MIDDLE EAR DISEASE IN CHILDREN IN THE COURSE OF THE ACUTE EXANTHEMATA.

BY CLARENCE J. BLAKE, M.D.,

MASSACHUSETTS.

THE importance of this subject is sufficiently attested by the large number of cases of middle ear disease presenting themselves in an exclusively aural practice in the persons of both adults and children, in which the initial lesion occurred in the course of one or other of the more common exanthemata of childhood. Of the cases of purulent inflammation of the middle ear presenting themselves at the out-patient clinic of the Massachusetts Charitable Eye and Ear Infirmary for instance, more than 35 per cent. were referred to scarlet fever and measles as the exciting cause. Statistics of deaf-mutism show, moreover, that in a large majority of the so-called acquired cases, the loss of hearing is the result of an acute inflammation of the middle ear originating as one of the complications of scarlet fever. an illustration of this may be given the results of the examination of 41 cases of deaf-mutism made by the writer.

In this investigation, the division being made into congenital and acquired of the 41 cases examined, all of those where the history gave no clue to the cause of deafness and where the loss of hearing was noticed before the age of two years, or where, under the latter circumstance, it was referred to some one of the diseases incident to early childhood, were put down either as congenital or doubtful, unless the middle ear showed positive traces of inflammatory action, thus excluding several from the list of acquired cases, which nevertheless numbered 17 out of the 41, or 40 per cent. In 12 of the acquired cases there had been perforation or destruction of the membrana tympani on one or both sides. In 13 out of the 17 the deafness was traceable to scarlet fever or measles, 11 of the 13 being scarlet fever, 27 per cent., therefore, of the whole number having lost their hearing as the result of this terrible disease.

Until very lately my experience in the acute inflammation of the middle ear in children during measles had been very limited, amounting at most to not more than two or three per cent. of all the cases of acute middle ear disease. During the past winter, however, the epidemic of measles prevailing in Boston and vicinity has given an ample opportunity for the study of these cases and for comparison of their course and symptoms with those accompanying the disease in scarlet fever.

In both exanthemata we have to deal with an acute inflammation affecting, primarily, with one exception to be hereafter mentioned, the mucous membrane lining the middle ear, forming the inner coat of the membrana tympani, covering the membranes of the fenestra ovalis and fenestra rotunda, investing the ossicula and their articulations, intimately connected with the periosteal covering of the tympanic walls, and, in fine, bearing so close a relationship to all parts of the delicate sound transmitting apparatus as to readily engage them in its inflammatory process and seriously endanger and impair their integrity.

The fact that this inflammation of the middle ear occurs principally during the acute stages of the exanthemata, and runs its course with great rapidity, and that it is in the early stages of the inflammation that conservative measures, especially so far as the hearing is concerned, can be most effectively employed, renders the subject of great importance to those having to deal especially with the diseases of children, and makes my excuse for presenting it to the consideration of this Section of the Association.

That our aural clinics afford so large a number of cases, especially of chronic purulent inflammation of the middle ear, originating in the course of scarlet fever and measles, and that the conservative exercise of aural surgery has had so little opportunity to prevent the disastrous results which those cases present, is due probably to several causes; in the medical profession at large to a wise hesitancy in regard to acting without sufficient knowledge, trusting rather to the vis medicatrix naturæ than to the "half of knowledge, less than none"-to the fact that the reparative powers of tissues so vascular as those here implicated are very great and afford recovery with a fair amount of hearing in many cases, and that normal hearing is at best but a comparative term-and among the laity to the prevalence of such opinions as that quoted by Dr. J. A. Andrews in a paper

recently read before the Richmond County Medical Society, reputedly originating with Fallopius, that the discharge of pus from the ear of a child should not be interfered with because it evidences an effort of nature to throw off morbid secretions from the head through the ear;-an excellent illustration of the legacy of obstructive misconception left to us in medicine from the past, and which we in our time should take good care against constructing for the future.

The increase of comparative clinical experience in certain classes of cases, and the opportunities thereby afforded for the more minute investigation and differentiation in both symptoms and treatment, which is one of the advantages of the growth of specialism in medicine, shows that much may be done in the early stages of acute middle ear disease accompanying the exanthemata to diminish the severity and shorten the duration of the inflammatory process, and proportionately to preserve the integrity of the important structures implicated. The time for judicious interference is in the beginning of the trouble, and it is at this time that the case is usually under the observation of the family physician. The aural complication is sufficiently common, moreover, to make it advisable that its possibility should be borne constantly in mind, and, indeed, in this connection, the often quoted remark of the late Dr. E. H. Clarke is none too forcible. "So important," he says, "is a proper attention to the ear during and after the acute exanthemata, that a physician who treats such cases and neglects to give it his attention cannot be said to perform his duty to his patient."

The most conscientious watchfulness, stimulated by an appreciation of the justice of this remark, is at best valueless without a sufficient knowledge of the morbid processes in question, and of the best measures for their relief; the special text-books and the special clinics now established in almost every large centre in this country place this knowledge within the reach of all, its acquirement becomes, therefore, all the more a duty. Of especial importance for practical purposes is a knowledge, in this connection, of certain peculiarities of the structure of the ear in childhood as compared with adult life. Among these may be here mentioned the greater vascularity of the tympanic mucous membrane, congestion of which more readily closes the Eustachian tube, and produces serous effusion into the tympanic cavity and tissues of the membrana tympani, this together with

the readier solution of continuity of the tissues more aptly favoring an ulcerative process, the progress toward acute purulent inflammation of the middle ear being in children usually more rapid than in adults.

In examining the ear, as well as in operating upon it, the comparative shortness of the external auditory canal and the fact that the plane of the membrana tympani (forming an obtuse angle with the posterior wall of the canal), is more nearly on a line with the long axis of that passage than in the adult, should be borne in mind.

The middle ear complication in scarlet fever and measles presents certain differences of type, which are worthy of note, especially in reference to the treatment to be pursued.

In scarlet fever the aural trouble may occur at any time during the prevalence of the acute symptoms, the inflammation usually extending from the naso-pharynx along the Eustachian tube to the middle ear, rapidly running its course, with a degree of tissue destruction bearing a more or less definite relation to the persistence of high temperature, and furnishing within a very short time a well marked acute purulent inflammation of the middle ear.

In measles there are, according to my observation, two distinet originating types of middle ear disease; the first corresponding in its symptoms and course to the acute catarrhal inflammation of the middle ear accompanying "head colds" in children, and occurring generally during the persistence of the acute preliminary coryza, the second originating primarily in the membrana tympani and accompanying the appearance of the facial eruption.

In scarlet fever the advent of the aural disease is usually signalized by a rise in temperature, an increase of the general malaise, and if the child is old enough, reference to fulness or pain in the ear; this pain is at first occasional, and more liable to occur after an hour or more of sleep, then increasing in frequency and in severity, until finally the pain is constant and exhausting and referable together with the sensation of fulness and pressure to the depth of the ear.

In very young children, unable to explain their sensations, there is usually at this stage constant moaning and unrest with occasional sharp cries marking the exacerbations of the pain, a tendency to press the affected ear against the warm pillow or