cavity, presumably through the entrance of amniotic fluid into the Eustachian tube during swallowing movements of the fetus. On the basis of this observation he considers at least some of the instances of infantile otitis as an inflammatory reaction, due to the presence of foreign bodies in the middle ear.

This otitis, complicating so many of the diseases of early infancy, is clinically latent when the child is very sick and apathetic. In other instances it is suggested by restlessness and tossing of the head. A sudden rise of temperature may be due to it, as it has been shown that puncture of the drumhead may lower the fever during the course of other ailments complicated by concomitant otitis. It has also been pointed out (Ponfick-Barth) that this purulent otitis with escape of pus through the Eustachian tube can account for intestinal disturbances observed in such children.

It is not easy to diagnose this inflammation of the ear in the infant. The small meatus permits only the use of the smallest speculum. Very strong light is hence required. The meatus is apt to be filled by epidermis scales, which it is better to scoop out gently than to remove by syringing. The drumhead, very oblique at this age, is not easily distinguished from the posterior upper wall of the meatus. It is relatively little congested, but more turbid on account of the exudate than normally. It is yet to be determined by future observations how much this concomitant otitis, with its nearly latent course, adds to the danger of the disease which it complicates. Whether or not to puncture the drumhead is also an open question. There certainly should be more systematic attention paid to the ear of all sick babies.

Entirely different from this almost latent form of concomitant otitis is the ordinary purulent otitis, with perforation, which can occur in infants at the earliest age, and which presents the pronounced symptoms to be described in ¶ 356.

354. A latent form of purulent otitis seems to be the invariable rule in all cases of measles even when no pronounced aural symptoms are observed. In every fatal case of that disease examined by Bezold and his assistants the middle ear and mastoid pneumatic spaces were found filled with pus. Yet the great majority of patients with measles present no clinical symptoms of ear disease. In scarlet fever various observations on a more limited scale have also shown at least a frequent coincidence of a clinically latent purulent effusion into the middle ear. The same statement applies in diphtheria.

355. True pyogenic inflammation of the middle ear, which, however, does not lead to perforation of the drumhead, is observed at times in children and somewhat less frequently in adults. It begins with slight fever and sharp pain. The pain, however, is not continuous, but intermittent, generally worse at night. Fulness and deafness increase gradually during a few days, and when the climax has been reached, the pain subsides. The drumhead is either uniformly reddened or at least congested in its upper posterior portion (compare Fig. 5, Plate II.). Auscultation during inflation shows the presence of fluid in the middle ear. During healing this fluid becomes absorbed.

This form of otitis without perforation (which is not generally recognized) has been described by Politzer as a type of disease not identical with the ordinary perforating form of otitis. According to my experience, it is really but a milder type of the same disease which usually causes the drumhead to give way, but perhaps with a different localization. It occurs mainly in connection with the milder forms of nasal or pharyngeal disturbances. Coryza or tonsillitis, especially in the presence of adenoids, may lead to involvement of one or both ears. It may last from one to more than two weeks. The distinction between this form and purulent otitis tending to perforation is based at first upon the intermittent character of the pain. The distinction is not a difficult one

when the drumhead is only partially injected, but uncertain when it is diffusely vascularized. Subsequently the diagnosis is established by the subsidence of the symptoms without perforation of the drumhead. The disease differs from exudative catarrh by the more pronounced inflammatory symptoms at the onset. After these have subsided the difference between this form and acute catarrh is not so pronounced. The exudate, however, usually scant, is never as tenacious as the catarrhal secretion.

The tendency to recovery is decidedly aided by rest and protection and Eustachian inflation. The symptoms may, indeed, subside as promptly after a single inflation as they often do in exudative catarrh, but like in the latter instance, they increase again until the next treatment. Inflation stops the sharp pain at once. Instillation of carbolated glycerin (10 per cent.) seems to help in shortening the duration. After a few days of treatment inflation sometimes seems without further influence. Pneumomassage, while less effective in its inmediate influence, is, however, of some benefit until the hearing becomes normal. Politzer warns against paracentesis of the drumhead. This, indeed, is usually unnecessary. But with the more recent methods of guarding against secondary infection through the meatus by absolute asepsis and gauze drainage paracentesis does not involve the risk of protracted suppuration, which Politzer cautions against as the danger attending puncture of the drumhead in this disease. The operation may hence be done when the case does not show a steady improvement under treatment by inflation, provided inflammatory symptoms or intratympanic exudation persist.

CHAPTER XL.

ACUTE PURULENT OTITIS MEDIA (WITH PERFORATION OF DRUMHEAD).

356. Acute suppurative inflammation of the middle ear is a disease prevalent at all ages, but most common in childhood on account of the predominance of its causes during that period. As the course of the disease is quite variable according to its etiologic conditions, it is best to begin with a review of its causes.

The disease is caused by the invasion of the middle ear by pyogenic microbes. In more than one-half the cases it is the pneumococcus, next to it, the streptococcus, less often, the staphylococcus, occasionally, the pneumobacillus (Friedländer), the colon bacillus, or the bacillus pyocyaneus. As a rule, only one variety of germs is present originally, but in neglected cases streptococci and staphylococci may come in as secondary infection. The invasion takes place mostly from the nasopharynx through the tube. Much less common is the infection from the external meatus in consequence of traumatism, such as careless removal of foreign bodies or plugs of wax, or as the result of extension of eczema. Cold water entering through a previous perforation of the drumhead may also rekindle an otitis. The most frequent starting-point of the disease is acute nasal catarrh. It is popularly believed, and not improbable, that the extension through the tube may be due to "taking cold." But simple uncomplicated coryza does not often infect the ear unless aided by other conditions. nurslings this may be teething. In older children the presence of an enlarged pharyngeal gland is the predominating factor more than any other. Later in life nasal

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stenosis favors the spreading of suppurative rhinitis to the ear of the same side. These predisposing conditions play the same rôle in connection with the nasal inflam-* mation accompanying eruptive fevers. One of the most frequent underlying conditions is scrofula, but its influence depends largely on the existence of the enlarged pharyngeal tonsil so common in this affection. Suppurative otitis, often quite severe, may result from the entrance of water through the tube while using the nasal douche or while diving. Acute tonsillitis is not a rare cause. Diphtheria leads to clinically manifest otitis only in a small proportion of cases, but when it does occur, it is of a severe type. It is more often the streptococcus than the diphtheria bacillus which reaches the ear in diphtheria. Scarlet fever infects the ear often, and, as a rule, severely; measles much less frequently, at least clinically manifest, and generally not so severely. Rhinitis during small-pox, typhoid fever, or pneumonia may likewise extend to the ear. Influenza produces relatively often ear trouble, either a streptococcus otitis or a special form of influenza otitis, which will be described separately. Nasopharyngeal inflammation does not always extend along the lining membrane of the tube to reach the ear. In some cases the infection travels through the lymph-spaces. If purulent otitis does ever occur through direct infection of the middle ear by way of the blood-current, it is certainly not

common.

Of the various causes of otitis, simple nasopharyngeal inflammation leads, as a rule, to the mildest type, especially in young children. The ear disease following scarlet fever and diphtheria represents, on the other hand, the most severe and destructive form. Of the various causative germs, the streptococcus produces the most severe infection.

357. The morbid changes are those of purulent inflammation in general-viz., inflammatory swelling of the mucous membrane, with partial destruction of the