of Rhodes. Spurious works Andronicus.

The American journal of obstetrics and diseases of women and children online

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the lung exudate B. influenzae were found as the predominating
organism. A moderate number of pneumococci were also
present here. In the pericardial fluid a few influenza bacilli
were found in pure culture. The result of the examination of
the peritoneal fluid and emulsion of the spleen and peribronchial
lymph glands for influenza bacilli were negative. A few colon
bacilli, probably a contamination, were recovered from the
peritoneal fluid. Careful search was made for influenza bacilli
in the nasal secretion, but none were found. Many pus cells
were found and a few staphylococci and many saprophytic
organisms. The nasal cavities were badly contaminated by
material from the stomach.

Serum from the heart's blood obtained at the autopsy did not
specifically agglutinate the bacilli from the spinal fluid even
in low dilutions. Animals were not highly susceptible. One c.c.
of the cerebrospinal fluid injected immediately after the autopsy
intraperitoneally into a guinea-pig was not fatal. As a rule,
growth from two to three slants of pigeon blood agar given
intraperitoneally was required to kill.

Autopsy Report of Case III (C. C). — The autopsy was made
six hours after death and the following anatomic diagnosis given;
acute fibrino-purulent leptomeningitis; catarrhal bronchitis;
acute rhinitis; edema and congestion of the lungs; acute splenitis;
fatty liver; cloudy swelling of the heart and kidneys.

The child is a negro female baby and well nourished. Both
eyes deviate to the left, and the pupils are equal but dilated.
No discharge from the ears. The peritoneal cavity contains

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a few drops of clear fluid, and the surfaces appear normal. The
pleural cavities contain no fluid and are free from adhesions,
and the pericardial cavity contains a few cubic centimeters of
clear fluid and is normal. The thymus, thyroid, heart, larynx,
and pharynx present no significant changes. The nasal mucosa
is covered by a thin layer of tenaceous mucous and is distinctly
reddened and edematous. No pus was present in the nasal
cavities. The tonsils appear normal. The upper and middle
lobes of the right lung crepitate rather feebly, and the lower lobe
is nearly airless. The pleural surface is everywhere smooth and
glistening and in places dark purple in color. On section the
tissue is very moist and bloody, but no regions of consolidation
appear. From the bronchial tubes a frothy nonpurulent fluid
exudes on pressure. The lobes of the left lung also crepitate
everywhere through very feebly in portions of the lower lobe
where the tissue is dark red in color and soggy. The cut surface
is moist and bloody, and from the smaller bronchi on pressure
exudes a distinctly mucinous fluid. No areas suggesting
pneumonic consolidation appear. The peribronchial lymph
glands are enlarged and dark red in color, but without central
softening or other change.

The liver shows slight fatty change, and the spleen is firm,
swollen and has indistinct Malpighian bodies. The adrenals and
genito-urinary organs show no important changes.

The anterior fontanel tends to bulge slightly, and on opening
the skull the cerebrospinal fluid is increased in amount and is
distinctly turbid but not bloody. Over the base and surface
of the brain especially along the larger blood-vessels is a thin
gray fibrino-purulent exudate. In general, the meninges are
edematous, and the convolutions are slightly flattened. The
dura is deeply congested. In the meninges of the spinal cord a
similar exudate is found. The tympanic cavities are both

Microscopical Examination, — ^In sections from the cortex the
exudate in the meninges is thin and composed almost entirely
of polynuclear cells. In places a few mononuclear cells appear.
The blood-vessels are intensely congested, but no hemorrhages
are seen. Slight infiltration into the cortex of polynuclear cells
occurs in places especially along blood-vessels. Small bacilli
can be easily seen in the exudate. The exudate covering the
cerebellum is more abundant, but is composed of similar cells.
Extending along the spinal cord and enveloping the spinal roots

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is this same exudate rich in polynuclear cells. The lumen of
the central canal is filled with exudate composed almost entirely
of polynuclear cells. Little or no infiltration occurs in the
surrounding tissue.

