This may ness, without visible lesion of the drumhead. be due to a hemorrhage or merely a concussion of the labyrinth. The effects pass off in a few days at the most, unless the ear was previously the seat of a catarrhal process which is sometimes considerably aggravated. A blow may also cause a rupture of the drumhead. The same lesion is sometimes the result of explosions, and necessarily follows any direct traumatism by pointed implements. Traumatic ruptures of the membrana tympani are linear and show bloody suffusion of the edges. The hearing is temporarily impaired. They usually heal without reaction if not irritated or infected by injudicious treatment. Nothing beyond rest of the parts is called for. Syringing and applications are at least useless, if not injurious. More serious is any traumatism of the drumhead which leads to bruising as well as to rupture. This may happen from the entrance of tree twigs or stalks or from unskilful manipulations in the meatus. The damaged drumhead often sloughs for a number of days with gradual enlargement of the perforation, and, of course, with suppuration of the middle ear. The treatment in such cases should be that of acute otitis (360). When violence causes a fracture at the base of the skull it is apt to rupture the drumhead as well. The diagnostic sign of this accident is the discharge of cerebrospinal fluid, more or less bloody, through the meatus. If the patient survives, severe suppurative middle-ear disease is apt to follow. It should be guarded against in such cases by immediate asepsis of the meatus with carbolic acid solution and the introduction of sterile gauze drains as in the treatment of purulent otitis. 332. Myringitis, inflammation limited to the membrana tympani, is a rare occurrence which the writer has never seen in the acute form unless of traumatic origin. It is described by Politzer as a formation of small circumscribed blood blisters, serous vesicles, or even minute abscesses on the cutaneous side of the drumhead. It causes more or less shooting pain, with scarcely any impairment of hearing, and heals, as a rule, within a few days. The vesicles may be pricked with a needle and the membrane dusted with boric acid. Chronic inflammation limited to the drumhead is not quite so rare as acute myringitis, but is, as a rule, a secondary affection resulting from eczema or a desquamative dermatitis of the meatus, or is a sequel to suppurative inflammation of the middle ear. The drumhead appears cloudy, and its surface macerated and sometimes covered with moist scales. Politzer describes a papillary form in which the membrane is partly covered with minute granulations. The disease produces very little disturbance beyond slight discomfort and itching. After cleansing, boric acid powder may be blown in. If this produces a temporary watery discharge or if no improvement follows within a few days, a 10 per cent. solution of nitrate of silver can be tried. For the papillary form Politzer recommends brushing with tincture of chlorid of iron. CHAPTER XXXV. DISEASES OF THE MIDDLE EAR. CATARRH OF THE EUSTACHIAN TUBE.-SEROUS 333. Diseases of the middle ear are divided into affections-(a) without and (b) with suppuration. The division is justified by the difference in the prognosis and therapeutic indication of the two groups. The non-suppurative group includes― Catarrh of the Eustachian tube; Serous or exudative catarrh of the middle ear; CATARRH OF THE EUSTACHIAN TUBE. Inflammatory obstruction of the Eustachian tube accompanies all inflammatory affections of the middle ear. But as a lesion limited to the tube, without primary disease of the middle ear, it is not commonly seen in adults, though very common in childhood. It is due in most instances to the presence of an enlarged pharyngeal tonsil (adenoid vegetations) and occurs in the course of subacute inflammatory processes involving the nasopharynx. In rare instances it is the result of an acute nasal catarrh without permanent enlargement of the pharyngeal tonsil, and under these conditions it is sometimes seen during adolescence. Any systemic disease accompanied by nasal or pharyngeal inflammation may be the remote cause of Eustachian occlusion. The only manifest symptom of Eustachian obstruction in children is reduced hearing acuity. The impairment begins either acutely or, as a rule, more gradually, accord ing to the intensity of the nasopharyngeal inflammation. It remains more or less stationary for a variable or even indefinite period of time, and does not usually reach any high degree. Hypertrophy of the pharyngeal tonsil prevents, as a rule, complete spontaneous recovery, or leads to frequent relapses if the hearing has been restored temporarily. When the pharynx becomes normal after a transient catarrh, the Eustachian affection disappears entirely. The impairment of hearing is sometimes so slight that it is detected only by the child's inattention. Tests show that there is reduction of air-conduction only, not of bone-conduction. Both ears are always involved, though not necessarily alike. Adults complain of a sense of fulness in the ears. Young children either do not feel or do not notice this sensation. FIG. 126.-Retracted membrana tympani in Eustachian catarrh, with serous fluid in the middle ear. The level of the fluid is marked by a straight line. Sometimes they admit it after being relieved by inflation. Occasionally sharp earache—especially one-sided—is complained of, most likely during the night. Although the cases with this pain follow the same course and yield equally rapidly to treatment as typical painless Eustachian catarrh, the pain is probably due to some slight lesion in the middle ear. This view is supported by the presence of vascular streaks-congested vessels-along the handle of the hammer, which are not seen in ordinary Eustachian catarrh. The drumhead is normal in color and luster, but is distinctly drawn in. The handle of the hammer hence appears foreshortened (compare Fig. 2, Plate II.). In some instances, but not as a rule, an effusion of clear serum can be seen through the drumhead (Fig. 126). 334. A single successful inflation of the middle ear by Politzer's method or by means of the catheter removes all results of the Eustachian obstruction, except in longstanding disease with secondary lesions. The hearing becomes normal at once or in a few minutes; the fulness, if felt before, disappears, and the drumhead regains its normal position. If fluid is visible through the membrane, it is apt to be churned into foam, and air-bubbles can now be seen. The fluid disappears gradually by absorption. Although there is but little opportunity to study the pathology of simple Eustachian catarrh in the dead-room, its nature and mechanism are clearly understood. Indeed, this knowledge is the key to our understanding and treatment of all the diseases of the middle ear which are complicated by Eustachian obstruction. The obstruction is due to swelling and venous engorgement of the mucous membrane at the pharyngeal end of the Eustachian tube. The immediate and often permanent results of inflation leave no doubt that the swelling depends mainly on serous infiltration-inflammatory edema-of the Eustachian lining. The imperfect postrhinoscopic view, which, as a rule, is all that can be obtained in children. with adenoids, shows no gross change at the Eustachian orifice. The inflammatory process itself does not always extend into the tube. The assumption of some writers that adenoid vegetations can block the tube mechanically is not supported by actual examination of the nasopharynx in the living or dead. When the Eustachian channel remains closed without periodic ventilation of the drum cavity, the air confined in the middle ear is gradually absorbed by the circulating blood in the vessels. The tension of the air in the drum cavity hence falls below the pressure of the external atmosphere. As a result, the greater pressure on the external surface of the membrana. tympani forces this membrane inward. This faulty position of the drumhead is recognizable by the obliquity of the manubrium and the elongation of the triangular light |