The diagnosis of middle-ear disease is completed by full examination of nose and pharynx.

All ear instruments should be scrupulously cleaned after use, and all those coming into contact with diseased surfaces should be sterilized. For this purpose nothing is so satisfactory as boiling soda solution (see ¶ 30, Chap. III.).

316. Paracentesis (operative perforation) of the drumhead is often done for therapeutic, rarely for diagnostic purposes. The meatus is syringed to remove wax and scales and sterilized by a bath of at least three minutes' duration with a reliable disinfectant (3 per cent. solution of carbolic acid or carbolic acid in glycerin 12 per cent.). A needle or knife mounted on a shank at an angle of 140

FIG. 123. Paracentesis needle and knife for operation on drumhead, with universal handle for ear instruments; also two forms of curets for middle-ear surgery.

degrees (Fig. 123) is thrust through the drumhead, making a long vertical slit, of course under good illumination and through a wide speculum. The incision is preferably made where the membrane bulges most. Paracentesis causes a momentary sharp pain, especially when the drumhead is inflamed. It is not possible to produce local anesthesia by means of a watery solution of cocain, since this is not absorbed through the skin. Cocain dissolved in anilin oil (Gray) has likewise proved inefficient. A solution consisting of equal parts of cocain, menthol, and carbolic acid (Bonain) gives a partial and not always reliable anesthesia. As this mixture is slightly caustic, it should be applied cautiously on a minute pledget of cotton on a probe to the area to be incised.

A paracentesis properly done, and with aseptic pre

cautions, is practically free from danger. There are on record a few instances in which the bulb of the jugular vein protruding through a defective floor into the tympanic cavity was wounded. The alarming hemorrhage

FIG. 124. Conversation tube.

was controlled by a tampon in most instances. It is hence best not to cut down to the inferior rim of the drumhead. After paracentesis the syringe should not be used.

317. Defective hearing can be assisted by intensification of sounds by means of speaking-tubes or ear-trumpets (Figs. 124 and 125). Their underlying principle is the concentration of soundwaves in a funnel-shaped receiver. A simple hollow hard-rubber cone with softrubber tube leading into the ear is usually the most satisfactory pattern for listening to individual conversation. It is not possible to advise a patient which model he should select for general purposes.

It is better to let him choose by actual trial of different patterns. As a rule, the larger, and hence the more undesirable, the trumpet, the more it collects the sound. Some patterns modify the timber unpleasantly.

Small

contrivances are generally useless. The audiphone of Rhodes, a slightly curved fan of hard rubber held against the teeth as a resounding board, is a very convenient instrument, but is generally not found quite so useful as a trumpet.

All patients with progressive impairment of hearing should be advised to learn to "read" speech by watching the lips of the speaker. By proper and long-continued attention, begun while they can still hear fairly well, they will ultimately be able to compensate in part their deficient hearing by interpretation of the lip-move

ments.

CHAPTER XXXIII.

DISEASES OF THE EXTERNAL EAR.

OTHEMATOMA. — PERICHONDRITIS.

ECZEMA. - DIFFUSE OTITIS EXTERNA.-FURUNCLES.-PARASITIC INFLAMMATION OF THE MEATUS.-WAX AND EPIDERMIS PLUGS.

318. Othematoma is a localized swelling in the auricle due to extravasation of blood under the perichondrium. It forms a soft tumor of variable size, with some discoloration of the skin, usually in the upper part of the auricle, never in the lobule. It causes but little annoyance, but is sometimes tender to touch. It is, as a rule, due to blows upon the ear, hence seen mostly in pugilists. It was evidently more common among the fighters of classic antiquity, whose writers mention it and some of whose statues show the deformity which othematoma sometimes leaves. It is of remarkable frequency (about 1 per cent.) among the insane, in whom probably preceding degeneration of the cartilage predisposes to effusions of blood, perhaps even without trauma.

It

The effusion is underneath the perichondrium. usually clots and sometimes becomes encysted. The smaller accumulations of blood are apt to disappear spontaneously in the course of many weeks. They may, however, leave some shrinkage and deformity of the cartilage, especially after recurrent attacks. The absorption can be favored by daily massage. When no favorable change is seen after the lapse of three or four weeks, an incision may be made into the cyst. But since reaccumulation is apt to take place, the cavity should be cleansed as far as is necessary with a sharp scoop and the wound packed with iodoform gauze.

319. Perichondritis of the auricle is very rare. It shows its inflammatory nature by diffuse doughy swelling, redness, tenderness, sometimes with considerable pain. The course is very tedious and lasts many weeks. The inflammation may disappear, or it may lead to abscess and phlegmonous sloughing. Its cause is usually not known, but it has been ascribed to syphilis in some instances. As long as there is no suppuration tincture of iodin and ichthyol may be applied locally. As soon as pus is suspected, it must be treated surgically.

320. Eczema is a frequent skin affection and the only common one involving the auricle and meatus. It begins in the form of minute vesicles, which spread at first rapidly and soon change into moist scabs covering. an excoriated surface. It is usually seen in its chronic form and may persist indefinitely. The subjective annoyances are burning and itching. When seen in children, it raises the suspicion of scrofula, but it does occur as well in apparently perfect health, both in children and in adults. In the writer's experience the only prompt treatment has been the free use of nitrate of silver in strong solution-30 per cent. or the solid stick-to the excoriated surface after complete detachment of all crusts. The pain can be relieved by the previous application of cocain. The abraded surface becomes covered with a thin eschar, which blackens when exposed to light, and underneath this film regeneration of the epithelium takes place. Sometimes one application suffices to check the secretion, but mostly a few repetitions are needed. Wherever moisture is seen, the eschar should be detached daily and the surface brushed again until permanently dry. The persisting dry dermatitis and the liability to immediate relapses are effectually checked by the use of a salve of oil of cade (1 in 4 of lanolin stiffened by oxid of zinc). If objections are raised to the pain and blackening produced by the nitrate of silver, Peruvian balsam may be applied instead, but with less prompt effect. The various dusting-powders used for eczema