DISCUSSION.

very

While generwell acquainted

M. L. Ravitch, Louisville. al practitioners are with the importanve of the teeth in relation to the general condition of patients, I would

like to call your attention to the fact that the teeth have relationship to dermic disturbances. Many a case of localized erythema or eczema have been cured by correcting diseased teeth. I have met with some cases with persistent angioneurotic oedema due to pyorrhea.

A very peculiar case came under my observation about nine years ago, which was also seen by Dr. Yager. The case was exhibited by me before the Jefferson County Medical Society, and was considered one of cancer of the check in a young man, 26 years of age. Some of the best surgeons in Louisville saw this case and believed it was cancer of the cheek. Taking in consideration the age of the patient and the rapid growth of the ulcer, I could not believe it was a cancer. A bacteriological examination was made in this city and in Chicago, and the reports from both laboratories showed that there was an excessive proliferation of cells, and the diagnosis of cancer was substantiated. Since the ulcerative process could be traced back to the upper jaw, I found the patient had trouble with an upper molar. I took him to Dr. Yager, who examined him, and found a large abscess in the upper molar. He recommended extraction of the tooth, which was done, and under the use of mild antiseptics the supposed cancer healed rapidly and left only a slight scar.

When we encounter such cases as this, it is very essential to go into details and make a thorough diagnosis of every suspicious case if we want to get results.

The subject of focal infections is important, and physicians ought to pay more attention to it. W. W. Anderson, Newport: I would like to ask Dr. Yager whether in the presence of focal infection, which he has illustrated, the tooth or teeth are not found to be tender to touch in many cases, or how would he guess there is an abscess there?

John J. Moren, Louisville: One of the pictures you have seen is a picture of my mouth: I began to suffer pain in my joints and especially my hands, so that shaking hands was absolutely painful to me. I had a lower molar tooth that was hurting me a good deal. I wanted my dentist to look at it with a view to extracting it, but he refused to do so because he wanted to save the tooth. I had heard a good deal about focal infection and decided to take the initiative myself, Dr. Keith made an X-ray picture which showed an abscess on two roots. It was a crowned tooth; the dentist removed the crown, and found the tooth in bad condition. Dr. Yager removed the tooth, and within a short time, I will say within two weeks time, I had practically no

pain. I d not take any medicine. I did it purposely to ce if it had any influence. To-day Dr. Yager asked if I could shake hands. He grasped my hand firmly without any pain being experienced on my part. That tooth was very painful to the touch, and in chewing, if I caught the food at a different angle, pressed it outward or inward, the tooth, which rather loose, would be very painful. I could not chew on that side any more. So I am firmly convinced that this tooth had something to do with my pains. I have had none since, and I have not used any medicine.

was

One thing more about teeth. For two or three years I have had a number of children come to me with twitching of the face, so-called habit spasm, that had resisted all medication, tonics, sedatives, and so on, but which were relieved by extracting teeth that were decayed. I have referred two or three cases to Dr. Yager for treatment, and he himself has noticed that by getting rid of the local infection or irritation the spasms ceased..

M. Casper, Louisville: I think the program committee should be congratulated on having had this subject presented so well. Radiographers find a surprising number of unerupted teeth. There was a time when we thought unerupted teeth were a rare occurrence, but now we know they are by no means rare, but rather a common thing for patients to have unerupted teeth. A great many of the facial neuralgias and headaches, especially lateral headaches, are explained by unerupted teeth which are not discovered until radiography is resorted to. In the case of an abscess of the root of a tooth, that particu lar tooth feels to the patient longer than the rest of them. The patient will always give the symptom, or nearly always, it feels a little longer than the rest of the teeth, and it is more sensitive." Radiography will readily diagnose an abseess of the root or several abscesses as case may be.

Doctors and dentists should get together more on this subject than they have in the past. A great many systemic conditions are due to these focal infections, and it has been brought out clearly in a recent meeting of the American Medical Association at San Francisco through its splendid exhibition, showing the relation of focal infections, and also demonstrating very graphically the cause of those conditions as due to a specific organism. I forget the exact name, but I think it is amoeba buccalis. I saw the organism under the microscope at San Francisco. It is easy to isolate, and its hearing upon systemie conditions generally is really a large field which will be rapidly opened up in the near future, so let dentists and doctors get closer together and work out these problems.