In the lungs there is marked infiltration of round cells and
leukocytes into the bronchial mucosa with intense congestion
of the blood-vessels. In the surrounding alveoli is a small
amount of exudate containing some red cells and leukocytes.
Marked edema occurs generally. No extensive hemorrhage.
Sections of the nasal mucosa show marked infiltration chiefly
of round cells into the mucosa with congestion of the blood-
vessels. The peribronchial lymph glands, stomach, intestines,
pancreas, adrenals, liver, and kidneys show no noteworthy

Bacteriological Report. — The cerebrospinal fluid which con-
tains a large number of polynuclear leukocytes and a few mono-
nuclears in smear preparations shows many small Gram-negative
bacilli, both within and without the leukocytes. In culture a
pure growth of B. influenzae was obtained from the exudate
of the brain and spinal cord. From the exudate of the left
lung, which contained a considerable number of leukocytes, in
culture was obtained many influenza colonies in symbiosis with
the few pneumococcus colonies also present. Cultures of the
heart's blood also gave pure growth of the influenza bacillus.
In the mucus scraped from the nasal mucosa a few colonies of
the bacillus was obtained, and in addition many pneumococcus
colonies. The pericardial and peritoneal fluids and the bile
were sterile.

The homologous serum did not agglutinate the bacillus
isolated from the hear's blood even in low dilutions. Growth
from two pigeon blood agar slants introduced intravenously
int9 a small rabbit apparently produced no symptoms. The
same amount injected intraperitoneally produced death in
twenty-four hours, and the bacillus was isolated pure from the
peritoneal fluid and the heart's blood.

General Considerations. — These two cases of acute meningitis
caused by PfeifFer's bacillus present certain interesting features
worthy of note. Its occurrence in young children housed
together, the one case shortly following the other, strongly
suggests the passibility of this disease being at times contagious.
Analogous to this is the occasional occurrence of cases of meningo-
coccic meningitis in the same family. The abundant meningeal

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exudate in the first case is in rather striking contrast to the thin,
slight exudate in the second. These cases must be considered
as septicemias; whether the septicemia precedes the localization
in the meninges cannot be determined, but in all probability
an initial infection of the upper respiratory tract with B. influ-
enzae occurs with subsequent spread to the meninges and the
blood. The bacilli are not highly pathogenic for animals, and
morphologically and culturally are identical with B. Influenzae
isolated from other sources.
2314 North Clark Street.



Visiting Pediatrist to the New Coney Island Hospital and to Brooklyn

Central Dispensary.


It occurred to the writer that a consideration of the subject
of acute otitis media would be of interest to this Section, for the
reason that such a large number of cases are seen by any man
who practises much among children, and, therefore, its recog-
nition and early treatment at least must rest with him. In
preparing this paper the writer has endeavored to select the
points that have seemed to him would be of most interest to the
general practitioner. If he succeeds in interesting the members
of this Section so as to give this subject a full discussion he will
feel that he has accomplished his purpose.

A disease occurring so frequently, causing so much sufifering,
attended by so much danger to life, particularly from its com-
plications, and so often followed by some degree of deafness
must ever be of interest.

There are two types of this afifection not always distinguishable
the one from the other. They are the acute catarrhal and the
acute purulent. That the catarrhal form is in most, if not all,
cases an infection is now generally accepted. It is needless to
say that the purulent form always is. The bacteriology of the
two forms is much the same and usually one of the following
organisms is present: Streptococcus, staphylococcus, pneumo-
coccus, bacillus diphtheriae, bacillus pyocyaneus, Friedlandet's
bacillus, the influenza bacillus, or mixed infections. The most

♦Read before the Pediatric Section of Kings County Medical Society.

