SECTION ON OPHTHALMOLOGY.

FOUR CASES OF COMPLICATED, CHRONIC OTORRHŒA, TREATED BY THE DRY METHOD.

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BY GEO. P. HALL, M. D., GALVESTON, TEXAS.

HE treatment of chronic suppurative diseases of the middle ear according to the antiseptic or so-called dry method, has certainly marked an important epoch in the history of otology. That it is greatly superior to the old or moist method is now beyond question, if we are to accept as of any value the experience of the leading otologists in al parts of the world. Owing to the anatomical configuration of the tympanic cavity, a purulent process once established has a peculiarly inviting field for permanent residence. According to the researches of Ogston, Cohnheim* and others, it would seem that the formation of pus is the result of parasitic invasion of the tissues, especially by micrococci. In these cases where, through a perforation in the m. t. the middle ear cavity is in open communication with the atmosphere, the presence of bacteria seems especially invited, and the conditions perfect for the formation and decomposition of purulent products. The antiseptic treatment, then, in virtue of its power to check sepsis, to limit pyogenesis, and to prevent the presence of microphytes, ought—according to the scientific theory of the day-to be, par excellence, the treatment, and so I believe it is.

It is not my purpose, in this paper, to discuss the merits of the dry treatment, as applied to the uncomplicated cases of chronic otorrhoea, but to present, instead, the more salient features in the history of four cases in which this disease was complicated by the presence of granulations, mucous and fibrous polypi.

CASE I.-M. S,, from the interior, age 8, was brought to me by her

father, who is a physician, for treatment of a chronic otorrhoea of two years' standing, dating from a severe attack of scarlatina. Nothing in the way of treatment had been done other than to use carbolized washes to cleanse the parts when the discharge became offensive. The general condition of the patient was excellent. The discharge was profuse and offensive. After thoroughly cleansing with warm water and drying with absorbent cotton, inspection showed a large perforation in each rut. The mucous membrane, in both cavities, was found to be studded with granulations, and on one or two small polypi were present. H. D. R. & L. c-24. Eustachian tubes were easily inflated; the post-nasal space in a state of chronic inflammation. In this case I had the valuable assistance of my friend, Dr. B. A. Pope, of New Orleans. The dry treatment was used, all secretion being carefully wiped out with a tuft of absorbent cotton, on the end of a probe; the middle ear was then inflated, and, after removing any further secretion which might be discovered, the impalpable powder of boracic acid and resorcin, according to Burnett, was blown on the diseased surface, packed in and a pellet of cotton pushed down on it. The discharge became almost nil after two weeks, and in one month had ceased entirely. On inspection no trace of either granulations or polypi was discoverable; the perforations, though not closed, were much smaller, while the H. D. in each became 1-24.

CASE II.-Miss E. M. from North Texas, age 17, has suppuration of both middle ears, of ten years duration. H. D. R. 1-24, L. 3-24; eustachian tubes pervious; has some nasal catarrh. Secretion is scant. In L. a good sized perforation was found, and lying in the cavity, on its floor, was a small mucous polypus. A similar condition existed in R., the perforation being smaller, while the discharge was more profuse. The local application of dry powders, as in case No. 1, was continued for three weeks, with the effect of diminishing, but not stopping entirely, the discharge. This treatment was then discontinued, and a solution of boracic acid in alcohol substituted. Under this the polypi became paler and perceptibly smaller. In one month I again changed to boracic acid and resorcin. At this time the growths were about onehalf their original size, and the discharge reduced to a minimum. After one application of the powder to L. and three to R. all discharge ceased. In fifteen days after no foreign growth could be detected in either ear. Subsequently both perforatons closed, and the H. D. became, in R. 3-24, L. 8-24.

CASE III.-P. R., age 19; had yellow fever, in Havana, when three years old, and says the double otorrhoea dates from that time. Has chronic naso-pharyngeal catarrh, with some adenoid vegetations of the pharyngeal vault. H. D. R. c-24, L. p-24; discharge slight in both. In L. a small perforation was found; in R. a large one, with a growth in plain view. This proved to be a mucous polypus, with a broad base The m. t. in its superior segment, was covered with granulations. E tubes pervious. After one application to L. all discharge ceased, and the perforation soon after closed. In R. the granulations rapidly disappeared, the secretion became greatly lessened, but the neoplasm seemed unaffected. The alcohol treatment was then pursued, for a while, with the effect of diminishing the size of the tumour, but this process finally seemed to come to a standstill. I again used the powder, making three applications in as many weeks. The discharge was promptly checked, and on examining the ear at the end of the fourth week, found the canal perfectly dry, no trace of the growth, and the perforation evidently closing. H. D. became, in R. 6-24, L. 8-24. The perforation finally became quite small, but never entirely closed.