C. E. Purcell, l'aducah: Generally speaking, I think the conditions the doctor has brought out

in his paper have been neglected, and I think the reason they have been neglected is, first, that while there has been an attempt on the part of dentists and internists to show the importance of these focal infections, it has been a hard matter to get physicians and specialists to see the full importance of it. I might relate two cases that will not only show the importance of the subject, but it will also show the value of treatment, and the prompt cure when the right treatment is instituted.

I recall having seen a few years ago a young lady who had intolerable pain over the side of the face, and her condition had been diagnosed as tic douloureux and she had been advised to have the ganglion resected. It was at a clinic where some of the most famous surgeons in the United States were in attendance. Antral disease had been excluded. The diagnosis had already been made of tic douloureux, and the surgeon was going to remove the Gasserian ganglion, but for some reason or other, his time was so taken up that he did not get to this case, and the girl was dismissed from the hospital. She went home; her physician extracted a molar tooth, and she got well. She did not need any other operation.

The second case was a man who had intolerable pain in his canine tooth. He went to his dentist, and the dentist unfortunately broke the tooth and left a part of the root in. The case came under my observation. Whether it had any connection with the antrum or not I did not then know, but the patient had intolerable pain all over the side of the face. He suffered so much pain his physician gave him morphine to keep him quiet, and even morphine did not quiet him. Transillumination was practiced which with other evidence was positive. He had a molar that was loose, and the peculiar thing about it was the patient did not think there was anything wrong with the antrum. His doctor did not think he had any trouble with his antrum, and I had not only the patient to convince but also his physician. But the indications that he had trouble with his antrum, were positive, and I suggested and urged that he would make no mistake by having the tooth removed, and if there was a diseased condition of the roots a puncture of the antrum could be immediately done, and it would not only establish the diagnosis, but if the trouble was there, it would quite likely cure it it would give sufficient evidence that would lead to a cure. The tooth was removed, and an abscess was found at the roots of the tooth; the antrum was washed out, and the patient got well immediately and has remained so.

In the future, not only specialists, but physicians generally, must pay more attention to searching out these focal infections. We must not be content to pass on a case by merely looking into the nose and mouth. We must come more to rely

on team work and complete and exhaustive examinations.

O. O. Miller, Louisville: One of the distressing complications in pulmonary tuberculosis is a mixed infection developing some time during the course of the disease.

Not infrequently this secondary infection finds its origin in diseased conditions existing in the mouth.

One of the best prophylactics is strict oral hygiene. All decayed teeth and suppurating conditions about the gums should receive appropriate treatment. If this be done one can expect better results with the treatment; there will be less gastro-intestinal disturbance and less likelihood of secondary infections.

N. T. Yager, (Closing): I do not believe I clearly under stand the question of Dr. Anderson. W. W. Anderson: I asked the question as to what evidences there are of focal infection or apical abscess without the use of the X-ray, whether the tooth is not tender at times, which would lead us to suspect that is the focus.

N. T. Yager: No, the tooth is not necessarily tender. I tried to bring that out in my paper. Many apical abscesses exist for an indefinite period without any local manifestations. There may be a cavity that should be filled, and in attempting to fill it you may find that the tooth should be extracted, which would show up the abscess. Unless you take an X-ray picture there is no way you can find out.

Another thing: I have observed that where a tooth is sore, and abscessed, it is not of sufficient duration to give the patient much systemic derangement, because it is usually attended to at the time. The infections that play the most important part with the general condition of the patient, are the blind abscesses from which the patient, as far as you are able to learn, suffered no local inconvenience.

I thank you for the discussion and the courtesy shown.

Clinical Forms of Whooping Cough.-Shiperovich reports four cases of whooping cough with unusual clinical manifestations. In one there were acute emphysema of the lungs, emphysema of the entire skin of the body, head and extremities and pneumothorax, the case terminating fatally from rupture of some alveoli in the lungs. In the second case the attacks of coughing were followed by unconsciousness; necropsy showed hemorrhagic encephalitis and pulmonary edema. In the third case the unconsciousness, clonic convulsions and glycosuria were probably caused by capillary hemorrhage in the fourth ventricle. The glycosuria disappeared afterward, and the patient recovered. In the fourth case, bloody tears showed during the cough. They contained numerous lymphocytes. This child also recovered.

