Acute Affections Of The Tympanic Cavity And Eustachian Tube

Acute Affections Of The Tympanic Cavity And Eustachian Tube
By HORACE G. MILLER, A. M., M. D.,
OF PROVIDENCE, R. 1.

THE acute affections of the middle ear are of great importance, for three principal reasons : First, on account of the pain which usually accompanies them ; Second, because of the deafness produced, which may become permanent; and Third, because they may endanger life by extension to the brain. Each of these reasons would be sufficient to demand the earnest attention of the physician. Together, they present a subject which be cannot possibly afford to neglect.

Pain. Usually the first symptom to appear is “earache," so common in some families as to be thought one of the necessary ills of childhood. In nearly every case this is evidence of an actual inflammation of the mucous membrane lining the middle ear. A child “subject to earache” is in danger of deafness, and no care should be spared, not only for the relief of present distress, but in ascertaining and removing the cause. It will rarely be found, even after a single attack of pain, that the hearing of the affected ear is normal. This fact is likely to escape attention if one car only be affected. After the suffering is allayed, all anxiety on the part of the parents and friends ceases. But if the hearing be compared with that of the healthy ear, the simplest test will show the defect; and a new interest should be at once awakened, and a new sense of responsibility aroused.

The pain may vary from a dull ache to the most intense anguish. Often the pain is most severe at night, causing loss of sleep to the patient and his family. It may nearly or wholly subside by day, leaving only a tenderness when the auricle is touched, which is discovered by the nurse or mother when making the child's toilet. In children too young to tell the cause of distress, its seat will often be pointed out by unconscious movements of the band to the affected part. Frequently in young children, after several days of suffering, a discharge of pus from the meatus reveals the diagnosis to the astonished friends; so that when a child cries and shrieks from an unknown cause, the ears should be among the earliest organs to be investigated. The pain is not always confined to the ear itself, but extends to the adjacent parts; almost all the nerves of sensation on the affected side of the head may share in the distress, which is further aggravated by movements of the muscles, as in mastication. Eructation, coughing, and sneezing are greatly dreaded. All loud sounds increase the suffering. Frequently the pain extends to the teeth, especially if any of them are decayed, until the patient scarcely knows whether toothache or earache most predominates. The severity of the pair] is to some extent a gauge of the violence and character of the inflammation, the severer form, especially when constant, indicating the probability of suppuration with all its attendant dangers. As in many other diseases, the presence of pain, when rightly interpreted, is fortunate, for it comes as a warning of impending danger to the hearing, demanding measures for instant relief, which at the same time shall furnish a safeguard against the rapid impairment of a delicate and sensitive organ.

. Next in importance to the urgent necessity for the relief of pain comes the prevention and cure of deafness. Much has recently been written to impress upon the profession the need of the most careful attention to this subject; but it is a matter upon which too much cannot be said, and reiteration cannot be too frequent, since it has become known how much can be accomplished in this direction by preventive medicine and surgery. Heredity in this direction means the existence of local causes which may be successfully controlled; and no child should be allowed to acquire deaf¬ness because, as is said, "it runs in the family." On the contrary, such a tendency should lead to the earlier and more active fight against such a fate. The baleful influence of poor hearing upon the development of children is so disastrous as to call for our warmest sympathy for its victims and our most earnest efforts for their rescue. Blamed and misunderstood by his teachers for supposed inattention, neglected and ridiculed by his companions, the child who is deaf often actually becomes the stupid and useless creature which be is at first only in appearance.

