treatment. Its radiation and the accompanying headache can usually be controlled by antipyrin. Severe earache itself may necessitate morphin or opium. Hot applications (the hot-water bag or the Japanese stove) often give some relief. The only local application which sometimes mitigates the pain before perforation is carbolated glycerin (10 per cent. solution). In mild cases of otitis permanent relief is sometimes seen after the use of this fluid in the form of a prolonged ear-bath. But this is true only of those instances which do not end in perforation of the drumhead. Whether the use of carbolated glycerin can mitigate the disease so as to avert perforation is an open question. All popular ear drops, camphorated oil, laudanum, and the like, are entirely useless and delay necessary intervention. Eustachian inflation may give momentary relief, but is never of any permanent benefit. It has been severely condemned—perhaps unnecessarily so-by many recent observers as dangerous on the ground that it may carry the infected material into hitherto healthy spaces.

Paracentesis should be performed at once as soon as all hope must be abandoned of regarding the case as one of non-perforating otitis. When severe pain has lasted without intermission for more than about eight hours and the diagnosis is apparent by the uniform redness of the drumhead, it is the safest and wisest plan to puncture immediately. The operation is free from danger, requires no special skill, gives quick relief, and assures the shortest possible course. It should be done with the broad paracentesis needle or bistoury (Fig. 123) in the most prominent part of the membrane or in the inferior posterior region. When the disease is limited to the attic, as shown by the localized vascularity, Shrapnell's membrane should be divided horizontally. Too large an incision is better than too small a cut. There is a momentary sharp pain, which cannot be prevented by anything except general narcosis, which, as a rule, is superfluous. The bleeding is insignificant. Before

the paracentesis the meatus should be cleansed of wax and dust by syringing, and thereupon sterilized by filling it and the concha for at least three minutes with a solution of carbolic acid in water (3 per cent.) or in glycerin (10 per cent.). After paracentesis the meatus should be packed with a strip of sterile gauze about 1 cm. wide and 10 to 15 cm. long, pushed through the (sterilized) speculum gently with a flat probe. The entrance to the meatus and the grooves in the auricle are then loosely filled with strips of gauze until enough of a pad has been formed to absorb the most copious discharge for at least half a day. If necessary, this is held in place by a narrow strip of adhesive plaster across the auricle. As often as the external pad of gauze gets moist it should be replaced, which the patient can do himself. The strip in the meatus should be replaced only by the surgeon at intervals of one or two days. As it is impossible to assure asepsis by means of sterile gauze alone, various antiseptic additions have been tried, which, however, must be nonirritating. Chinolin-naphthol gauze is lauded by some. The writer has been well satisfied with a powder of boric acid mixed with one-sixth of salicylic acid dusted freely into the meshes of the gauze. A freely absorbing gauze must be selected, since the object of the dressing is to remove the discharge as fast as it forms. When the fluid is serous, this is easily accomplished. A change of serous. discharge into pus indicates inefficiency of the surgeon's antiseptic precautions and means a serious prolongation of the disease. When the fluid is purulent from the start, the strip of gauze in the meatus must be changed. oftener, in order to maintain a continuous flow from the middle ear to the surface of the absorbing pad. Syringing is of no benefit whatsoever in this disease. If done with ordinary water, it may even cause secondary infection. Syringing with sterile water or salt solution is less harmful and may sometimes be called for when thick discharge has not been properly absorbed by the dressing. In the case of purulent discharge maceration of the skin

of the meatus is at times annoying. The skin should be cleansed by mopping with wet and subsequently with dry sterile cotton and brushed with a 2 or 4 per cent. solution of nitrate of silver. Anointing the wall of the meatus with a thick zinc oxid ointment is also of service. The regular dressing should thereupon be replaced in the usual way. As the discharge diminishes, the amount of gauze may be lessened and the intervals of dressing lengthened. By the time the fluid has become scant, its secretion usually ceases abruptly. In cases properly treated according to this method from the start relapses of the disease are almost unknown and complications quite infrequent. When the discharge has ceased, the hearing is, as a rule, still very much impaired. Spontaneous recovery follows, however, in the course of weeks without further treatment. After closure of the perforation Eustachian inflation and pneumomassage are sometimes of some service.