COMPLICATIONS OF MIDDLE EAR SUPPURATION.*

By L. S. GIVENS, Cynthiana.

When our worthy President assigned me the foregoing subject as selected by the committee, I felt sure that there would be a companion paper-taking up the symptomatology, prognosis, treatment, etc., which in itself, would require additional volumes for reference, but lo, when the program appeared printed in the JOURNAL I gave it "the once over" which glimpsed me at once that I was the only one, the ne plus ultra, the sic semper Maginnis, or, as Marse Henry Watterson would say―words to that everlasting bloomin'

effect.

So I shall endeavor to briefly mention in a general way some of the most frequently met with complications in middle ear suppuration. The presence of pus in any locality depends upon a necrotic process involving the deeper tissues of the region.

In the middle ear the upper portion of the tympanic cavity presents an exceedingly favorable site for the development of a purulent inflammation, since in this region considerable connective tissue is is present, forming the framework of the mucous duplications of the tympanic vault as well as of the ligamentous bands fixing the ossicles to the walls of the tympanum and uniting them to each other.

There is no small individual cavity in the human body which occupies so distinctly vital a position in its relations to surrounding areas as does the cavum tympanum.

Therefore a study of its anatomical relations will definitely reveal the close interrelation which exists between the cavum and its many accessory areas, viz. the Eustachian tube, the mastoid antrum, the lateral sinus, the carotid canal, the labyrinth and the temporosphenoidal fossa.

Suppurative otitis media is simply a generic classification of the varieties of pus producers which may invade the middle ear cavity. On the virulence or activity of the specific coccus or bacillus responsible for this suppurative process will depend the frequency, severity and rapidity of extension of such an active destructive process into the surrounding vital intra-cranial tissues.

Involvement of the mastoid process is almost always secondary to an acute or chronic suppurative middle ear condition by extension backward to the mastoid antrum from the middle ear cavity, through the additum ad antrum. The antrum is then the first portion involved, subsequent infection spreading from this cell as a center. Such infection will fol

*Read before the Kentucky State Medical Association, Louisville, September 21-23, 1915.

low the course of least resistance. If purely inflammatory in character it follows the mucous lining of the mastoid cells until subsequently the entire mucous surface is involved.

With the further infection suppuration begins, pus collects within the areas involved and tension results, thus hastening the process.

In examining a temporal bone we find that the mastoid portion has relations with both. the middle and posterior cerebral fossae; that in the posterior fossa it is in intimate relation with the sigmoid sinus. So we draw our conclusions as to what can and what does often happen.

In the acute diseases of the middle ear cavity which may lead to brain abscesses the two most vulnerable spots by which infectious matter may enter the brain tissue or its membranes directly are the tegmen tympani or tegmen antri, by erosions or through dehis

cences.

Internal ear complications resulting from middle ear suppuration has been muchly written about and discussed. Labyrinthitis in connection with acute otitis media (and Gerke, for example, puts acute suppuration of the labyrinth and acute exacerbations of chronic suppuration in the same category) is usually the avenue to a fatal meningitis in those cases in which death occurs a few days after the beginning of the suppurative pro

cess.

Secondary involvement of the labyrinth is seldom met with in chronic suppuration. When present, the mischief has usually been done in the acute stage of the disease, and although both the oval and the round window may have remained bathed in pus for years, extension to the labyrinth seldom follows.

The frequency with which purulent involvement of the brain substances follows acute or suppurative otitis media, was made interesting in a report of "A study of twenty-one such cases coming under the personal observation of Dr. Edward B. Dench" a few years ago.

In four of the twenty-one cases the duration of the suppuration was unknown, in seven there was a history of chronic suppuration, while in ten. intra-cranial involvement followed an acute suppuration of the middle ear.

