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Indeed, although DuVerney recommended camomile decoctions in 1683, for acute ear troubles, it has clung to the laity to this very day. It is largely used among the Polish and German people, so that I have grown to recognize those ears which have had this substance dropped into them, by the sediment or gum adhering to their tympanic membranes. I believe it wise in tea ching to condemn drops broadly. In acute conditions they can be only in the sense of a fetish or amulet. We are forced to this conclusion by considsring the conditions as they here exist. First, in all except those rare cases in which violent necrosis of large areas of the tympanic membrane takes place, the perforations are at first very small, measuring in diameter from that of a hair to that of a pin-head. The surface tension of a drop of water alone, or a column of water, which the external auditory canal will accommodate, will prevent its penetration through such a small opening, let alone solutions with greater specific gravity. And even if such solutions did enter beyond the perforation, what can we hope to accomplish? Entrance can take place only by the solution diffusing more or less with the contents of the tympanic cavity, and when this occurs we have merely the formation of an insoluble precipitate in the case of the mineral or organic astringents, and a disorganization of the secretory contents of the cavum in the case of anodynes and antiseptics. That this is bad treatment will appear later on.

Cataplasms, detergents, leaches, etc., have in turn been extolled by one and decried by another. The general treatment, too, has varied, from the purgatives and emetics of DuVerney, to the opium and quinine of the present day. In the meanwhile, the main issues have been lost sight of.

Mark you, I do not wish to hold up to ridicule the therapeutics of our forefathers. Far from that, I realize that the history of otology, like the history of all other things, is one of development. Step by step we have marched on to a larger comprehension of the various manifestations of acute infection of the structures within the ear. What I do wish to insist on is, that as regards the ear, therapeusis up to a very recent past, has not kept pace with pathologic knowledge. And it seems to me, a fit time to strike out into new paths, as regards the treatment of acute middle ear disease; to endeavor to follow a more rational mode of action, in the light of the advancement which has been made in the bacteriology and pathology of acute otitis. In doing this we must entomb some pleasant fancies mayhap, but the discomfiture which this causes, will be amply compensated for by the more satisfactory results of treatment.

Clinically we divide the inflammatory conditions of the middle ear into. acute and chronic catarrh, acute and chronic suppuration, etc., and these

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again into mild and severe forms, but the lines which divide these types are not fixed; for it is common experience to see one form passing into another. Especially is this so as regards acute catarrhal and suppurative otitis. Maggiora and Gradenigo, after examining bacteriologically twenty cases of middle ear inflammation, came to the conclusion that the clinical division of otitis into suppuration and catarrhal forms is not justifiable from a bacteriologic standpoint. But it will be the endeavor of the writer to demonstrate that the clinical division has a well-marked foundation, pathologically, if not bacteriologically,

Whatever the inflammatory type, catarrhal or suppurative, pathogenic organisms play the most important etiological role. The germs most frequently present in the exudate, are the dipplococcus pneumonæ, streptococcus pyogenes; less frequently occur the staphylococcus pyogenes albus and aureus, the pneumobacillus of Friedlander, the bacillus pyoccaneus, staphylococcus cercus albus and the micrococcus tetragenes. Lately Pes and Gradenigo have found the bacillus pyoceaneus as an unmixed infection. The studies of these authors, as well as those of Gessard and Chasrin, with this micro-organism prove that it is capable of producing local as well as general infections. (The so-called "maladie pyocyanique.") Microorganisms are seldom found in pure culture. Kanthack out of 31 cases of acute otitis, examined before the perforation had occurred, found pure culture of dipplococcus pneumoniæ only three times. The staphylococcus pyogenes is most frequently found as the mixed infection.

ROUTE OF INFECTION.

The tympanic cavity may be infected by way of

I. An intact drumhead, as in erysipelas, furunculosis.

2. Through a perforation of the tympanic membrane, augmenting always an existing inflammation.

3. By way of the circulation.

(a) In congenital otitis media accompanying infectious diseases in utero-variola, recurrens, typhus, diphtheria (Moose), etc.

(b) In the same diseases occurring later in life.

(c) In endocarditis (Trautmann).

4. Via the tuba Eustachii, (a) indirect, by way of the lymphatic inter spaces of the connective tissue. (b) Direct, by continuity of the mucous. membrane, and this is the most frequent way. (c) Through the lumen of the tube, as in forcing infection-laden mucous into the ear, by coughing, vomiting, douching, etc. It is said that infections may reach the middle ear by way of the fissura petrosquamosa, and Gradenigo in a case of cere

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bro-spinal meningitis has found the same micro-organisms in the tympanum about the region of the canalis Fallopii as were present in the meninges.

Apart from the peculiar pathogenic character of the various microorganisms, there are other factors which determine the type of an otitis. In other words, the same organism, may, under different conditions, give various types of inflammation. This is dependent on the intensity of virulence, the number of organisms, the resistance of the tissues, the rapidity of invasion. On this data Moose has divided the resulting inflammation into three catagories:

Those cases in which a relatively small number of organisms gain an entrance to the tympanum through the lumen of the tube, and produce there by a mucoid metamorphosis of the cell protoplasms the secretory form of middle ear catarrh, which without treatment may exist for months and years without suppuration occurring. Suppuration supervenes only when the organisms increase in number on account of a change occurring in the nutrient media of the mucous membrane, from taking cold, injury, or when additional organisms are forced into the middle ear.

2. Those cases of hematogenous invasion which causes infiltration of numberless polymorphous wandering cells in the mucous membrane, as for example, in measles, scarlet fever, diphtheria, etc. Each foci is enclosed in a fibrinous network, causing the mucosa to become hyperplastic. In this form there is no tendency to suppuration. Instead, the microbian products of metabolism may be exerted to produce changes in bones, necrosis of the blood vessels, etc., but metamorphosis occurs in the end without the formation of pus. The most probable cause of this is a relatively small number of microbe of attenuated virulence.