He becomes ill natured and peevish in disposi¬tion, stunted and undeveloped in intellect. His whole career is blighted. But few forms of employment or industry are open to him. Even his physical development is hindered by his inability to engage in the athletic sports which his fellows delight in; and from the resulting debility and malnutrition be readily becomes a prey to any cachexia to which be maybe constitutionally inclined, or any disease to which he may be exposed. Many of these evils might be avoided or relieved by a wise prophylaxis or by proper treatment. But owing to the prevalent ignorance on the subject most of the cases in the schools are neglected until the proper season for interference is passed. It is to be hoped that the time is soon coming when the examination of the ears and hearing of children by compe¬tent physicians will be a matter established by law, not only as a preliminary to the beginning of a course of education, but from time to time subsequently as promotions are made to higher grades. The result of this would, of course, be the enforced attention of both teachers and parents to this vital matter and the consequent medical treatment of those capable of improvement; the better understanding on the part of the teachers of some scholars whose slowness to learn has been ascribed to a different cause; and the elimination of those scholars who would require the special training in lip¬ reading, so useful to those whose hearing is defective. It is true that but few children would be found suffering from an acute attack of inflammation of the middle ear at the moment of examination ; but most of those found to be deaf will have acquired their deafness from an acute attack ; and many of them will be liable to future accessions of the trouble if preventive measures are not promptly taken.

Danger of Extension. The third principal point of interest in acute affections of the middle ear lies in the fact of their liability to extend to the surrounding parts. Primary inflammation of the entrain and mastoid cells may occur, but in nearly every case the disease comes by extension from the middle ear proper. This may be followed by caries and necrosis of the bony walls of these cavities, and the disease may then extend inward to the membranes of the brain, causing a meningitis or abscess of the brain, with lethal result. There may be a like extension still more directly through the tegmen tympani, where the attic portion of the tympanum is separated from the brain only by the thinnest laver of bone, perforated by foramina for vascular anastomosis.

Thrombosis may also result from contact of the diseased bone with the walls of the venous sinuses, with a result equally fatal.

General pyemia may also ensue, either by absorption of purulent products or by rupture into the walls of a sinus. These possibilities should lead us to look seriously upon every painful manifestation of ear trouble, and make us willing to submit to criticism for too much zeal rather than have to blame ourselves for not having taken prompt and efficient measures at the time when they could most avail. Let us then remember that in every case of acute otitis media we may by proper treatment be the means of saving patients from pain, from deafness, or from death. Too often they have been treated with indifference or neglect, resulting in the tacit permission for the use of remedies often both inefficacious and far from harmless. That these affections are trivial no one who has once witnessed the suffering or its results can for a moment maintain. It is not true that the diagnosis is very difficult. Any intelligent physician may feel himself competent for it. The use of that most important, aid in physical diagnosis, the head mirror, should be familiar to every medical man, not for the ear alone, but for the illumination of every orifice of the body, especially at night; and tinder many circumstances where both bands are needed for operation and manipulation. With this mirror, and the light from a window by day, or the light from the ever ready kitchen lamp by night, the inspection of the drum membrane is usually easy. But nowhere in the physician's practice is gentleness and delicacy of touch more necessary. One careless thrust of the speculum or ungentle pull on the concha, and all intercourse between a young patient and the doctor may be at an end, except by the aid of a general anesthetic. The old fashioned bivalve ear speculum should never be used. It is awkward and apt to cause pain, and requires one band to retain it in its proper position. Should it be necessary in order to complete a full inspection for the purpose of diagnosis, it is proper to resort to general anesthesia; and if operative interference be found necessary, this condition may be taken advantage of to complete the procedure.

Types. As to the usual distinction between catarrhal and purulent inflammation of the middle ear, it is difficult to draw the line in making the diagnosis. Only after the disease has run its course can we tell which form we have had to deal with. If we could always know the cause of infection, this, with the severity of the symptoms, would furnish an early indication. But this is not always possible. It is therefore better simply to look upon cases as more or less severe and not of a wholly different character.

