stachian tube for the purposes of diminishing secretion, loosening the mucous membrane or ossicles, or dissolving inspissated secretions. After the catheter has been introduced a few drops of the drug are injected by means of a Pravaz syringe, and propelled into the middle ear by forcing air through the apparatus. With the otoscope the drug is heard to enter the middle ear with a bubbling sound. Quite often it can be seen behind the drumhead; in such cases the manubrium is usually congested and may present ecchymoses. If the tube is permeable and there is a perforation in the drumhead, the tympanic cavity can sometimes be very satisfactorily flushed out with the catheter. For this purpose sterile water at a temperature of 28° C. (95° F.) is gently injected into the cavity with a large piston syringe or through a small elastic tube (Weber-Liel) introduced directly into the cavity through the catheter. The water returns through the affected ear.

(0) The Use of Bougies in the Eustachian Tube.-If stenosis persists in spite of inflation, an attempt may be made to remove it by introducing a celluloid bougie through the catheter, the thickness varying from to 11 mm. (Urbantschitsch). The bougie incidentally furnishes a means of recognizing a stenosis and its situation. In a normal tube a bougie of 1 mm. will easily pass the narrowest portion-the isthmus of the tube. Before introducing the bougie, the length of the catheter is indicated by a mark; 23 cm. further back another mark is made. After the bougie has been introduced as far as the first mark it has passed the length of the catheter, after which it should gradually be pushed forward an additional distance of 23 cm., as far as the second mark, when the narrowest portion of the isthmus will have been passed. If the bougie has been pushed in too far,--over 3 cm.,it will enter the tympanic cavity and endanger the integrity of the ossicles. After the bougie has been in place ten minutes it is removed and air is forced in through the catheter. If the catheter was improperly introduced,

the bougie, instead of entering the opening of the tube, is forced into the mucous membrane of the nasopharynx and may produce lacerations. If, on removing the bougie, the end is found to be bloody, inflation must not be practised and the patient must be warned against blowing his nose on account of the danger of subcutaneous emphysema. The passing of the bougie is often followed by distinct improvement in the hearing, and may act reflexly by stimulating the auditory centers (Urbantschitsch). In the treatment of stenosis bougies of gradually increasing calibers must be used. By rapidly moving the bougie to and fro and setting up a slight vibration, massage of the tube can be practised. The mucous membrane can be cauterized by means of medicaments painted on the bougies, or a metal bougie to which a caustic, such as silver nitrate, has been welded may be employed. [The bougie should be employed only in the hands of experts.]

10. General Examination.-If the examination of the ear leads the surgeon to suspect that the aural affection depends on some general disease, such as tuberculosis, diabetes, anemia, leukemia, syphilis, etc., a general examination of the entire body and its secretions-urine, sputum, and blood-is indicated. An aural affection. caused by some general disease cannot be cured by local measures without the co-operation of constitutional treatment. If there is any suspicion of intracranial disease, the eye-ground must be examined (choked disc, optic neuritis-rare in uncomplicated cases of otitis media, most frequent in perisinuous abscess with sinus thrombosis: choked disc is more common in tumors; optic neuritis, in brain abscess). Lumbar puncture may also afford valuable information in intracranial complications. Before administering an anesthetic the general condition must always be subjected to a rigorous examination.

II. Malingering.-Wide experience, an extensive knowledge of human nature, and a thorough examination and functional test of the ear are requisite to the

detection and conviction of a malingerer. Malingerers feign unilateral or bilateral, partial or complete, deafness. When a malingerer is to be examined, his eyes should be tightly bandaged. If he pretends bilateral deafness, which he rarely does, the fraud being, as a rule, easily exposed by witnesses, he can be convicted only by a trick, such as by suddenly saying to him, " You may go," or by rousing him from normal sleep or that induced by anesthetics by calling to him, or by watching him while he is in a state of intoxication. When bilateral deafness is alleged, each ear is tested separately, the other being carefully closed. In performing the test certain definite words, as well as the acumeter, are used. The distance at which the individual hears is carefully noted, and his statements are subjected to a rigorous control test by repeated examinations. The control test may be made even more rigorous by closing both ears with aural specula, one of which is open while the other is sealed with wax (Tschudi). By means of the tuning-fork the time of perception for individual notes, both for air- and bone-conduction, is tested, and the tests repeated several times. In this test also there is room for cunning on the part of the examiner. If, for example, the individual says that he hears the tuning-fork when it is placed on the vertex, the examiner proceeds to stop up both ears. If the subject is malingering, he will frequently say that he can no longer hear the tuning-fork, whereas as a matter of fact he should be able to hear it better than before. When unilateral deafness is alleged, the truth or falsity of the statement will again be decided by performing repeated tests, both with the voice and with tuning-forks, and carefully comparing the patient's statements at each examination. If the malingerer is suffering from middleear disease and the tuning-fork is placed on the vertex, he will rarely say that he hears it in the affected ear. Usually he says that he hears the note in the sound ear, and, if the sound ear is stopped up, he will say that he does not hear anything, which at once convicts him of

malingering (Moos). As a further test the power of hearing whispered conversation may be determined first for the sound ear, and then for the pretended deaf ear, without stopping up the sound ear. If the individual examined says he hears nothing, he is a malingerer, since he must be able to hear with the sound ear (Hartmann). Another plan is to pretend to stop up the sound ear, using a perforated cork (Voltolini). If one shouts into the pretended deaf ear while the sound ear is closed tightly, the malingerer must hear with the sound ear in spite of its being closed. If the bulb of a double otoscope is inserted into each ear of a malingerer, and a tuningfork is placed on the T-piece of the otoscope behind the patient, the note-if the right ear, for example, is alleged to be deaf-should be heard only by the left ear of the examiner. If the rubber tube going to the right (deaf) ear is compressed, the sound should be louder in the left (sound) ear. If, on the other hand, the right ear is really deaf, the sound should disappear completely if the tube leading to the healthy ear is compressed (Bloch).

As a further test an ear-trumpet may be inserted into each ear, and two examiners, standing behind the subject, at the same time whisper certain words in rapid succession, the suspected malingerer being asked to repeat immediately what he has heard. If he is really deaf on one side, the words whispered into the healthy ear are at once repeated without hesitation; but if he is malingering, some of the words whispered into the pretended deaf ear are also repeated or else he becomes confused (Luce, Hummel).

The artificial production of objective symptoms, such as aural discharge (Chimani), and attempts to deceive by alleging subjective symptoms, such as tinnitus, vertigo, and pain, may be detected by examination or by careful observation in a hospital.

12. Bacteriologic and Histologic Examination.-Pus, cerebrospinal fluid, etc., are to be examined microscopically and by making cultures. If streptococci

are found in active suppurative processes, the prognosis is more unfavorable than when the secretion contains only diplococci. The course of a streptococcus otitis is likely to be more severe than that of a pneumococcus otitis; in the latter variety mastoid disease and epidural abscesses are more likely to remain after the otitis media has subsided. Pyemia is most common in streptococcus otitis. In chronic suppurative processes staphylococci are usually found (Zaufal, Leutert). The finding of diphtheria bacilli, tubercle bacilli, actinomyces, aspergillus, and cholesterin crystals in aural pus is of great diagnostic significance. In certain cases the diagnosis may eventually be determined by excising small portions of tumors in the pinnæ, auditory meatus, or tympanic cavity (carcinoma, sarcoma, polypoid granulations, fibroma, etc.).