3. Cases in which suppuration occurs, the same being divided into : (a) Those in which suppuration is slight without perforation; (b) Those in which suppuration is profuse with perforation; (c) Those in which the onset is rapid, the suppuration enormous, with destruction of large areas of the tympanic membrane and exfoliation of the ossicles.

I will not consume your time with well known macroscopic and microscopic appearances of an acutely inflamed mucosa. There is little difference between that lining the ear and that found elsewhere in the body, with perhaps these differences: the glandular element is scant in the otitic mucosa, and the membrane here serves the double function of periostium and mucous membrane. The mucous of the cavum is largely elaborated by the pavement epithelium; the latter peculiarity explains the proneness with which otitic inflammations result in necrosis.

Now, all experience proves that the purely catarrhal as well as the suppurative form of otitis media may be caused by the same micro-organisms,

and I believe that still another factor always enters into the determination of the type of otitis. than those enumerated by Moose, and that factor is the route of invasion. It is my opinion that the difference is altogether due in the large majority of cases to the mode of invasion. That is to say, when the invasion is from the surface, i. e., via the lumen of the Eustachian tube and remains superficial, we have a catarrhal inflammation. That a purely catarrhal otitis may become purulent there can be no doubt, and when this does occur it is likely that the substrata of the mucosa is invaded either through the circulation, as a general infection-which is relatively rarefrom the pharynx, through the lymph spaces of the tube Eustachii which is less rare, or from the surface of the mucosa, the superficial protecting epithelial cells having been destroyed, though this is not a conditio sine qua non. I believe that when we have a purulent type of discharge, we may be sure that the infection is affecting the substrata of the mucosa.

In approaching the treatment of acute otitis media, let us consider the factors which confer immunity in regard to the invasion of the structures, and study, if possible, the measures which nature adopts in arresting such invasion. The question arises at once: "Can we regard the normal tympanum as an aseptic cavity?" Though there have been attempts made to prove that it is aseptic, I hesitate to so believe. When we consider the close relationship which exists between the naso-pharynx and the ear, our doubts are excusable. That it possesses rather strong antiseptic powers is proven by those cases of known septicity which recover in a few days. The truly aseptic cavities, such as the joints, plura, etc., do not so react. Indeed, in order to retain the power of resisting microbian invasion it would appear that that power should be continually exercised. That such a power is possessed by the nasal mucosa would seem to have been proven by the researches of Thompson and Hewlett, and that the same attribute is possessed by the mucosa of the tympanum is highly probable. In what does this bactericidal power reside? From observations which I have made on two cases of hydrops ex vacuo of the tympanic cavity, I am led to believe that it largely exists in the secretion itself. The external auditory canals of these cases were carefully sterilized with sublimate packings for two days. and after paracentesis the clear, somewhat tenacious mucous was collected in sterilized capillary pipettes. A drop of this transferred to a cover-glass and placed in a cell, will remain sterile until it quite dries up. A drop inoculated with an attenuated culture of staphylococcus pyogenes aureus, and kept at brood temperature in a moist atmosphere was found sterile after ten hours. These germicidal powers are, however, easily destroyed. For instance, if, after the first four hours, additional staphylococci be added, or

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if we may mix with it at the beginning about one-fifth by volume of egg albumen, the bacteriocidal powers fail. A fraction of a drop of a one per cent solution of zinc sulphate will produce the same destructive results.

The treatment which I will here outline has been followed during the past two years in my service at the Michael Reese Hospital, at the PostGraduate School, and in my private practice. It is based on principles first advanced by Pes and Gradenigo.

Local bleeding has been carefully eschewed. I regard cataplasms as not only of doubtful service, but actually harmful. They denude the skin of its protective covering, and thus open up new portals for the entrance of infection. And if a mastoid operation should become necessary the dangers. of sepsis are increased by the raw suppurating surface left by the blister, in the very field of operating. Further, I am far from being convinced that they have any marked influence on the pain or course of the infiammation.

I regard the employment of cold as of distinct worth in many cases. This is employed by means of the Leiter's coil or a common ice bag. The ordinary condom is a very good form of bag, being light and flexible, and on account of its peculiar shape especially adapted for coiling around the mastoid region. Heat may be employed if deemed necessary by applying hot antiseptic fomentations or the sand bag.

Anodyne and all other drops have been abandoned, for reasons already mentioned at the beginning of this paper. That anodynes are absorbed at all when dropped into the ear is doubtful. That they are infectious is certain. Therefore, as our whole endeavor is toward asepsis they have been abandoned. Narcotics for the relief of pain are best employed internally or hypodermically. Syringing has also been proscribed for reasons already mentioned, in speaking of drops. Before perforation occurs irrigation can do no good as a means of cleansing and antisepsis in the middle ear, because the intact tympanic membrane closes off the cavity from the external auditory canal. The external auditory canal may be rendered aseptic much more readily by a moist dressing. It is my experience that irrigation as a means of applying heat or cold to the deeper structures of the ear for their antiphlogistic or quieting effects, is not well borne; that is, in a number of cases, it had added to the pain and increased the congestion. Besides, an apparatus which will enable us to use continuous irrigation in the external auditory canal is very cumbersome. The wetting of the bed and patient is almost unavoidable, especially when the patient is young. Intermittent hot irrigation has proven harmful in my hands. Occasional syringing with sterilized saline solution has been allowed in orde! to clear the external auditory canal when the secretions take on a cheesy character, which accu