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severe forms of the inflammation have the streptococcus or
pneumococcus, and the milder forms the staphyloccus. •

Pathology, — In considering the pathology it is well to have
in mind the small size of the cavity and the relatively large
surface of mucous membrane because of the many folds in the
upper part. This is important for the reason that in the stage
of hyperemia and infiltration, i.e., congestion, there may be
considerable pressure, even before exudation or increased pro-
duction of mucus takes place. In some cases there may be
resolution at this stage, but if it goes on, then, following the
stage of congestion, there is, in the catarrhal type, increased
production of mucus and exudation of serum which may fill the
whole cavity and cause bulging of the membrane. The mem-
brane becoming infiltrated and eroded gives way under pressure.
With the purulent type there are all the above but more intense
and, in addition, tissue necrosis and exudation of pus corpuscles.
The necrosis may extend to the ossicles and walls of the tympanum
and an early rupture of the membrane may result. With this
form the inflammation is more intense in the upper part. Here,
too, there is more danger of the dreaded extensions to the mastoid
or meninges. The Eustachian tube closes early in this form.

Etiology. — ^The etiology of this disease is important from its
bearing on the treatment, especially the prophylaxis. Common
predisposing causes are the presence of adenoids in the naso-
pharynx, hypertrophied tonsils or nasal obstruction of any sort.
Rheumatism may possibly be a predisposing factor, as also
may be the catarrhal dyscrasia or habit, if there be such a thing.
Climatic conditions, such as cold and wet, favor it.

Among infrequent causes may be mentioned traumatism as
by violence to the parts, as stab wounds, injury from foreign
bodies, and forcible syringing for removal of foreign bodies,
blows, and by fracture through the temporal bone. It may
also be caused by scalding or by irritants in the ear; by sea
bathing, and solutions used through the nose to cleanse nose and
throat. Sometimes it seems to be caused by exposure to cold
and wet, even without a nasopharingitis. A "head cold" is
quite a frequent cause of the catarrhal form — sometimes from
blowing some of the discharge into the ear while blowing the
nose and sometimes by direct extension of the inflammation.
The most common and most important causes, however, are the
acute infectious diseases, and four of these stand out prominently;
they are measles, scarlet fever, influenza, and diphtheria. The

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first three account for a very large percentage of the cases.
Others are smallpox, chickenpox, typhoid fever, whooping-
cough, syphilis, erysipelas, tuberculosis, cerebrospinal menin-
gitis, mumps, and pneumonia. It might be mentioned here
that the association of measles, scarlet fever, or diphtheria
with adenoids is particularly liable to produce middle-ear inflam-
mation. Dentition and bad teeth seem at times to bring on this
trouble. Of all the cases of scarlet fever, it is probably a low
estimate to state that 5 to 10 per cent, have middle-ear inflam-
mation and of measles ten to 15 per cent. When seen as a com-
plication of scarlet fever or diphtheria, the symptoms usually
come on from the seventh to the tenth day, rarely much later.
With measles it is usually earlier.

Symptoms. — Pain and fever are the most constant symptoms.
Pain is an important symptom, both on account of its severity
and because it is often the sjrmptom that draws attention to the
ear; exceptionally, it is slight or absent and may be masked by
the sjrmptoms in the primary disease. In very young children
it is evidenced by restlessness or by putting the hand to the
affected side, or by marked tenderness when the ear is touched.
Pain is worse at night and may be severe then and absent during
the day. The temperature varies within quite wide limits, and
is often irregular and remittent. The moderate cases running
between 10 1® and 103® F. The severer forms may reach 104*^
or 105° F.; exceptionally it is very slight or absent, more par-
ticularly in the catarrhal form in infants or marasmic children.
Occasionally fever is about the only symptom present, and it is
these cases that escape notice until the discharge comes on.
This happens so frequently that in any case of obscure febrile
symptoms the ears should be examined. Usually pain and
temperature are a fair measure of the severity of the inflam-

Impairment of hearing varjdng from slight diflBculty to quite
marked deafness is present. In the moderate catarrhal cases
this clears up, as a rule, soon after a free discharge, and if it persists
is usually of a slight degree. In the severer types its persistence
may depend largely upon whether proper treatment is established
early. Tinnitus and other subjective noises may be complained
of by older children. Other symptoms are anorexia, nausea,
vomiting, and in some cases marked dullness and apathy. In
some cases there are also cerebral symptoms, as severe Jieadache,
extreme restlessness, and even delirium and convulsions without

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meningitic involvement. Local tenderness in front of the ear is
usually present. Objective signs in the membrane are acute
redness and congestion of varying degrees. At first there is a
lack-lustre, pinkish appearance, which, if it be a severe case, goes
on to a more congested condition and a bulging of the membrane.
As a rule, if a good light be thrown on the membrane from a
head-mirror this condition can be made out by any practitioner.
If there has already been a rupture or puncture, there will be a
discharge. In the catarrhal form the discharge is rather
thick, whitish, and profuse, and usually continues when once
established. Later this may become purulent. The purulent
may not be so profuse and may become dis-established with an
exacerbation of constitutional symptoms. As the case improves
it becomes serous in character. At times it may not be possible
to locate the rupture, but usually is.

