lining, causing more or less rigidity of the ossicular articulations, as well as a variable amount of fluid exudate. These latter changes are not influenced immediately by inflation. Hence the degree of immediate improvement resulting from artificial ventilation through the tube is inversely proportionate to the extent of the morbid changes in the drum. In some instances inflation is followed only gradually by an increasing improvement in hearing and comfort until the full benefit is obtained some hours later. The effect of Eustachian ventilation is not limited to the prompt relief of the mechanical anomaly. For by restoring the normal air-pressure in the drum an important factor in the maintenance of vascular engorgement is eliminated. There is every reason to assume that in the ear, as elsewhere, vascular congestion of mechanical origin interferes with the normal resolution of an inflammatory process. While in Eustachian catarrh a single inflation ends all disease manifestations, the effect of an inflation is only temporary when there is disease in the middle ear itself. The greater the immediate effect, the longer it will persist and the less complete will be the return of the previous symptoms. But in any case the effect of inflation begins to decline in the course of a day.

338. The treatment hence consists in the repetition of inflations at least once a day. In the mildest case complete recovery can thus be obtained in about eight to ten days. Inflation is often more efficient by means of the catheter than by the Politzer method, as judged by the immediate result. The Politzer bag may, however, be intrusted to the patient's hands, if necessary, though, as a rule, it is not to the patient's benefit to expect him to carry out any part of the treatment to which the surgeon ought to attend. Eustachian inflation generally stops promptly any earache in the earlier course of middle-ear catarrh. The pain can also be controlled by antipyrin. In the less favorable instances the benefit of inflation is nearly or wholly lost within twenty-four hours. There

may even be occasional exacerbations in spite of treatment. In such cases it is best to advise the patient to use the Politzer bag several times daily. Extensive trials have been made to increase the effect of inflation upon the absorption of the inflammatory swelling and of the exudate by adding the vapor of iodin, chloroform, or oil of turpentine, or finely divided chlorid of ammonium, or hot air (315). It is very difficult to judge the efficacy of these measures in a given case, or even in a series of cases, on account of the positive, but somewhat variable, influence of the inflation itself, particularly, however, on account of the impossibility of foretelling accurately the course of an individual case. It cannot be said of any one form of vapor application that it has received decided praise by many except the original author. While it would be unjust to deny the utility of vapor inflations entirely or to refuse them some trial, it cannot be said that by their employment results can be obtained which are not possible without them. Chlorid of ammonium deserves perhaps trial more than any other substance.

The injection of a few drops of fluid into the tube through the catheter must be spoken of with less reserve (nitrate of silver solution 2 per cent. or zinc sulphate solution 0.5 to 1 per cent.). Its benefits are, at the best, doubtful. A few drops blown in do not penetrate beyond the tube, which is usually not diseased throughout its middle half. A larger quantity may cause and has caused suppurative otitis.

When fluid exudate persists in the drum without being absorbed and the disease is thus prolonged, it may be removed by a paracentesis (316). It is only in a small minority of cases of exudative catarrh that paracentesis is indicated, but when called for it is of decided benefit. When done aseptically, it causes no unpleasant consequences. After making a free inci

sion the exudate is blown out by a Politzer inflation. If viscid, it may be seen adhering to the wound. Boric acid is insufflated lightly, and a piece of ab

sorbent gauze is left in the meatus to absorb the fluid. Syringing must be strictly omitted after paracentesis. On account of the high position of the tympanic opening of the Eustachian tube fluids in the drum do not escape through the tube, except as the result of overflow. Suction through a flexible tube pushed in through the catheter is hence irrational. Exudates disappear by absorption when the tympanic mucous membrane is not too much diseased. But the presence of the exudate itself keeps up the inflammation of the mucous mem

brane.

The only other direct mode of treatment which can exert an unmistakable though feeble influence upon aural catarrh is pneumatic massage (313). It is of most service after the acuteness of the process begins to decline.

The persistence of catarrhal otitis in spite of local treatment is due in many cases to the persistence of the nasal or pharyngeal condition which started it. It must be remembered that the direct cause of extension to the ear is the nasopharyngeal inflammatory process. If this has subsided spontaneously, no nasal treatment is called for. But if the inflammation of the upper air-passages remains, its treatment produces a beneficial effect upon the ear proportionate to its influence upon the nose or throat. In proportion as we succeed in reducing purulent secretion and turgescence of the nasal cavernous tissue we will find an improvement in the ear. If the disease in the nose and pharynx can be made to yield to sprays, the douche, and medicinal applications, the aural lesion improves correspondingly. But if the persistence of the nasopharyngeal inflammation depends on the presence of permanent structural changes, such as stenosis due to septum irregularities, or hypertrophy of mucous membrane or of cavernous tissue, or pharyngeal adenoids, operative treatment is required in order to stop the morbid process both in the respiratory passages and in the ear. It does happen at times that the nasopharyngeal inflammation recovers completely in spite of a stenosis, and in such a

case the ear will also recover without nasal operation, but relapses are to be feared. On the other hand, our present means of treatment of nasal and pharyngeal diseases are not infallible, and hence a catarrhal otitis may drag on in spite of nasal treatment.

Aural catarrh will occasionally prove obstinate, even after disappearance of the nasopharyngeal affection. Recovery depends on the normal resisting power of the tissues. This may be enfeebled by a variety of other disturbances of the system-for instance, anemia, intestinal derangement, etc. Hence proper hygienic management

must not be overlooked.

339. Syphilitic Catarrh of the Middle Ear.-Various observers have described occasional instances of severe middle-ear affections apparently due to syphilis, but neither their discordant reports nor a few scant autopsies suffice to establish a definite clinical type. I have personally seen some instances of a form of middle-ear affection which seemed to me peculiar to syphilitic patients. It was apparently a severe catarrhal inflammation of moderately acute onset, bilateral, with considerable impairment of hearing, much noise and fulness, and some dizziness. The impairment referred to air-conduction, not to bone-conduction. The drumhead was cloudy and sometimes slightly injected. Eustachian inflation showed diminished patency and the presence of a very scant exudate. Inflation, however, did not improve subjectively or objectively. Specific treatment likewise produced no noticeable benefit inside of two to three weeks. Unfortunately, none of the patients were observed for any great length of time.

CHAPTER XXXVI.

ADHESIVE OR PROLIFERATIVE INFLAMMATION OF THE MIDDLE EAR.

340. The names adhesive, proliferative, plastic, or hypertrophic" otitis, or "dry catarrh" of the middle ear, refer to an affection of the middle ear which must be considered the analogue and extension of hypertrophic rhinitis. Very rare in early childhood, it cannot be called common until after growth is finished, from which time on its frequency increases until every third or certainly every fourth individual in advanced age presents some evidence of this disease. The disease is rarely one-sided-mostly bilateral. But quite often one ear is less affected than the other, sometimes so little that the patient calls his disease one-sided. The progress of the disease is not necessarily parallel in the two ears.

In typical cases it begins so gradually that its exact date of origin can often not be stated. Ringing in the ear, perhaps only occasional at first, may be ignored for a long time until it becomes annoying. Later on it may become the main complaint, more serious to the patient even than the deafness. In neurasthenics tinnitus can cause much suffering and unhappiness. "Stuffy" sensations are usually not present to any distressing extent except in complicated cases. Dizziness is likewise not a strictly "normal" symptom of adhesive otitis, but it does occur in a small proportion of cases on account of some special localization of the lesion or as a complication, and it may prove very distressing. The hearing becomes affected gradually. Sometimes the patient is not conscious of any impairment for many months; in other cases he is annoyed from the start. The impairment is, of course, most perceptible when listening to