Causes. The acute affections of the middle ear come most frequently by extension from the naso pharynx. Consequently the exanthemata, and especially scarlet fever, are among the most frequent causes of a systemic nature. A large percentage of the inmates of the institutions for the deaf date their infirmity from an attack of scarlet fever in childhood. In measles the ear is still more frequently affected. It has recently been shown that the cars are probably involved in every case of measles. an exudation containing the specific organism of measles is formed on the lining mucous membrane of the tympanum by the eruption. But unless this be mixed with one of the pyogenes germs, this exudation is rapidly absorbed without perforation of the drumhead and without injury to the hearing. The deafness of typhoid fever is caused usually by a catarrhal condition of the middle ear; but in this case also it seldom goes on to suppuration. As one result of the recent epidemics of influenza there has been a great increase of acute otitis media. This has been characterized by great intensity of pain and a greater tendency to suppurate, and consequently spread to the mastoid, than is usually the case in acute otitis media. Diphtheria may also produce inflammation of the middle ear, the characteristic bacilli being found in the discharge. The same is true of tuberculosis. Here the onset of the disease is comparatively painless ; but it may result in great destruction of the tissues, both soft and bony, contained within the tympanum. Both a rheumatic and a gouty diathesis may favor or superinduce acute otitis media, either primarily or by' extension from inflammation of the pharynx. Syphilis, in the secondary stage, when the naso pharynx is involved, is often productive of acute otitis media, varying in all degrees of intensity. Later on, when the bones of the nose are diseased, the same result may ensue. Of all external causes, taking cold, in the ordinary sense of the expression, from exposure to droughts of air, or in any way productive of coryza, is by far the most frequent. Whooping cough and the catarrhal affections commonly classed under the head of hay fever may also result in acute inflammation of the middle ear. Sea bathing, if too frequent or long continued, is a common cause; and the same is true to a less extent of bathing in cold, fresh water. But it seems that the surf, either from its violence or from its saltness, is directly dangerous to the ear, .especially if a perforation of the drum membrane exists. Perforation of the drumhead also admits air, which, from its temperature or from being laden with any of the infectious germs, produces inflammation of the mucous membrane. Acute otitis media may be the result of adenoid vegetations of the pharyngeal vault; and many children who are subject' to earache will be found to have this cavity closely packed with this form of' hypertrophic growth. This may act by causing a retention of the natural secretion through obstruction of the orifices of the Eustachian tubes, or by predisposing to naso pharyngitis which is propagated by extension, until it reaches the cavity of the tympanum. The importance of the recognition of this condition cannot be overestimated.

Hypertrophied tonsils undoubtedly have a similar effect upon the ear; but the adenoid growths which so often coexist with them are no doubt more frequently responsible. Otitis media may also follow the intratympanic hemorrhage of Bright's disease. It may be produced by the extension of erysipelas from without. Trauma figures among the less common causes of' middle ear disease of acute form; the tympanum by its situation being greatly protected from external violence. But when a wound admits infectious germs, or when infection occurs from a rupture of the drum membrane by an explosion, a blow, or any other violent cause, inflammation of the middle ear may follow. The same is true of the destruction of the drum membrane by scalding or corrosive liquids or molten metals. Fracture through the temporal bone may also form an avenue for infectious germs. Among the rarer causes, perforations produced by mycosis or vegetable fungi of the meatus, or by accumulations of dried wax and epithelium, may lead to the same result. The teeth, both at the time of their development and eruption, and when diseased, are productive of much middle ear trouble. During the first and the second dentitions, at the eruption of the sixth year molars, and at the appearance of the wisdom teeth, the ears are peculiarly liable to suffer from reflex irritation and inflammation. At all times of life caries and necrosis of the teeth and alveolar processes, with their accompanying ulcerations and suppuration, are closely connected with the production of disease of the tympanum. The examination of the teeth should, therefore, be a constant matter of routine in the examination of these cases.

That the causes, both immediate and remote, of the disease under consideration are so numerous and varied, shows the need of diligent research in every case, that we may avail ourselves of all indications from such sources, both for present treatment and for prophylaxis.

Symptoms. Of the symptoms of acute otitis media, next to the pain, which we have already considered, comes tinnitus. Subjective noises of some kind are rarely absent. A thumping, pounding, or beating sound synchronous with the heart's action, is most common in the earliest stage of the disease. Children often mistake these sensations for real, objective noises; and an inquiry as to their meaning or cause is sometimes the first indication of the existence of disturbances in the ears. Later, the tinnitus is of a more steady .and continuous character, described as rushing, roaring, singing, or buzzing. Those sounds of a pulsatory or rhythmic character are due to the increased circulation in the arteries and dilated capillaries in close contiguity to the sound perceiving termination of the auditory nerve Those of a steady and ,continuous character are due, at first at least, to increased venous circulation, which is heard by the ear itself in the same manner. In a later stage there may also be tinnitus due to pressure on the contents of the labyrinth through the oval and round windows from swelling or retained secretion in the middle ear. To children these noises are often terrifying. In all cases they are productive of a greater or less degree of nervousness and distress.

