change in the pressure, which, when not quickly compensated through Eustachian ventilation, may cause rupture. Too sudden a diminution of such extreme airpressure leads to liberation of air-bubbles in the capillaries, often with minute hemorrhages, and this accident has occurred as well as in the labyrinth of the ear as in the central nervous system.

304. Heredity is an important factor in the predisposition to ear disease. The liability to aural affections. is decidedly increased by the history of disease in the parents or near relatives. While plastic and sclerotic middle-ear processes are the commonest forms observed in predisposed families, still the individual under the influence of a bad heredity may acquire any type of ear disease. The intermarriage of deaf-mutes leads to a large proportion of deaf-mutes in the offspring, but still with a preponderance of normal children.

SUBJECTIVE

CHAPTER XXXII.

SYMPTOMS AND METHODS OF EXAMINATION AND TREATMENT IN EAR DISEASES.

305. Pain in the form of more or less severe earache is produced by acute inflammation in either the meatus or the middle ear, and especially in the mastoid bone. Its severity and duration are proportionate to the intensity of the inflammatory processes. Chronic disease does not cause pain. Subacute catarrh of the Eustachian tube is sometimes productive of earache in children. Acute pharyngeal lesions near the Eustachian orifice, such as ulcers near the lateral recesses of the pharynx and wounds of the upper part of the tonsil, give rise to sharp pain referred to the ear. Erupting wisdom-teeth and disease of any tooth back of the bicuspids can induce otalgia— neuralgic pains in the ear.

Itching in the ears is at times a source of great distress to nervous people. It may be due to an easily overlooked area of slight eczema in the meatus, or, on the other hand, to venous congestion around the Eustachian orifice in neurasthenics with irritable nose. It is often very annoying in hay fever.

A full or "stopped-up" feeling in the ears results from occlusion of the meatus by wax, especially if the latter presses on the drumhead. Furuncles and diffuse inflammation of the meatus cause stuffiness in proportion to the swelling present. Stuffiness is characteristic, too, of serous catarrh, while in the plastic form of middle-ear disease it is a less constant or prominent symptom. It is, of course, present during the acute stage of purulent otitis.

In connection with the "stuffy" feeling patients mention the subjective want of resonance of their own

voice. It sounds muffled to the patient, even though his hearing for external sounds may not have suffered appreciably. A similar muffling of the sound is often noticed, especially in one-sided disease, when a noise is produced by scratching the region around the ear. Quite different from this subjective muffling of the voice is the excessive resonance, which has been termed "autophony." It is complained of by patients without ear disease, but whose Eustachian tubes presumably gape to an abnormal extent on account of inflammatory rigidity of their walls or perhaps from wasting of the cushion of fat in the external wall of the tube.

Vertigo varying from momentary slight dizziness to a more or less continuous feeling of insecurity may result from various ear affections. Pressure of wax against the drumhead, syringing with cold water or with too much. force, especially when there is disease of the attic, can cause it. Persistent dizziness is a grave symptom in suppuration of the middle ear. Disease limited to the tympanic cavity without retention of pus in the attic does not provoke vertigo unless there is caries of the labyrinth. This symptom, however, is characteristic of any involvement of the semicircular canals, whether the disease be primarily labyrinthine or due to extension to the internal ear. Severe ear vertigo leads to nausea and vomiting, staggering, or even the inability to rise from the recumbent position.

306. Noises and ringing in the ear, technically termed tinnitus, are a serious annoyance to many ear patients. Some neurasthenics have been driven by it to suicide. Wax in the meatus may cause a roaring sound. In suppurative otitis tinnitus is usually absent, sometimes, however, following later by reason of intratympanic adhesions. In serous catarrh it is a minor symptom. But the hypertrophic form of middle-ear disease-and to a much less frequent extent sclerosis-is characterized by subjective noises, sometimes as the earliest symptom. Disease of the internal ear is not always accompanied by subjective

CHAPTER XXXI.

GENERAL ETIOLOGY OF EAR DISEASE.

297. Notwithstanding the deep protected location of the organ of hearing, it is very frequently affected by disease. According to various statistics, the external ear is involved in 25 per cent., the middle ear in 70 per cent., and the internal ear and nerve in about 5 per cent. of all ear patients. Traumatism plays but a small rôle in the production of ear disease. Blows may lead to bloody effusions in the auricle with subsequent deformity or to rupture of the drum-head. Foreign bodies in the meatus, a frequent accident in childhood, cause serious mischief only if violence-for instance, during attempts at extraction-wounds the meatus or drumhead and opens the gate to infection. Slight traumatism combined with subsequent infection is a common result of scratching the meatus with pins, hair-pins, and other articles. The thin skin is very easily abraded, and, being covered with dust containing living germs, furuncles, diffuse inflammation of the meatus, and even extension to the middle ear are not an uncommon penalty for this habit. Diving under water accounts for some ear disease, especially when certain unfavorable conditions preexist. Wax present in excess will swell when wetted and may now occlude the meatus. A former cured suppuration may be rekindled if a perforation of the drumhead permits the water to reach the middle ear. Cold water pressing against the intact membrana tympani sometimes, though rarely, starts the extension of a catarrhal process from the pharynx to the ear. All this can be guarded against by a plug of ordinary non-absorbing cotton in the ear while bathing.

Less common, but more serious, is acute otitis media due to the entrance of water through the Eustachian tubes as the result of swallowing under water.

298. The majority of affections of the middle ear, excepting tubercular otitis media and sclerosis, originate from extension of disease in the nose or pharynx. In a broad way it may be stated that all cases of catarrhal or purulent middle-ear disease are preceded by nasopharyngeal lesions, except that some of the eruptive fevers (measles and scarlatina) may involve the mucous membrane of the middle ear and of the nasopharynx at the same time. In all the various forms of inflammation of the middle ear nasopharyngeal lesions are either present or were present at the start. In some instances of proliferative and of serous catarrh of the middle ear the dependence on the lesions in the air-passages can be shown by the successful results of nasopharyngeal treatment. This success is, however, not always obtained. Suppuration of the middle ear, on the other hand, after it is once started, continues independently of the condition in the nasopharynx, and is hence not cured by their successful removal. But when the history shows frequent recurrences of otitic suppuration after natural or surgical cure, the benefit of proper nasopharyngeal treatment is easily demonstrable. The nasopharyngeal origin of ear disease is often plainly suggested in one-sided affections by the limitation of the ear disease to the side of the nasal stenosis.

The etiologic relation of the different forms of nasal and pharyngeal disease to aural affections can be summarized as follows: Ordinary acute coryza and pharyngitis or tonsillitis do not often cause ear trouble if the respiratory passages had hitherto been structurally normal. The liability to involvement of the ear increases, however, with the degree of previous structural anomaly, especially if of an obstructive character. In children the most important predisposing lesion is enlargement of the pharyngeal tonsil and, to a much less extent, hyper