OPERATIVE TREATMENT FOR THE RELIEF OF 
CHRONIC SUPPURATIVE AFFECTIONS OF 
THE MIDDLE EAR: REPORT OF 
THREE CASES.1 
BY FREDERICK L. JACK, M.D., 
Assistant Aural Surgeon, Massachusetts Charitable Eye and 
Ear Infirmary. 
Chronic suppurative inflammation of the attic of the tym- 
panic cavity may justly be considered a serious trouble. 
Especially is this true if the disease begins during childhood 
and continues for a long period. In many instances caries 
of one or more of the ossicles, is present, with or without 
disease of the bony walls of the attic, and the small space in 
the cavity is crowded with granulation-tissue or polypoid 
growths, causing defective drainage and consequently reten- 
tion of septic matter. Exacerbations are in many cases 
frequent, and at these times the possibility of extension of 
the middle ear inflammation to the meninges of the brain or 
mastoid antrum is a constant source of danger. In the 
majority of instances the hearing power is practically gone, 
but a point of far greater importance is the danger to life 
itself. Indeed, a fatal termination is to be expected in a 
considerable number of these cases. In the light of what 
has been demonstrated within a few years, and realizing the 
possible effect of neglecting or ineffectually treating such a 
trouble, does it not seem somewhat surprising that the 
disease is allowed to progress unchecked when surgical inter- 
ference has proved very successful in the majority of in- 
stances? The result of the operation has been either rapid 
cure or at least such improvement as to make the disease 
amenable to after-treatment. 
I desire, therefore, to call attention to what has been done 
1 Read before the Boston Society of Medical Observation, March 7,1892. 2 
OPERATIVE TREATMENT FOR THE RELIEF OF 
in aural surgery towards the relief of this class of almost 
hopeless cases. I believe it to be of general interest, for the 
rule of procedure is the common-sense surgical one of remov- 
ing diseased bone or whatever obstruction is found to free 
drainage. 
As far back as 1875, Dr. Kessel, of Jena, published the 
report of a case in which he removed the drum membrane, 
malleus, and incus.9 He cited this case to show that the 
ossicles could be removed without danger. As to the pathol- 
ogy of the affection, Professor S. Moos, of Heidelberg, is of 
the opinion that the hammer is most frequently affected, and 
that often before caries can attack the anvil, it is exfoliated, 
being loosely held in place by the adjoining ossicles and 
tissues. The stapes is most rarely affected. He further- 
states that he has never observed or seen described a case of 
primary caries of these bones ; that the mucous membrane 
must first be diseased before caries can attack the ossicles.3 
On July 20, 1886, Dr. Samuel Sexton, of New York, in a 
paper read before the annual meeting of the American Oto- 
logical Society, described “A New Operation for the Radical 
Cure of Chronic Purulent Inflammation of the Middle Ear 
Tract.” Previous to that, a paper written by Dr. Schwartze, 
in 18854 gives a rSsumS of the literature of operations on the 
transmitting mechanism of the ear. Since that time the ap- 
plication of this line of surgery has developed very rapidly. 
I have endeavored to summarize the results in the few re- 
corded cases since Schwartze’s paper in 1885 ; and I add the 
report of three cases operated upon by myself for chronic 
suppuration of the middle ear. 
In 1887 Dr. Sexton reported nineteen cases of this disease, 
with results as follows: In five cases a cure took place in less 
than one month ; in two cases, in two months; in two cases, 
in three months ; in one case, in six months. In five cases, 
still under observation, there was slight improvement ; in 
2 Archiv. f. Ohrenheilk, vol. xiii. 
3 Archives of Otol., March, 1885. 
4 Deutsche Chirurgie, Stuttgart. CHRONIC SUPPURATIVE AFFECTIONS OF THE MIDDLE EAR. 
3 
three cases5 still under observation, there was no improve- 
ment ; in one case the treatment was not continued. He 
does not mention in any case the duration of the otorrhoea, 
except in a general way, that it had long continued. The 
malleus alone was removed in six cases and the malleus and 
incus in ten. He estimated that the hearing power was in- 
creased from 75 to 100 per cent, in the cases cured. 
Dr. Burnett, of Philadelphia, before the American Otolog- 
ical Society last July, reported a case of seven years duration 
in which he excised the drum membrane and malleus. In 
thirteen days the discharge from the ear ceased. Three 
months from the time of the operation a cicatricial membrane 
was found over the promontory. No discharge. Hearing 
increased from nothing to whispered words at fifteen feet. 
In my search for information as to the frequency of 
purulent inflammation of the superior portion of the tympanic 
cavity, I found, in a paper by Dr. Alexander Randall, of 
Philadelphia, “Notes on the Shrapnell Perforation,”6 a total 
of 120 cases among ten thousand patients—somewhat small 
number. If, however, to this number is added those cases 
with perforation of the drum membrane, my impression is 
that the number would be largely increased. 