I know that later day statistics vary to a great degree from the teachings on this subject of old time instructors. A number of years ago, I was a student in London's best throat and ear hospitals, namely the Central Londan with Lenox-Browne and Dundas Grant, and the Golden Square with Sir Morrell McKenzie and Mark Hovell. The latter (Mr. Hovell) remarked more than once that "acute suppuration of the middle ear was comparatively seldom followed by cranial

complications; the reason, the lymphatics are intact, and any septic matters which might find their way into the cavity are probably destroyed.

Psychical disorders of various kinds and epileptiform convulsions are sometimes due to chronic middle ear suppuration; obstinate cough and frequent sneezing have been observed to accompany a chronic discharge from the ear.

Complications in the heart, pleura, joints and kidneys coexist with startling frequency. There is no doubt that a certain degree of phlebitis in connection with purulent ear disease, leading to thickening of the coats of the vessels and to thrombi, especially in the sig. moid sinus, sometimes exists.

So long as the thrombus is firm and solid, obstructing the circulation, the danger of general blood infection is not as a rule great; but when it becomes infected, soft and disintegrated, the broken down and septic thrombi are detached by the current of blood and become emboli in some near or remote part of the body, giving rise to fresh septic centers.

In this way septic thrombi, swept on by the circulation, give rise to infarctions and metastatic abscess, especially in the lungs.

The lungs, liver, spleen, joints or subcutaneous connective tissue may, however, be the seat of such infective abscess formations. Thus the general mass of the blood may be infected, causing pyemia or septicemia. Indeed, this is probably a much more frequent complication of ear disease than is usually supposed.

The position of the tonsil is well establish ed in this respect, and we know it is frequently the source of infection in other organs. Then, why not a discharging middle ear trouble?

Complications threatening the life of the patient may arise at any time in the course of middle ear suppuration, and this should always be bourne in mind, in spite of the fact that a large number of patients suffering from this disease never present any serious symp

dle ear troubles originate in the throat or nose. Furthermore, we know that this trouble extends from the throat or nose through the Eustachian tube. Where we have a pathological condition within the Eustachian tube we have an increased blood supply in the middle ear. From the middle ear it is only a step to the antrum, and only a short step from the antrum to the mastoid cells. When the mastoid cells are involved you may not only have abscess in the brain but have the lateral sinus denuded, and your patient dies before you think he is seriously ill. It is up to the man who sees the case first to try and stop the invasion or spread of the trouble from the throat to the middle ear. If you are not capable of distinguishing a change within the ear drum, get your head mirror, practice upon your coachman; if you cannot practice upon him, practice upon your wife; but above all things, learn to distinguish the first symptom of middle ear infection. When the border of the ear drum is red, when you have a bulging, an incision from top to bottom of the drum head will give good drainage and possibly prevent the patient from having mastoiditis. You will have relieved the patient not only from great pain, but saved him from having a mastoid complication. I do not believe the middle ear can be infected without having an infection of the antrum, and whenever you have infection of the antrum itself, the cells in the mastoid are affected. In the future, we should not let a child suffer pain due to middle ear infection for the drum head must be incised and free drainage established.

B. A. Bledsoe, Newport: I want to repeat a couple of paragraphs that were in Dr. Givens' paper which are very important. One is, "there is no small individual cavity in the human body which occupies so distinctly a vital position in its relations to the surrounding areas as does the cavum tympani." Another one is, "the presence of pus in any locality depends upon a necrotic process involving the deeper tissues of the region.'

Given a middle ear abscess that has ruptured or has been perforated instrumentally, you must always consider and keep in your mind's eye the fact that there is destruction going on beyond the area upon which you look. In a chronic otitis media, with a large perforation in the drum, a large abscess going through the perforation, you only see a small portion of the necrotic area. The destruction is going on in the entire middle ear, possibly back into the mastoid antrum, the mastoid cells. You must remember this that unless tension is increased in the mastoid cells you are not going to have marked symptoms of mastoiditis. With the symptoms of acute mastoiditis you are all familiar, but in the chronic cases, where drainage is free, you may have a mastoid inflammation as a result of a slight cold, producing an exacerbation, or it may go on to one, and

I consider the most important complication with which the doctor has to deal is brain abscess. Brain abscess is undoubtedly the most important complication of middle ear abscess. I would like to speak one word in regard to them, and then I will have finished. Brain abscess is very treacherous. I have seen a few cases-I won't say how many, but there is one I might refer to in particular, and possibly it may enlighten you more than an array of words.

