat this condition, or, as for that matter, any other affection of the ear. After cleansing the ear with a syringe and warm water, the membrana tympani should be examined by means of an ear speculum and mirror. It is only occasionally possible for a person to get a view (and a very poor one at that) by having the patient sit by a window in such a manner as to let the light fall into the ear, and examinations by this method are absolutely valueless and useless. The condition of the membrana tympani, the mucous membrane of the cavity of the tympanum and the throat, and the state of the eustachian tubes must be taken into consideration. The throat is many times the starting point of the ear trouble.

The treatment should be both general and local. Without doubt patients having the so-called scrofulous diathesis will be benefited by iodide of iron, cod liver oil, and salutary hygienic measures; but the local treatment, too frequently entirely neglected or improperly carried out, is the treatment par excellence, and should be followed out attentively. The local treatment has for its object two principle points, viz. to prevent the stagnation and decomposition of pus in the tympanic cavity, and to check the discharge and promote cicatrization of the perforation of the drum. It should be similar to that which is given to mucous membranes in general. Proper syringing with warm water, frcely used two or three times a day; stimulating astringent and caustic applications as often as necessary to the mucous membrane of the tympanum and throat; the use of the eustachian catheter and Politzer's air douche; removal of polypi when present, and the use of artificial membrane tympani form the groundwork of successful treatment. Blisters and setous, so much in vogue formerly, have passed out of fashion and are really useless in a majority of cases, their principle effect, seemingly, being to add to the suffering of the patient.

It has not been my intention to give you a technical disserta

tion upon the subject, but simply to call your attention to its importance, and to the fact that all cases are curable when acute, and a majority when chronic. Also that every case is susceptible of amelioration, and in no case does the condition of the ear act as an emunctory necessary for the maintenance of the general health, or is there any danger of causing trouble in other parts of the body by checking the discharge, as is popularly believed.

I will close by calling your attention to the fact that the means furnished us by the advances of modern science are sufficiently powerful to successfully combat nearly all diseases of the ear if they are treated sufficiently early.

ON THE PREVENTION OF DELAY IN SOME PRESENTATIONS

OF THE BREECH.

BY A. F. KINNE, A. M., M. D., OF YPSILANTI.

For the purpose of introducing the subject of this paper and of showing how my attention was first called to it, I must ask leave to say some things personal to myself, which, with no such object in view, might be deemed irrelevant and of no particular consequence.

In Churchill's Midwifery (Am. ed., p. 399), in treating of breech presentations, he makes use of these remarkable words: "In these cases it is peculiarly necessary that pressure should be applied over the uterus from the time that the chest is expelled in order to secure the regular expulsion of the afterbirth.'

I wish to invite particular attention to this extract from Churchill, for there is a good deal of meaning in it,-more, with a little thinking, than our learned author himself intended. For, in the first place, what have we here but what is now called Credé's Method" for the expulsion of the placenta by forcible pressure from above? And when Credé wrote, in 1853, Churchill's Midwifery had already been published a dozen years at least. And in the next place, of course, our author cannot be understood as saying any thing about it, and very probably, nay, almost certainly, the delivery of the head was not then in his mind, but the physician who should practice supra-pubic pressure in accordance with Dr. Churchill's directions, whatever his purpose might be, would plainly be practicing what is now familiarly known as Professor Penrose's method for the delivery of the after-coming head. And if I am correct, we have here in this single sentence of Churchill's, as in a nutshell, two of the most important procedures known to recent midwifery.

I hardly think that the current medical opinions of thirty or forty years ago will warrant us in believing that Dr. Churchill fully understood the meaning and importance of his own pre

cept, or that very much should be subtracted on account of what he wrote from the great merit which has usually been attributed to the monographs of Penrose and Credé. But there stands the precept, nevertheless, upon a page devoted to the treatment of breech presentations; and those practitioners who have resorted to supra-pubic pressure, and, in compliance with our author's directions, have "applied it over the uterus from the time the chest is expelled," have practiced, more or less intelligently, both Penrose's maneuver for the delivery of the delivery of the head, and Credé's, also, for the prompt expulsion of the afterbirth.

Such, I must be permitted to say, has been my own experience since 1843; and, looking back now over a period of thirtyfive years, I find that the ordinary mishaps, such as retained placentas, hour-glass contractions, and still-born, head-last children have been seldom met with. Occasionally, in cases where at the critical moment I could not be present, they have occurred, but at other times very rarely.

But in 1853 I had a case for the treatment of which neither my reading nor my experience had given me adequate preparation. Mrs. A. P., American, age twenty-eight years, quite fleshy but well-formed and healthy, was in her first labor. I found a dense and unyielding cervix. The liquor amnii was discharged prematurely. The child turned out to be large and fleshy, and the labor was a "powerless" one throughout.

The fatal element in this case was delay; and it was delay in the first stage of the labor, while the breech, which was the presenting part, was still within grasp of the cervix. I had the assistance of Dr. Calvin F. Ashley, of this city, but our united efforts were insufficient to bring the case to a successful issue. The authorities which we then had-and among them were certainly some of our ablest writers-did not contain the precise directions which we needed. The hydrate of chloral now so much relied on for the softening of an obdurate cervix, we did not have; and we did not have chloroform then in hand, although it had been discovered some five or six years, and its very great value for facilitating obstetric operations was already beginning to be understood.

I made my first attempt here to push up the breech and bring down a foot, preferring this maneuver to the use of the blunt hook or fillet, applied in Ramsbotham's way, within the uterine cavity above the superior strait. But I found the breech immovably impacted, and the effort was rendered abor

tive.

The terms "arrest" and "impaction," whether so discrim