CASE IV.-J. G., from South Texas, age 12; says he had "brain fever" seven years ago, since which time his L. ear has been discharging. He suffers, at present, from chronic malarial toxæmia. Says his ear has been treated frequently, and he was finally told that "if the discharge were stopped it might go to his brain and prove fatal, but if he would let it alone he might outgrow it." On inspection I found the ext. auditory canal so swollen that only a narrow slit-like aperture existed. It was, of course, impossible to determine the exact condition of the tissues further in. The discharge was profuse and offensive; the walls of the canal somewhat "boggy," and covered with granulations. A little more and there must have been complete closure of the canal, with retention of pus and its dangerous sequences. No air could be driven through, with either bag or catheter. In this case I used a warm solution of bicarb. sodium to,cleanse the canal as thoroughly as possible. After drying it as well as I was able to, brushed a 100 gr. solution of nitrate silver over the swollen, granulating surfaces. Subsequently I introduced a short bit of rubber tubing, as large as the calibre of the canal would accommodate, allowing it to remain in during the intervals between visits, and increasing the size of the tubing gradually. In ten days I had the satisfaction of seeing the canal restored to nearly its normal size. I then found the entire m. t. swept away, the ossicles

gone, and springing from the promontory was a fibrous polyp, with a broad base, some larger than an English pea.

The E. tube was catheterized, the parts cleansed, and the boracic acid packed in gently but firmly, and a plug of borated cotton pushed down on it. This treatment rapidly minimized the formation of pus, but caused no change in the tumour itself. Alcohol and silver nitrate,

according to Knapp,‡ was then tried, for a reasonable length of time, without apparent effect. I again commenced the dry powder, packing the cavity as before. On the 18th day after the last change, I decided to explore the cavity again, the discharge being almost nil, with a view to removing the growth, but great was my surprise to find it already very much smaller. Of course, I continued treatment, and after a few more applications the growth atrophied and finally disappeared altogether. It is almost superfluous to say that the hearing was not improved.

No mention is made as to treatment of throat and nose complications which existed in these cases, inasmuch as-though regarded as positively essential to the success of my plan—it was not thought to have a specific bearing, over any other, on the plan in use. Not a few, who are regarded as authorities on otology, have asserted that the dry method is applicable only to the simple cases of chronic otorrhoea. On the contrary, others claim that it is sometimes successful in the most complicated cases. There are different views as to what constitutes dry treatment. The combination of boracic acid with alcohol was, I believe, introduced by Loewenberg, of Paris, he believing it to be a more effective germicide. It is usually classed under the head of dry treatment. Some use the syringe steadily for cleansing the tympanic cavity. Often a syringe is quite indispensible, but I believe, where all secretions can be effectually removed with absorbent cotton, that the latter is, by far, the better plan, as it seems to leave the mucous lining of the cavity in a condition decidedly less favorable to the formation of granulations, polypi, etc.

The limited number of cases reported in this paper, while too small to allow the formulation of positive conclusions as to future or continued success, are of positive value so far as they go. At the risk of being considered hasty in deducing inferences, after a study of the above cases I believe I have some warranty for the expression of the following opinions :

Ist. That the alternate use of alcohol and some antiseptic powder is

much more likely to be effective than the use of either agent alone. 2d. That the alcoholic treatment, even when partially or totally unsuccessful, changes the condition of the diseased surface to one peculiarly favorable to the successful application of antiseptic powders.

In conclusion, I will say that, notwithstanding the dry method is advised chiefly in simple cases of chronic otorrhoea, in all the more recent text-books which I have seen on this subject, it is my belief that it will undoubtedly obviate the need of surgical interference in not a few cases in which, a short while back, the latter would have been rightly considered a necessity.

*Belfield: The Relations of Micro-Organisms to Disease. +R. Resorcin, zi.

Acid Boracic, 3i.

M. bene.

-Burnett in Am. Jour. Med. Science, Jan. '83.

Arch. Otology, Sept. '83.