Deafness is the next objective symptom noticed by the patient. In the milder cases some days may elapse before the hearing becomes much impaired. Slight degrees of deafness may not at first be noticed by the patient, especially if the affection be unilateral. But soon familiar sounds, like the ticking of a clock, become inaudible, then the patient begins to ask for a repetition of what is said by those around him, and finally bearing is for the time almost totally abolished. The degree of deafness, in the earlier stages at least, depends much upon the localization of the affection. Should the attic of the tympanum be most affected, the bearing may suffer but slightly at first, although the pain be most severe. When the Eustachian tube is most affected, the stopped tip feeling predominates over the deafness. When the whole lining of the atrium is involved at the outset, the deafness is most marked. Besides deafness there may be the modified hearing of autophony in which the patient hears his own voice strongly ecanged and resonant. There may also be diplacusis, or bearing sounds in a different pitch from that perceived by the unaffected ear.

The constitutional symptoms are sometimes ushered in by a chill. There is general uneasiness, loss of appetite, and increased temperature ; sometimes headache, dizziness, and possibly nausea are present. As in other acute diseases, the general disturbances will be greatest in patients of a nervous temperament.

If a tuning fork in a state of vibration be now applied to the vertex or to the teeth, the sound will be beard more clearly in the affected side, the closed cavity with its thickened walls acting as a sounding board to intensify the effect of the vibrations. Examination of the drum membrane usually reveals more or less redness; even in the early stages of the attack the hyperemia shows itself by beginning at the tympanic margin and extending toward the center with more or less rapidity. The vessels which follow the handle of the malleus, unseen in a state of health, now become visible. All the landmarks may be lost, as the hyperemia involves the adjacent portion of the dermoid meatus; swelling shows itself at any point according to the localization of the inflammation, and may also extend to the inner end of the meatus (see Plate 11, Fig. 8).

As in all inflammations of the mucous membrane, the secretion soon begins to increase. A serous exudation is poured out, which may sometimes be distinguished through the still transparent membrane, partially filling the cavity of the tympanum, like the liquid in a spirit level (see Fig. 495). In severe cases the cavity quickly becomes filled, and a few hours may suffice for the pressure of the confined liquid to cause a rupture of the drum membrane. As the Eustachian tube has been closed by the swelling of its lining membrane, the drumhead affords the point of least resistance, and becoming softened, yields to the pressure from within. Often the liquid takes on a purulent character, and may be seen pointing at some bulging portion of the membrane before a rupture takes place (Fig. 496). After the evacuation of the secretion, whether from spontaneous giving way (Fig. 497) of the membrane, or from surgical interference, there is usually great relief from pain. The amount of discharge may be very slight, but is at times most profuse and continuous, so as to moistet; many thicknesses of compresses and bandages. Often at first the secretion is tinged with blood, or there may be quite a free hemorrhage. In favorable cases the untoward symptoms now rapidly subside. The pain diminishes and disappears, the noises become less violent and annoying the temperature falls, the patient is able to obtain rest, and the general recovery is rapid. The deafness, the last effect to disappear, gradually or sometimes quite suddenly gives place to perfect hearing. Unfortunately" manv cases do not end so happily.