Diagnosis. — In most cases the diagnosis is not difficult.
Cases of earache occurring in any one of the conditions enumer-
ated under the etiology above given usually means one or the
other of these forms of the inflammation of the middle ear.
This, together with local appearances mentioned, makes the
diagnosis. Fortunately, most of the cases are thus easily
diagnosed. In the very young children where they are unable
to direct attention to the seat of pain or where pain may be
slight or absent, it is more difficult. The history will help some,
and if one remembers the ears, there will usually be found some
tenderness in front of or about the ear. Having been directed
to the ears, one is usually able by gentleness and patience to
find some evidence in the appearance of the membrane.

In cases masked by severe symptoms in the primary disease,
for instance measles, scarlet fever, diphtheria, or influenza, it
is recommended that frequent examinations be made of the
ears, remembering that this affection is most likely to come on in
from seven to ten days in scarlet fever and earlier in measles.
As mentioned before, in obscure febrile diseases there should be
an examination of the ear. In case of any doubt, if it be possible
secure the services of an otologist. In every case both ears
should be examined.

Prognosis. — The prognosis in the acute catarrhal form,
provided one is sure of the diagnosis, may be given as favorable.
In frequently recurring cases, however, it may be followed by
serious trouble. In the purulent form the prognosis must be
guarded — the much greater danger of destruction of parts of the

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middle ear, of its serious complications, and of its running into
the chronic form make this type a most serious afifection.
Those cases coming on in the course of scarlet fever are most
serious, as a rule.

Complications. — It is mostly from its complications that acute
otitis media assumes the importance of being a dangerous disease.
They are mastoiditis, meningitis, cerebral abscess, infectious
thrombosis of lateral sinus inflammation of the internal ear, and
facial nerve paralysis. Here only will be considered very briefly
the most common complication — mastoiditis. The mastoid
cells are in communication with the epitympanic space through
the antrum, so that many of the cases occur by direct extension
through the mucous membrane, others probably by some infec-
tious material being forced in through pressure. Scarlet fever,
measles, and influenza are the diseases in which this complication
occurs most frequently. One authority states that influenza
has more mastoid inflammations than all others, but I think
this statement will be questioned * by others. To give an idea
of the frequency of this complication — quoting figures from a
paper by Dr. Alderton — in 178 cases of scarlet-fever otitis there
were forty-seven cases (26 per cent.) that required operation, and
probably there were more than that inflamed; and of 326 cases
of otitis media due to measles thirty-four cases or 10 per cent,
required operation. Often the course of otitis media and mas-
toiditis is continuous; sometimes there is remission, the otitic
condition improving for a time when suddenly there is a return
of pain, rise of temperature, etc. In some cases where the
otitis seems to improve and gets to a certain point and stops,
the child seems ill, has temperature discharge and anorexia,
etc. The local symptoms are pain, tenderness above and behind
the ear and at the tip of the mastoid, also there may be a char-
acteristic swelling which makes the ears stand out from the
head. These cases should be seen by the otologist and treatment
left to him.

