cannot be foretold with certainty. Of most cases, however, it can be said that nasal treatment will tend to arrest the ear disease in proportion to its result upon the nasal disease. It must again be emphasized that in hypertrophic rhinitis operations which relieve the patient subjectively do not necessarily restore the normal state of the nasal mucous membrane, and that, indeed, our therapeutic control over this disease is limited. But, on the whole, all measures benefiting the nasal affection give the ear the best chances possible for the arrest of the disease. This applies not only to operations and medicinal treatment, but equally to all hygienic measures referred to in ¶ 14 to ¶ 17. But in spite of all care, the prognosis is doubtful in many instances, even at the beginning, and bad in most advanced cases. The history of steadily progressive deafness with tinnitus not controllable by inflation, the demonstration of Eustachian stenosis, and the absence of gross lesions in the nose give the therapeutist little chance for successful intervention.

CHAPTER XXXVII.

OPERATIONS FOR THE RELIEF OF DEAFNESS DUE TO ADHESIVE PROCESSES IN THE MIDDLE EAR.

346. The uncertainty of treatment in hypertrophic disease of the middle ear has led to various operative attempts.

A striking observation is the exemption of those ears from any form of progressive deafness in which there is a permanent perforation of the drumhead. When this is one-sided, the ear does not even participate if the other ear with intact drumhead becomes gradually deaf from plastic inflammation. In view of the frequency of hypertrophic middle-ear disease this exemption is quite remarkable. As long as a middle ear with perforated drumhead still continues to suppurate the hearing is occasionally further damaged by subacute exacerbations. But after the suppuration has ceased, the hearing of such an ear remains stationary. It is self-evident that a perforation in the drumhead prevents all the pernicious consequences of Eustachian obstruction. Observations on ears with healed suppuration but persisting defect in the membrane suggest, moreover, that even those intratympanic changes which so often occur in connection with but moderate impairment of the Eustachian patency are secondary to the latter. It would hence be a perfectly justifiable operation to make a permanent fistula in the drumhead in all cases of beginning middle-ear catarrh, if we only knew of any method to maintain a permanent perforation. It sounds paradox that we cannot imitate nature in the example she sets in every chronic. purulent otitis. In the latter case the edges of the perforation are cicatrized and covered with epithelium, and

the hole is permanent and can be closed only artificially. On the other hand, every attempt to maintain a permanent perforation by exsecting a piece of or even the whole drumhead or by inserting a cuff-button-shaped cannula or clamping a U-shaped perforated tube around the manubrium mallei has proved a failure. When the tendinous insertion of the membrane in its bony frame. is chiseled away, regeneration is often, but even then not always prevented. The preventive operative treatment of chronic middle-ear catarrh is hence a matter of the future. There is no good reason, however, to believe that a permanent perforation would necessarily prevent the continuance of adhesive and ankylotic processes in the middle ear after they have been well started. In advanced cases of middle-ear catarrh some temporary relief is sometimes, but not always, obtained by puncturing the drumhead.

A different procedure was suggested by observations in chronic purulent otitis rebellious to conservative treatment. It has been found that the removal of the ossicles, together with the drumhead, does not often damage the impaired hearing, but, on the contrary, is quite apt to improve it, sometimes to a striking extent. In favorable

instances ordinary conversation can be well heard in the absence of the drumhead, the hammer, and the anvil, although, of course, the hearing is far from being perfect. Attempts have, therefore, been made by many surgeons to remove these parts in progressive deafness due to plastic processes without suppuration. The operation, moderately painful, can be tolerated without general narcosis only by a courageous individual. Cocain is of service only after the drumhead has been opened, not before. Suprarenal solution is of considerable help in suppressing troublesome hemorrhage. The operation through the meatus is feasible only when the latter is normally wide. Otherwise preliminary detachment of the cartilaginous meatus would be necessary (327). The most advantageous illumination is that by an electric lamp on

the forehead. The drumhead is detached from its insertion by a curved peripheral anterior and a similar posterior incision from above downward. A fine bent knife then severs the tensor tympani tendon and the joint between the long processes of the anvil and the head of the stapes. A delicate snare is pushed up until it grasps the head of the hammer, and with cautious prying movements the latter is taken out. If the anvil does not follow, it may then be searched for with the snare, or with small, variously bent hooks. The removal of the anvi is not easy, and sometimes impossible. Under absolute asepsis and the avoidance of syringing there is very little reaction and no suppuration. The after-treatment consists only in placing a sterile gauze tampon into the meatus. With thorough knowledge of the anatomy the only accident to be feared--and that not a common one—is injury to the stapes. In the latter case severe dizziness may ensue for days. Severe purulent otitis may occur in case of imperfect asepsis. Through carelessness the facial nerve may be wounded.

347. There is no doubt that the operation has influenced the hearing favorably in a small proportion of cases. In a larger number of instances the distressing noises have been permanently benefited. It cannot be learned with certainty from published reports whether the hearing remained stationary in any large number of instances after this operation. Very few cases seem to have been watched for a sufficiently long time. On the other hand, in a minority of instances the tinnitus was not benefited, and in a large majority no gain accrued to the hearing power, while not rarely the latter was seriously damaged. The operation has been abandoned by many former enthusiasts; still, it does not deserve to be unreservedly condemned, but it should be understood that its prognosis is absolutely uncertain. In a number of instances the moderate benefit temporarily obtained was iost after the membrane became regenerated.

348. Tenotomy of the tensor tympani muscle has been

practised considerably in former years, sometimes with some temporary benefit, but has now been abandoned as inefficient.

The removal of the ankylosed stapes has been done quite a number of times, especially by Blake and Jack. The hammer and anvil need not necessarily be removed in this operation, but, of course, the drumhead must be partially detached. As a rule, there is severe reaction in the form of dizziness, if the foot-plate of the stirrup is really removed by the operation. Although some benefit has been claimed, this delicate operation has not gained favor among otologists.

In relatively rare instances an adhesion of the drumhead or even of the manubrium to the internal tympanic wall results from a destructive purulent otitis. In such cases a moderate benefit to the hearing, but especially a relief of tinnitus, may be obtained by dividing the adhesions with a minute knife bent on the flat.

349. Abnormal relaxation, with flaccidity of the membrana tympani, is sometimes met with from unknown causes, perhaps at times from imprudent repetitions of Valsalva inflation by the patient. Occasionally, too, large cicatrices of the drumhead are seen to be flaccid and possess abnormal mobility when tested with the Siegle pneumatic speculum. This condition reduces the hearing without other symptoms. In such rare instances an improvement in the hearing can be obtained by rendering the drumhead more tense by a coating of collodion. Whenever the condition returns by reason of the collodion peeling off, the membrana tympani may be brushed again with the solution.