treatment. The first point in the treatment is to remove, so far as possible, the cause. But in most cases the patient is not seen until the disease is well developed, and preventive measures are now of no avail. However, when a naso pharyngitis which has spread to the middle ear is still active, it should receive prompt and appropriate attention. Anything unfavorable in the patient's surroundings should be looked after, a mild and equable temperature should be established and the patient placed in bed ; and quiet, both as regards freedom from noise and from excitement, maintained. If there be a rise in temperature, a saline cathartic should be administered. Tincture of aconite may be given in small and frequent doses, where the pulse is full and hard, until the feverishness is reduced. Opiates should be used but sparingly, except at the outset, when a full dose may be employed. When given later, by their anodyne effect, they mask the symptoms, and may deceive into a fancied security when the danger is not yet passed. Inflation by Politzer's method should be tried with care and gentleness. It sometimes gives great relief to pain by equalizing the pressure of air within and witbout the tympanic cavity. With closure of the Eustachian tube, absorption of air takes place through the mucous membrane lining the tympanic cavity. This produces a partial vacuum, draws inward the drum membrane, causing pressure through the chain of ossicles upon the labyrinthine contents, and at the same time retards the flow of blood, causing or increasing venous congestion in the lining mucous membrane and exudation into the cavity. When the effect of this procedure is favorable, it may be repeated once or twice daily ; but when it increases pain or gives no relief, its use must be postponed until later in the treatment of the case. No simple measure is so helpful as the application of " dry heat." The hot water bag of India rubber is the readiest means of applying heat. This, when filled, should be covered with soft cloth and laid upon the pillow in contact with the ear. But still better, because of its lightness, is a bag loosely filled with common salt and heated in an oven. Moist and warm applications, like poultices in all forms, are. to be avoided. They soon become uncomfortable by evaporation, and tend by maceration of its dermoid layer to promote rupture of the drumhead, already perhaps softened in its inner layer. They may also serve as the means of Conveyance of all sorts of infectious germs, and in the end complicate far more than they benefit the disease. For this reason are injurious most of the popular remedies and poultices of all the vegetables in the kitehen garden. So, too, all the varieties of vegetable oils and animal greases are harmful, their sole value having been to carry beat. The vapor of chloroform may be used with much benefit in mild cases in children. A few drops of the liquid may be placed in a spoon, and the vapor, which is much heavier than air, be poured like a liquid into the ear. Chloroform liniment applied about the ear with a bit of flannel is also valuable. Aseptic aqueous solutions containing local anodynes and anesthetics may be used judiciously in the early stage of an attack. The sulphate of atropia, four grains to the ounce of solution, is efficacious. Cocain hydrochlorate, in solution of from four to twenty grains to the ounce, is still more effective transiently ; and better still is the combination of these two with morphin, e. g.:

Of this, five or six drops from a spoon previously dipped into hot water may be poured into the ear.'

The local abstraction of blood furnishes one of our most effective measures. The application of two or three leecbes to the tragus, or just in front of it, may cut short the whole trouble. After they have filled themselves with blood and fallen off, the bleeding from the bites may generally be allowed to continue until it ceases spontaneously. This subsequent bleeding makes the natural leech more effective than wet cupping. When leecbes are not at ban(], the artificial leech furnishes an excellent substitute, or my small knife can puncture the skin in front of the tragus, and any small cupping glass will serve if the special instrument be not at band. An ounce or two of blood may be taken, and if the relief experienced be but temporary, the process may be repeated. But when the simpler measures tried in quick succession have failed, or when the onset of the disease is such that it is not likely to yield quickly to tile other remedies, or when we find the earlier stages of the inflammation have passed before we have seen the case, paracentesis of the drum membrane must be made. This may be done with any long, slender knife, such as v. Graefe's cataract knife, or a delicate bistoury, which should be first carefully sterilized. The most convenient instrument for the purpose is the spear shaped knife (Fig. 498). The double edged point should be longer than is usually made, so that in penetrating deeply it will continue to cut, and not, after pricking through the membrane, fail to enlarge the opening. The meatus should be disinfected by gentle irrigation with a 1 :5000 warm solution of mercuric bichlorid, followed by mopping with absorbent cotton moistened with alcohol. A pellet of cotton dipped in a 10 per cent. solution of cocain should then be laid against the drum membrane for a few minutes to produce local anesthesia. This will not always be complete in an inflamed membrane, but the pain of the cut will usually be very slight and momentary. The point of selection for the incision may be where any swelling or tendency to point seems to indicate; but if there, be no such local indication; the posterior inferior segment is usually chosen as the region where less injury is likely to be done by the knife to the structures within. The cut should be a free one of several millimeters' length and carried down to the tympanic margin for the purpose of drainage, and so as to divide the plexus of engorged vessels which is usually present there.