When spontaneous perforation has occurred, the mildest and shortest possible course can be expected only if the same mode of dressing is begun while the discharge is still serous. If it has changed into pus, either from the continued influence of the original germ or by secondary infection after other germs have entered through the meatus, a more prolonged course must be expected and complications are more to be feared. As soon as the patient is seen after the spontaneous perforation, the meatus should be cleansed by aseptic syringing and an effort may be made to combat secondary infection by a prolonged ear-bath with carbolated glycerin. The previously described dressing should then be applied, and the case managed as detailed in the preceding paragraph. Any deviation from these rules will only result in a less favorable course.

After spontaneous perforation and occasionally after a paracentesis made too small or narrowed by a nipple of granulation tissue, the acute symptoms will, in exceptional instances, persist or return until a larger puncture

is made in the drumhead. When this treatment, properly carried out, does not result in the steady subjective improvement and diminution of discharge in the course of about two weeks, it is safe to assume that there is destruction going on within the mastoid cavity, even if there are no external symptoms of mastoiditis. This arbitrary period of about two weeks does not refer to the length of the disease or to its original date, but only to the time during which its symptoms are absolutely stationary under treatment. In such cases no cure can be obtained until the mastoid antrum is opened.

361. Influenza Otitis.-During the extensive epidemics of influenza for some years before and after 1890 a peculiar form of middle-ear inflammation was often met with early in the course of that disease. It was due to the invasion of the tympanic cavity by the influenza bacillus. It began with intense pain, often radiating in the form of a diffuse neuralgia, and with much fulness and often dizziness. Objectively it was characterized by hemorrhages in the drumhead and presumably the tympanic mucous membrane. Spontaneous perforation of the membrane did not always occur. When it did perforate or when it was tapped, the discharge was a bloody serum. In spite of its apparent severity this form of influenza otitis usually ended favorably in about two weeks or less if not interfered with by any active treatment. Paracentesis was generally not necessary or beneficial. Of late years this form of disease has become uncommon. It is well known that the entire clinical history of influenza is changing, either on account of altered virulence of the bacillus or on account of partial immunity of the population. Nowadays the usual form of influenza otitis is a late severe streptococcus infection of the middle ear, with the ordinary clinical course of an intense otitis.

CHAPTER XLI.

MASTOIDITIS.

362. The mastoid antrum participates in all severe forms of purulent inflammation of the middle ear. This has been shown by autopsies, and is. strongly suggested as well by the copious secretion found in many forms of purulent otitis, too copious indeed to be furnished by the small area of the tympanic cavity. This inflammation of the mastoid mucous membrane may not reveal itself at all clinically, or it may be indicated by pain and tenderness over the mastoid process. This superficial inflammation, however, limited to the mucous membrane, is not the pathologic basis of what is ordinarily called mastoiditis. Whenever symptoms occur which the clinicist interprets as mastoiditis, they are due to an extension of pyogenic inflammation into the bony substance of the mastoid process, complicated often, but by no means always, with caries or necrosis of the bone. In very rare instances an abscess is limited to some of the cells underneath the antrum and does not extend into the latter.

Primary mastoiditis is very rare and is probably an osteomyelitis of the mastoid bone. As a rule, mastoiditis is secondary to purulent otitis media. In rare instances it follows that disease after an interval of many weeks. after apparent cure of the otitis. As a rule, it is a complication during the continuance of an acute otitis with purulent discharge, sometimes beginning suddenly with a chill, more often developing gradually. In a small number of instances of severe otitis, especially the streptococcus variety, mastoiditis pursues an insidious course, with gradual abatement of its acute symptoms, continuing in a chronic, but none the less dangerous, form.