DR. CARL H. RUST, M.D., F.A.C.S.
Did you ever have a case of acute middle ear abscess cause you great anxiety as to whether the mastoid cells were so involved as to require a mastoidectomy or merely an inflammation that would recover without surgical interference?.
Of course you have. As I look back over my years of general practice it seems to me that acute mastoiditis is the type of ear sickness that gives the general practitioner the greatest anxiety.
As most of you, situated away from the large centers, make your own blood counts and radiographs, I am going to urge you to use these methods in determining the progress of your suppurative ear cases.
During my 37 years of medical observation I have noted a tendency for mastoiditis to begin recovery on the 15th day of the sickness. I say a “tendency”; I have not found it to be an established habit. It is very evident that this tendency has never been observed by those who feel it necessary to operate all cases as soon as possible.
That we may illustrate the great value and reliability of the blood count we will make use of recorded counts in the following patient.
When brought to the Hospital after 10 to 14 days sickness this case presented a perfect picture of mastoiditis, both ears involved and a temperature at 3 p.m. to 101.2. There was also manifest a slight mental haziness.
White count 19,000.
Polys 86 percent.
Lymphocytes 12 percent.
Large Monos 2 percent.
A continuance of this ratio would have indicated brain involvement but the next morning my first observation was.
I then consulted the radiograph and found a small area suggesting necrosis of cells in the left mastoid.
Had I seen this evidence before knowing that the inflammation has subsided sufficiently to allow a drop of 3000 white corpuscles, I would have operated at once.
The morning of the 3rd day we had:.
White count 10,300.
The morning of the 4th day:.
White count 8,150.
temp. 97. pulse 85.
On the 6th day the white count was 8000. From then on the temp. ranged between 97 & 98.6; the pulse from 60 to 80.
Now let us see what the Laboratory did for us in this case.
The young man was approaching the border line of meningeal involvement. There was a mental dullness which the patients physician did not like to see, and this mental dullness fitted in with the polynuclear percentage of 86, but the rapid drop in the white count within 15 hours showed that danger from that direction was probably passed.
In simple mastoiditis the leucocyte count may be high, indicating an acute inflammatory involvement, but if the polynuclear percentage is below 80, the meninges are not usually involved; but if the percentage goes to 85, 90 or more, pus is almost surely present as a meningitis or a brain abscess.
In other words, if your white count and polynuclear percentage remains high or increases, immediate operation is demanded but if, with or without operation, they decrease, your patient is improving.
If you have a white count 12000 or 15000, polynuclear percentage 85 and it comes down, your case is improving.
A white count of 15000 to 25000, polynuclear percentage 85 to 95, you probably have brain involvement.
A white count of 15000, polynuclear percentage under 80, gradually increasing, needs better prescribing or an operation.
It is interesting to note that in the case described we had, by laboratory tests, the proof of improvement before it was externally evident.
A second radiograph was taken 9 days after the first one, and it showed a disappearance of all evidence of necrosis that appeared in the first picture. Three weeks after the first radiograph the third and last one was taken, showing nothing wrong. Where would you find a finer verification of the scientific adjustment of laboratory, X-ray and physical finding.
There are people who have within their systems a high resistance to disease. You have brought them through many a severe illness and you know just about how much they are going to help you. There are others of low resistance whose tissues give way to inflammation, pus and necrosis following easily. These patients give you great anxiety, need careful watching and the blood count will be of great help to you.
The important points, briefly stated are as follows: Poly- nuclear percentage 80 or under with no necrosis showing in radiograph: patient is doing nicely.
High white count, polynuclear percentage 85, both yielding to medication: meninges probably not involved.
Polynuclear percentage 80 rapidly increasing to 85 or more: immediate operation.