If the opening be made very early, there may be little or no secretion and even the hemorrhage may be very scanty. If there be a purulent discharge, this may be gently washed away wit]; the warm bichlorid solution, otherwise no syringing or other interference is necessary. A wick of absorbent cotton, moistened with bichlorid solution, should be inserted, a small compress of iodoform gauze should be placed over the meatus and a larger one over the whole ear, and secured by a loose bandage. Every kind of meddlesome interference which might cause reinfection should be avoided. The progress of the disease may now be arrested. The opening made by incision quickly heals, the pain is relieved, and the swelling is soon dissipated. The subjective noises cease, and the patient's voice as heard by himself resumes its natural tone. The hearing regains its normal acuteness; and in a few days there may be no remaining sign, either physical or subjective, of the serious disturbance which has taken place. When the process of resolution is less rapid, especially if the pain returns on the following night, more active aftertreatment may be necessary. An anodyne may be given internally, and iodid of potassium should be administered, or a mercurial inunction used, or both. If, owing to a too rapid healing of the incision there be retained secretion, the operation may be repeated. If an abundant discharge occur, it must be removed by irrigation with warm antiseptic solution. When the deafness does not quickly disappear, the use of the Politzer's bag may again be indicated. For some weeks at least after an attack the patient should exercise

unusual precaution against the effects of exposure to the weather, and overfatigue. Should the ear be sensitive to the cold, a bit of absorbent wool should be tucked into the meatus before driving or exposure out of doors.

SALPINGITIS

Thus far we have considered the acute affections of the middle ear with reference to the principal cavity, the atrium. The disease may be especially localized in the accessory cavities, the Eustachian tube, or the attic of the tympanum. When the Eustachian tube is the seat of the inflammation, the most marked subjective symptoms are produced by the sudden closure of the isthmus of the tube by swelling. The effect of this obstruction is the formation of a partial vacuum, causing retraction of the tympanic membrane inward and the transmission of pressure to the labyrinth, producing annoying tinnitus and dizziness, which may be distressing. Autophony is produced most frequently by this cause. The pain is located under the ear and inward toward the throat or at the root of the tongue, rather than deeply in the ear itself. All these symptoms may be productive of great malaise and general ,disturbance of the nervous system. Often there is a sensation as of a plug in the ear, which the patient endeavors to remove by thrusting the finger into the meatus. Cracking sounds are common, at times rhythmical. The tympanic membrane may show little if any hyperemia, but only great retraction. At first there may be a thin serous secretion, and later the tube may be distended by a viscid and tenacious muco purulent exudation which may be discharged into the throat and from the mouth. By the rhinoscopic mirror the mucous membrane at the mouth of the tube may be seen to be swollen and covered with secretion.

The object of treatment will be first to relieve the local congestion and inflammation of the tube itself; and then by opening the closed passage to restore the rest of the apparatus of the middle ear to its normal condition. Mild aseptic sprays may be used through the nose and fauces, with gargles of a similar character and of' hot alkaline solutions to modify any existing catarrhal conditions of the nasal and pharyngeal cavities. The gentle use of Politzer's bag should then be tried, and if the obstruction is not too great, may be followed by immediate relief. Should the air not penetrate by this means the Eustachian catheter should be employed. An instrument of pure silver which can be bent to any curve should be used, and should be heated to redness in the flame and plunged in a cold boric solution. Its use should be preceded by spraying or mopping the nose and the mouth of the tube with a 6 to 10 per cent., solution of cocain. The air should be thrown in very gently at first to evacuate the secretion from the tube and not to force it onward into the middle ear. Soon the air will be heard through the auscultation tube entering the cavity of the drum. Sometimes the sudden change of pressure causes transient giddiness or faintness. The hearing is improved at once, the tinnitus ceases or is diminished, the feeling of fulness is relieved, and the tympanic membrane will return more or less completely to its normal plane. At the same time proper remedies may be applied through the catheter to the mucous membrane of the tube. Of these none is more effective than the weaker solutions of nitrate of silver From 5 to 15 grains to the ounce will usually be sufficiently strong. Only a few drops should be used, and but little force applied in driving it through the catheter as the effect is to be localized in the tube itself. This treatment should be repeated daily at first, and then at greater intervals until no longer required. In a few days, in most cases, the normal hearing will be restored as the swollen mucous membrane returns to its natural state. When, as sometimes happens, there is more permanent thickening or even stricture of the tube, dilation by means of delicate bougies passed through the catheter may be required.