I saw this case one day with a moderately free discharge from the ear; the temperature varied from 99 to 100, the patient complaining of severe pain in the frontal region, but of none whatever in the mastoid region, nor anywhere else except in the frontal region which, upon transillumination, was shown to be negative. In twenty-four hours that young man was a corpse. Upon postmorten we found that the tegmen had been ruptured and a small brain abscess existed.

Given any case of middle ear suppuration in the acute stage, or a mastoid irritation, it is your duty, either as a specialist or general practitioner, to immediately see that there is free drainage furnished that middle ear. That is of first im

portance. Furnish free drainage and keep it free until the trouble has been eliminated. One paracentesis is not sufficient in the vast majority of cases. Your duty is only finished when you are satisfied you have free drainage down to the floor of the canal. That is one thing I would like to impress upon you all.

W. B. McClure, Lexington: Just one word. I take it for granted that the one thing the otologist fears in a suppuration of the middle ear, and the one thing on which he looks with greatest anxiety is a possible mastoid involvement. "An ounce of prevention is worth a pound of cure."

I want to emphasize the statement made by Dr. Thomasson that the remedy to prevent this condition is free drainage by opening the tympanum. With a good light, I think the general practitioner might very readily, and with a proper instrument, establish drainage. and in a very large per cent. of the cases the other extensions following mastoid involvement may be thus prevented. I believe in every case, where you have a bulging ear drum, red, if you will make an incision and let out the contents of the middle ear, you not only relieve pain and establish external drainage, but you save those complications which we so much dread.

J. F. Reynolds, Mt. Sterling: My compliments to Dr. Givens for this excellent paper. It is not only of interest to the Otologist but equally so to the general practitioner and surgeon. No doubt you have all diagnosed abscesses in the liver, spleen, kidney, lung, appendix and various other organs without being able to tell the origin of this septic material.

Have any of you ever asked these patients if

they suffered from middle ear suppuration? If we find an abscess in any part of the system and cannot find the cause elsewhere make an examination for suppuration of the middle ear.

I want to call attention to a few of the most frequent complications which Dr. Givens has failed to mention, namely, constriction or stenosis of the Eustachian tubes, atrophy of the mucus membrane of the naso-pharynx, ptosis of the eyelids, divergent squint, unsteadiness of gait, aural-polypi, facial paralysis and perichondritis of the auricle.

Pomeroy mentions a case of peritonitis with sub-mucous ecchymoses in the intestines at an autopsy after a fatal ear disease.

In my opinion if the members of this society will study carefully Dr. Givens' paper, they will nanimously agree it has been one of the most important papers that has been read at this meeting.

L. S. Givens, (Closing): I feel very grateful for the able discussion of my paper and for some valuable points so clearly brought out, and will add a few words only as to the prevention of nearly all of these complications.

The sooner we make a diagnosis of middle ear conditions, the better will be the prognosis. That is an old time saying.

In a paper read before this society a few years ago in a symposium on the treatment of acute mastoiditis, etc., I remember laying great stress on the prevention of mastoid trouble in the treatment of middle ear complications. Of course, all middle ear diseases will be, more or less, mastoid complications, but with thorough opening of the tympanum and establishing free drainage, a clean cut cavity made, there will be less complications of mastoid conditions, which, of course, predominate in these middle ear complications. In the meantime the adenoids should be removed and the tonsils, if diseased, taken out. There should be a good draft made through the respiratory passages, so that the child can breathe, talk, sing and whistle, and eat in god shape. Free from obstruction in the upper respiratory tract, the child will have fewer colds and troubles from acute infections of the tubes and middle ear complications will be less.

I remember a discussion Dr. Wendell Phillips, of New York, made before the medical section at the meeting in San Francisco, when he said he believed it was his impression that in the Manhattan eye and ear and throat hospital, and the postgraduate, those cases brought to the hospital with middle ear complications were put to hed and proper drainage established, and careful moderr. treatment instituted, many of them were taken through without any particular operation.