From 1885 to 1890 inclusive, there were treated at the 
Massachusetts Charitable Eye and Ear Infirmary for chronic 
purulent middle ear disease 3,795 cases out of 21,818 patients 
applying for treatment. Among 8,337 °f all cases seen in 
the last two years, from 1889 to 1890 inclusive, there were 
noted 1,020 patients with chronic purulent trouble, and of 
these 94 cases of perforation of the flaccid membrane,— al- 
most 10 in every 100 cases. This is practically the same 
ratio per thousand for all ear patients as that reported by Dr. 
Randall, and illustrates the relative frequency of this affection 
in suppurative middle ear disease. 
Although without statistics to substantiate any figures, my 
5 In two of these cases suppurative inflammation seemed to continue in one 
because of caries of the acute, and in the other in consequence of the retention of 
the incus which could not be found. 
6 American Otological Society, 1890. 4 
OPERATIVE TREATMENT FOR THE RELIEF OF 
memory leads me to believe that in a large proportion of the 
cjises of suppuration, under my observation, the disease was 
confined to the attic or superior portion of the tympanic 
cavity. Most of the writers on this subject have advised the 
removal of the drum membrane together with the diseased 
ossicles. As the membrane forms a natural protector of the 
tympanic cavity I am impressed with the importance of ex- 
posing as little as possible of the mucous membrane to the 
effect of cold or what by chance may find its way into the 
ear. The cicatricial tissue closing the opening has been 
shown to form in many instances a vibrating surface capable 
of transmitting its movements to the stapes. Where the 
incus remains, its long process, through contact with this 
tissue, increases the hearing power, and in a measure also 
protects the delicate mucous membrane beyond. in my 
limited experience with this operation, but somewhat wider 
observation of the work accomplished by others, I have failed 
to find any evil effects which could be attributed to the oper- 
ation, whereas the results obtained, both as regards effecting 
a cure and improving the power of hearing, have been 
extremely favorable. I believe that in all these cases every 
effort had been previously made in the way of both vigorous 
and mild treatment. I wish, however, in no way to be 
understood as advocating operative interference even when 
rough bone is demonstrated until the usual treatment has 
been thoroughly tried. 
I might say in regard to the instruments necessary for the 
operation, that a series of triangular-shaped knives, bent at 
various angles, seemed sufficient for most of the tissues 
necessary to be separated. A case of Schwartze’s curettes 
enables the walls of the attic to be cleared of granulation- 
tissue, great care being necessary in case of caries not to 
enter too far, the anatomy of the parts to be kept clearly in 
mind all the time. The ear must be perfectly illuminated, 
during the operation. In addition, a small pair of ear forceps 
for removing the completely excised ossicles is especially to 
be recommended, as it is more easily directed by the hand CHRONIC SUPPURATIVE AFFECTIONS OF THE MIDDLE EAR. 
5 
and less likely to do harm by undue force. A small olive- 
tipped probe is very necessary in determining the location 
and extent of the disease. A small hook is also useful in 
finding any adhesions which may remain after the operation. 
They should all be separated before attempts are made to 
remove the ossicles. All antiseptic precautions were care- 
fully observed. Cocaine has proved a valuable aid in clear- 
ing from bleeding the very small field of operation. For the 
steps in the operation there is little I can add to the descrip- 
tion given by Dr. Kessel7 or by Dr. Sexton.8 
The house records of the following three cases occurring at 
the infirmary during my service for Drs. Green and Blake 
briefly illustrate what has been said : 
Case I. Mrs. M. F., forty-two years old. Has had a 
chronic, purulent discharge from the right ear for forty years, 
during which time it has never wholly ceased, considerable 
tinnitus. No pain, advised to enter the house for operation. 
Examination of the patient showed a slight discharge from 
the ear. Large perforation of the membrana tympani. Head 
of malleus rough to the probe and adherent to the promontory. 
September io, 1891. Patient was etherized and the mal- 
leus freed from all its attachments, which were very firm and 
dense around the head of the bone and handle, and then re- 
moved with forceps. The ear was thoroughly syringed with 
a corrosive sublimate solution (1 to 2,000), and tightly sealed 
with absorbent cotton and a collodion dressing applied. Ex- 
amination of the malleus revealed caries of head and short 
process. Most of the manubrium had sloughed away. 
September 14th. There had been no pain since the opera- 
tion. Dressing removed for the first time. The ear was 
found absolutely free from all discharge. Evening temper- 
ature 990 for three nights, normal the rest of the time. 
September 16th. Ear perfectly dry. Meatus kept closed 
with antiseptic cotton. 
December 5th. At the end of nearly three months, middle 
7 Archiv. f. Ohrenheilk, vol. xiii. 
8 Transactions of the American Otological Society, 1886. 6 
OPERATIVE TREATMENT EOR THE RELIEF OF 
ear found dry and the mucous membrane white in color. 
Hearing greatly improved for conversation. W=?}{- No 
tinnitus. 
Cask II. Miss L. V., about fourteen years old. On 
November iith, she entered the out-patient department for 
the relief of an otitis media suppurativa of the left ear, which 
had lasted for several years. Malleus was carious and had a 
large polypus growing from the handle. Hone very loosely 
held in place and partly destroyed by necrosis. Under ether, 
the malleus and polypus were removed with the snare and a 
few granulations in the upper part of the middle ear cavity 
were curetted. The meatus was then closed with cotton 
after being syringed with a corrosive sublimate solution (i to 
3,000). Evening temperature ioo°. 