INFLAMMATION OF THE ATTIC.

It is evident from this description that localized inflammation of the tube is less serious and less dangerous to the hearing than that of the atrium. When the lining membrane of the attic becomes inflamed, the condition is much more serious. The anatomical conditions are such that even slight swellings cut off the communication of this space from the atrium below. The bulkier portions of the malleus and incus, with their ligamentous attachments and folds of mucous membrane, nearly fill the communicating space between the two chambers, and but little swelling is required to complete the closure. The pain from the tension caused by the hyperemia alone soon becomes excruciating. As soon as inflammatory products appear, the pressure is still further increased. The flaccid membrane, already intensely reddened and contrasting strongly with the drum membrane proper below, becomes bulging and swollen over its whole extent, or forms pockets on one or both sides of the malleus along the anterior and posterior folds (see Fig. 496). This condition admits of little or no delay for tentative treatment. Although spontaneous rupture may give ease, it may be only temporary. A permanent opening in the flaccid membrane may result, with necrosis of the bony walls of the attic and of the ossicles, and the formation of adhesions which may impair the movements of the ossicles. Here a free and prompt use of the knife, under the same antiseptic precautions enjoined for the incision of the lower portion of the drum membrane, is both necessary and effective. Beginning just above the short process of the malleus, the knife, with one cutting edge turned backward, should be plunged deeply in, until it reaches a bony obstruction; then the cut should be prolonged until it strikes the posterior insertion of the membrane. Then with the other edge of the knife the division should be continued upward and backward for a quarter of an inch or more along the superior margin of the membrane, still cutting deeply, and dividing all the tissues until the bony wall is felt. This can be done in a satisfactory way only under general anesthesia. After the incision which will be followed by free bleeding and the evacuation of pus if suppuration be already present and oozing of serous effusion the wound should be irrigated with warm bichlorid solution of 1: 5000. A mesh of absorbent cotton should be left in the meatus to promote drainage, and the whole car covered with iodoform gauze, as before described. The result is usually prompt improvement. The hyperemic tissues are relieved of their engorgement, and the pain will have nearly disappeared when the patient returns to consciousness. The incision, although extensive and deep, heals with remarkable rapidity and leaves Do' visible cicatrix. The after treatment is the same as in simple paracentesis. However harsh and radical this operation may at first sight appear, it is so generally efficacious that its performance will never be regretted.

In the light of our present knowledge of bacteriology, nearly if not quite all the causes of acute inflammation of the middle ear are only the sources or excitants of bacteriological activity. No cavity of the body lined with mucous membrane is free from organisms of morbific character, which are ready to develop with amazing rapidity under favoring conditions; and the mucous membrane is a soil always ready to receive and nurture germs of the most virulent character. The nose and the fauces are always exposed to infection through the air; and that such infection is not always taking place shows what a wonderful defensive power against such morbific germs must exist when not in abeyance owing to disturbing influences. Usually the infection is at first by a single organism, either that of the systematic disease, of' which the nasal trouble is a local manifestation, or by one of the less virulent forms, which has for some reason been called into activity. After the opening of the drum cavity by spontaneous or artificial means reinfection may take place, and a varieiy of the most dangerous cocci, with their foul odors and poisonous products, complicate the disease. Hence the necessity of maintaining the strictest antisepsis and of abandoning many of the remedies and means of treatment which formerly seemed to be most strongly indicated.

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