tube and middle ear. For this purpose many devices have been resorted to at different times, the so-called nasal douche, the use of which is not free from danger, being one of the means of effecting its removal ; the use of a syringe for the posterior nares has been another method

of cleansing. Perhaps the most agreeable as well as the most efficacious mode of effecting this removal is by inhalations of alkaline steam from an atomizer, breathing through the mouth-some of it escaping through the nostrils as well as through the mouth. It practically is an application of the principle of a poultice to soften the secretions, effect their removal, and soothe the inflamed membrane. Although the steam will not under these circumstances enter the Eustachian tube, the effect upon the naso-pharynx will also be produced, though in a less degree, on the lining of the Eustachian tube. Where no abnormal perforation of the drum-head exists, the only route to the Eustachian tube and middle ear is either through the nostril or through the mouth. Advantage is usually taken of the nostril as the more direct route to these parts.

For the purpose of inflating the middle ear three principal methods are resorted to. The first of these, known as Valsalva's method, consists in closing the mouth and nostrils and expelling air from the lungs, which, because it cannot escape from the mouth or nostrils, is forced through the Eustachian tubes into the middle ear. The second, known as Politzer's method, is the reverse of Valsalva's; in it advantage is taken of the fact that the act of swallowing closes the soft palate against the posterior wall of the pharynx, thus bridging over the space, and while in that condition, if air be forced through one nostril, the other being closed by pressure to prevent its escape, the air is rendered more dense in the naso-pharynx, and in that way is forced through the Eustachian tube into the middle ear.

In the third method the Eustachian catheter is introduced gener

ally through the nostril to the opening of the Eustachian tube and air is pumped through that into the middle ear. Inflation simply with air is most serviceable in cases of hypertrophy with diminished calibre of the Eustachian tube frequently occurring in children. Where the air has

E.H. SARGENT

Pure silver Eu

stachian cathe

become rarefied in the middle ear such inflation will usually temporarily increase more or less the hearingdistance of the ear inflated. Where such inflation does not increase the hearing-distance, the structural change is usually chiefly within the cavity of the middle ear, and experience shows that the prognosis is less favorable.

The defects in what is known as Politzer's method of inflation are that the bulb used for inflation is larger than is necessary, thus exerting more violence upon the parts than is justifiable, and that where the Eustachian tubes are unequally open most of the force is exerted upon the more open or less affected ear, and also that the air thus forced in has no therapeutic effect, the result being simply mechanical. Therefore a method of treatment which combines with mechanical inflation proper medication to remedy the existing condition is what the case demands. Here some latitude exists in the selection of remedies to be used. It should be borne in mind that there exists the third or chronic stage of inflammation of a mucous membrane with the usual structural changes of such chronic inflammation of that membrane. The necessity for decided stimulation of the parts in that stage is recognized the same as elsewhere. The ear should be no exception so far as the principle is involved. The delicacy of the structure, as well as its importance, necessitates some modification in the method of applying the same principle. Of all remedial agents used, probably none on the whole has given such satisfactory results as iodine.

Air is medicated with iodine and forced through the Eustachian tube into the middle ear, thus stimulating sufficiently to produce a hyperamic condition of the drumhead, showing the impression made upon the lining of the middle ear. The effect may be increased by first cleansing the Eustachian tube with warm alkaline solutions as supplemental to the use of the steam atomizer and preceding the use of the iodized air. Since

ter (natural size).

there are imperfect circulation and imperfect nutrition, even in the hyper

trophied form, whatever will quicken the circulation and stimulate the

Buttles' inhaler and valve-bulb.

parts will have a tendency to restore normal circulation and normal nutrition. For that reason the galvanic current may often be advantageously used, not for an im pression upon this nerve of special sensation, but simply to improve the nutrition of the conducting apparatus. Mildly stimulating applications may also be made to the external meatus and to the dermoid layer of the drum-head. Since the parts have been deprived of the protection of the cerumen spread over the surface of the meatus, a substitute for that should be applied, and for this purpose the petroleum

VOL. I. Ser. 4.-22

products are among the best. Should the disease of the middle ear have so influenced the dermoid lining of the external ear as to have produced a soil favorable for the growth of parasites, such as aspergillus, some parasiticide should be used. For this purpose solutions

of carbolic acid, of peroxide of hydrogen, and of bichloride of mercury have been applied advantageously. In this state of imperfect circulation of the blood the normal temperature of the middle ear is not maintained. As a consequence, exposure to high winds causes discomfort and greater impairment of hearing and temporarily aggravates the existing difficulty. Therefore some protection, as by wool or cotton, should be introduced into the external meatus, but not habitually used, or the auricle be lightly covered, when exposed to low temperature and high winds.

FIBROUS TUMOR OF THE NASO-PHARYNX.

CLINICAL LECTURE DELIVERED AT THE ABERDEEN ROYAL INFIRMARY.

BY J. MACKENZIE booth, M.A., M.D., C.M. (Aberdeen), Surgeon and Lecturer on Clinical Surgery at the Aberdeen Royal Infirmary; Lecturer on Diseases of the Ear and Larynx in the University of Aberdeen.

GENTLEMEN,-I wish to direct your attention to the case of a lad who has been in one of the wards under my care for the last few days. The case possesses more than ordinary interest as being that of a growth which, though benign in character, has always been justly dreaded from its inaccessibility and its tendency to recurrence; also from the fact that our modern increased facilities of diagnosis have rendered its early recognition easier, while recent improvements in instruments have enabled us to cope with it with greater success than was possible heretofore.

The subject of this affection is a tall, thin country lad, sixteen years of age, who has of late been growing very rapidly. About four years ago, after being much frightened by the occurrence of a fire in the house where he resided, he was noticed to stammer; and shortly after, on account of this affliction along with his rapid growth, his medical attendant recommended a reduction in his tale of school work,-after which the stammering was lessened. Only for a time, however, did the improvement last, when the stammer recommenced, and then began the symptoms more distinctly referable to the present ailment. These were symptoms of nasal obstruction, interference with respiration through the nose, first in one and then in both nostrils, and a sensation of discomfort in the nasal cavity,-mouth-breathing, nasal voice, and snoring during sleep,—all of which symptoms gradually increased in severity and grew more constant as time passed. There was a mucopurulent secretion both from nose and mouth, necessitating oft-repeated efforts at hawking and spitting; and the breath acquired a somewhat disagreeable odor, though it could not be called fetid. His speech became so thick as at times to be almost unintelligible. Of late months. another and very characteristic symptom has appeared,―viz., bleeding,