November 12th. Considerable foul-smelling discharge 
from the ear. The patient was unable to bear the removal of 
the granulations so they were touched once a day with per- 
chloride of iron. Syringed with a 1 to 5,000 solution twice a 
day, and followed with instillations of resorcin and alcohol. 
Temperature 990. 
i November 16th Amount of discharge much less. Re- 
ferred to out-patient department ; since that time nothing 
has been seen of her. 
Case III. Miss L. C. B., thirteen years of age. Had 
been troubled with chronic purulent discharge from the left 
ear for ten years, at times annoyed with dizziness. Exam- 
ination showed patient in poor general condition and anaemic; 
large destruction of the posterior segment of the drum mem- 
brane; malleus firmly adherent to the promontory; and the 
probe revealed a small spot of necrosis on the anterior edge 
of the handle of the hammer. Granulations were found 
covering an area of diseased bone on the inner wall of the 
middle ear cavity posterior quadrant. 
October 1st. The patient was etherized, and an operation 
of half an hour performed. Malleus removed after some con- 
siderable difficulty, due to thick bands of tissue around the 
head of the bone. The granulations on the inner wall were 
curetted. Collodion dressing applied. CHRONIC SUPPURATIVE TREATMENT OF THE MIDDLE EAR. 
7 
October 2d. Rallied from the ether well. Complained of 
some headache and slight pain in the ear. Temperature 99.8°. 
October 3d. Dressing removed, and middle ear found 
filled with foul pus. Syringed three times daily, and pow- 
dered with iodoform. Evening temperature 99.50. 
October 5th. Discharge less. Slight headache and no 
pain in the ear. Temperature normal. 
October 12th. Amount of discharge is very small. Ear 
wiped dry, and powdered once in two days. 
October 17th. Ear perfectly dry in the superior portion. 
After omitting treatment for ten days, slight moisture only 
over spot of necrosis in lower portion of the tympanic cavity. 
No change in hearing. 
January 2, 1892. Ear without discharge. No complaint 
of dizziness. Hearing the same as before the operation. 
In Case III healing was delayed by the condition of the 
bone concealed by the granulations on the inner wall of the 
tympanic cavity, although curetted as thoroughly as possible. 
All discharge disappeared from the attic in a few days after 
the operation. In contrast to this case is the one reported 
first, in which, in spite of the long continuance of the sup- 
puration, the ear healed almost immediately after removal of 
the carious malleus. I think the two cases illustrate the two 
classes in-to which suppurative processes in the middle ear 
may be divided, considered from the point of time necessary 
for recovery after the operation. First, I would class as 
simple cases those in which necrotic bone is confined to one 
or more of the ossicles, the bony walls of the middle ear 
cavity being perfectly free from such a disease; second, as 
complicated, those cases in which some part of the bony wall, 
together with the ossicula, is diseased. The most speedy 
cure may be very naturally expected after operation in the 
first variety of cases, for the simple reason that everything 
interfering with recovery is removed. Experience has shown 
that the ears heal almost at once without subsequent treat- 
ment being necessary. In the second class of cases healing 8 
OPERATIVE TREATMENT FOR THE RELIEF, ETC. 
is necessarily delayed, depending largely upon the seat of the 
diseased bone in the tympanum. 
Removal of the ossicles and the membrana tympani will 
not cure every case of chronic otorrhoea; but I am certain 
that many may be cured and the rest relieved by operation. 
Of the cases mentioned in this paper (twenty-three in all,) 
twelve were cured in three months or less time; one in six 
months ; five cases were improved ; three cases were not im- 
proved and two passed from observation. As every variety 
of local treatment in most of the cases had previously been 
faithfully tried, it seems to me that the results of the opera- 
tion have been most satisfactory, and that from the cases re- 
ported we may draw the following valuable conclusions : 
(1) The removal of the drum membrane and ossicles is at- 
tended with little annoyance to the patient, proof of which is 
sufficient to warrant the performance of the operation as the 
only means ijf cure in many cases. 
(2) The operation often produces marked improvement of 
the hearing. 
(3) Satisfactory results may be expected towards the relief 
of tinnitus and vertigo. 
(4) The results of the operation seem to be permanent. 
Although not the chief purpose of this paper, I am tempted 
at this point to speak of operations on non-suppurating ears. 
The possibility of hearing well without the membrana tympani, 
malleus and incus has been successfully demonstrated in a 
number of cases ; and this suggests what operative procedure 
may be expected to do in some cases of deafness due to 
hypertrophic catarrh of the middle ear without fixation of the 
stapes. The distressing symptom of tinnitus has been re- 
lieved by the same operation. It has also been done with 
success in certain cases of disturbance of equilibrium from 
pressure transmitted through the middle ear. There are a 
few cases recorded in which the hearing has been in good 
part restored kpj removal of the membrana tympani and one 
or more of ftie ossicula. The successful operations have, 
however, been as yet too fe\y to enable us to establish a rule. 
—Reprint, Boston Medical and Surgical Journal, June 2, 1892.