Treatment. — Prophylaxis consists in the removal of adenoids,
hypertrophied tonsils, or other obstructions that promote naso-
pharyngeal catarrh, also in treatment for naso-pharyngeal catarrh
when present; in the means to prevent colds, such as cold sponging
and building up with tonics and fresh air; in the use of mild
alkaline sprays in measles, scarlet fever, influenza, and any form
of nasal pharyngitis to cleanse nose and throat, and also in the
use in these diseases of menthol-camphor and eucalyptol in

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albolene dropped with a dropper into the nose and allowed to
go back in the throat. (In spraying the nose and throat at
any time care should be taken not to blow the nose until all the
fluid has all run out; or, if the nasal passage is free, it may be
gently blown out without holding the nose. The same may be
said of the large amount of discharge.) It consists also in the
care of the bowels, skin, kidneys, and general health. Treatment
of an attack varies with the stage at which it is seen. If seen
early, it consists of the use of a saline cathartic; blood-letting by
leach applied to the tragus (excepting in young or weak children),
and the application of dry heat by means of hot-water bag,
hot-salt bag, or by aural douche of water at about i io° F. If
child will not lie on bag, a small bag may be bound over the ear,
first covering that organ with cotton, or a glove-finger filled
with hot salt may be put into the ear and bound on. Poultices
should not be used. The use of hot oil or laudanum and oil
or hot onion is condemned by most ear men as being uncleanly
and tending to macerate the tissues. Heat is the only good
point it has and that can be better given in other ways. The
question of whether other remedies, as cocaine, morphine, and
atropin, or carbolic acid and glycerin in weak solutions dropped
in the ear, are of any value or of harm seems unsettled, for
there are some good men who advocate their use and others
who condemn them. From a limited use, the writer has no
faith in their ability to relieve any severe earaches or in any
respect afFect the inflammation.

It is also unsettled whether an opiate should be used in the
early stages. The claim that by relieving the pain it may cover
up serious inflammation is made. In some cases in children
the writer has used Dover's powder, but has felt there was some
justice in the above criticism and has only used it where it
seemed necessary. Such treatment as above described may
stop the inflammation at the stage of congestion. If not, and
the pain continues severe or returns after a period of quiescence
and the temperature rises and other symptoms come on then,
whether the drum be only severely congested or there is fluid
and bulging, the proper treatment is to incise the membrane.
Should never wait until it ruptures if it can be helped. After
douching the ear with an antiseptic solution, as bichloride,
I to 5,000, or carbolic acid, i to 100, and cleaning out thoroughly,
then with an aseptic ear-knife, the drum should be incised. This
is best left to the otologist. After incision or spontaneous rup-

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ture of the membrane, the pain ceases, though temperature may
not fall immediately. The discharge then is the object of treat-
ment. Keep clean by syringing the ear with warm carbolic solu-
tion, I to loo or I to 200, or warm bichloride, i to 5000, through
a steady-flow syringe without too much pressure. Leave the ears
free so that they may drain freely. If drainage becomes imper-
fect it is usually noted by the rise of temperature, but if it per-
sists after drainage is again established look out for mastoid
trouble. Powders are better not used, because they cake up
and impede drainage. The discharge clears up in from one to
three weeks, as a rule. If it does not, other measures may be
tried. Saturated solution of boric acid in alcohol may be tried.
Some men advocate peroxide of hydrogen, i to 4, but on account
of bubbling tendency its use is open to criticism. Politzeriza-
tion is used both here and in some milder cases earlier. Hete,
again, special advice by, and treatment from, the otologist is
necessary. The acute cases running into chronic and the com-
plications before noted all demand the services of an otologist.
To briefly summarize them :

1. Acute otitis media is a very important disease, and its im-
portance is attested by the following reasons:

a. Because it is a common affection.

b. Because it usually means much suffering.

c. Because it may endanger life.

d. Because it may seriously impair one's hearing for life.

2. By removal of some of the causes, as adenoids, large tonsils,
and other nasal obstructions, and by treating acute and chronic
nasal pharyngitis and the same conditions existing in acute in-
fectious diseases, some cases might be prevented.

3. Attention to the general health in cases prone to these
attacks is of some importance.

4. Watchfulness for this trouble. In cases of measles, scarlet
fever, diphtheria, and influenza, of severe grade, where pain
might be masked.

5. Examine the ears in cases of obscure febrile symptoms.

6. In cases of doubt in diagnosis secure an otologist, if pos-
sible; also in cases requiring incision of the drum membrane and
in cases running into the chronic form or having complications.

Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 85 of 109)