Many cases which have received no treatment develop into a chronic purulent otitis, and a careful examination will show areas of bony necrosis in the walls of the cavity or confined to the ossicles. Death may result from direct involvement of the cranial contents directly or after the development of mastoid inflammation. Treatment.-In the first stage, before effusion has taken place, gentle inflation and filling the meatus with warm carbolated vaseline will often give relief. When the pain has become intense an 8 per cent. solution of cocaine or eucaine may be instilled into the ear. A small dose of morphia, in combination with atropia, may be given if needed. Opiates must be used, however, with extreme caution, as they often mask urgent symptoms of complications of adjacent parts. Leeches will occasionally give speedy relief. The bowels and general health should receive proper attention. Antipyretics should be used if indicated, but quinine must be avoided as it aggravates the existing hyperaemia and conduces to permanent deafness. If the pain continues and there is bulging of the drum head, an incision should be made in the posterior and inferior quadrant, which affords the most perfect drainage. When suppuration has not occurred, but the pain is severe, it is often advisable to make a free incision of the membrane in the vascular portion -the posterior and upper quadrant. This relieves the engorged vessels, lessens the pain and frequently aborts the disease before it reaches the suppurative stage. The ear should be syringed with warm sterile water or a weak antiseptic solution one or more times daily-sufficiently often to keep the meatus clear. When a perforation has occurred it is often necessary to enlarge the opening to secure more perfect drainage. When the discharge is not profuse, and the patient can be seen daily by the physician, little rolls of absorbent cotton placed in the meatus absorb the discharge and prevent a macerated condition of the tissues, which sometimes occurs when the meatus is bathed in fluids for a considerable length of time. Careful inflation forces the discharge from the middle ear into the meatus, where it can be readily removed. When the symptoms point to mastoid involvement, the Leiter coil or ice bag may be applied for thirty-six hours. If the symptoms do not rapidly subside operative measures should be resorted to. After the acute symptoms have subsided the meatus may be cleansed and dried and a small amount of boric acid applied with a powder blower. Aristol may be used in the same manner. This dry treatment often gives excellent results. Care must be taken, however, that the perforation is not clogged with these powders, and if they cause pain they should be discontinued. When the membrane and canal remain sensative and pain continues, a 12 per cent. solution of carbolic acid in glycerine often gives relief. General treatment should be resorted to when needed. Care should be taken to protect the body from sudden changes of temperature. Since this disease is frequently the result of acute catarrh of the nose and throat, treatment should be addressed to the nasopharyngeal affection. Our attention must be directed toward removing any causes of recurring attacks, such as hypertrophies in the nasal chambers, adenoid growths and enlarged tonsils. Chronic Suppuration of the Middle Ear.-An acute suppuration not uncommonly results in a chronic suppuration of the middle ear. It is one of the commonest affections of the ear and is often regarded very lightly by the laity. It is not uncommon for the patient's life to pay the penalty of this neglect. The close relationship between the tympanic and cranial cavities will at once suggest to the mind of the physician the importance of prompt interference with the destructive ravages of a suppurative process. It does not tend towards resolution, but rather towards dissolution. The whole tympanic cavity is usually affected, a perforation in the drum head always exists, and in cases of long standing the opening is large enough to afford some view of the interior of the cavity. In long standing suppuration there sometimes occurs a shedding of epithelium of the middle ear, which takes on an epidermic character resembling skin rather than mucous membrane; the moisture present converts it into a putty like mass, and we have a cholesteatoma which often causes destruction and absorption of the bone with which it comes in contact. I exhibited a remarkable case of cholesteatoma before this society about February, 1901. The mass was as large as a hen's egg, the lateral sinus had been obliterated, and very extensive destruction of the adjacent bones had occurred. Occasionally the discharge is very scanty, not more than a drop or so a day; this dries in scales of yellow crusts on the walls of the canal. The loss of hearing varies from a scarcely appreciable degree to total deafness. Small granulations may form on the border of the perforation, or large cherry red masses may cover the inner wall. Polypi sometimes spring from the membrane and occupy the canal. Carious bone is to be sus pected whenever granulations or polypi exist. While many attacks may appear to get well, as long as the diseased condition remains just so long recurring attacks will succeed each other A slight exciting cause sets up another exacerbation of the existing inflammation. Mastoid suppuration is an offspring of middle ear inflammation. Treatment. The first object in treatment is absolute cleanliness. This is best accomplished by syringing with at least a quart of fluid; sterile water or a weak bichloride solution of about 1-6,000 answers very well. The fluid should be used warm and with as much force as can be comfortably borne, especially at the first cleansing, in order to remove all the discharges from the ear. Dry with cotton and dust gently with a powder blower a thin coating of boric acid or aristol. Later the dry treatment may be employed omitting the syringing, but absorbing the discharge with pellets of absorbent cotton. Where the odor of the discharge indicates dead bone, iodoform in fine powder often gives good results. Peroxide of hydrogen was very extensively employed, but the danger of mastoid complications is a serious objection to its use. Bishop's ear aspirator, resembling a double syringe, answers a useful purpose in aspirating the discharges from the middle ear. Alcohol, either alone or in combination with boric acid, may be employed in some cases with marked advantage. Cases. The following brief reports represent different types of the disease. 1.-J. A., aged 10, was examined January 30, 1902. Patient had experienced slight pains in both ears for one or two days. Left ear had been very painful since morning. Inspection of right membrane showed some redness. The left was red and slightly swollen. Did a paracentesis of this membrane under cocaine anaesthesia. There was free hemorrhage, apparently free from pus. The ear improved rapidly with little. or no complaint of patient afterward. Five days later was called to see patient at his house. He was suffering severe pain in right ear. Examination was not quite as satisfactory as at office on account of character of light; membrane was somewhat red, but could detect no swelling. A swelling of the posterior superior wall of canal, near the membrane, pointed to involvement of the mastoid. There was considerable tenderness over the bone with a very little oedema. Temperature 103 2-3°. Applied antiphlogistine over mastoid and ichthyol in meatus. Symptoms gradually improved and patient was comparatively comfortable, with a normal temperature, two or three days later. February 12, one week from time of mastoid involvement, the tenderness was disappearing from mastoid. 2.-M. A., age 9, consulted me April 15, 1901. Complained of severe pain in left ear of two days' standing. Examination showed lumen of canal filled with impacted cerumen. Tenderness over the mastoid. The ear was syringed with sterile water, and part of the cerumen removed; the remainder was removed the following day. The membrane was red and swollen. An incision gave vent to a little pus and blood. The usual remedies were employed, and after six weeks' time the patient was discharged cured, with very little impairment of hearing. 3.-R. H., aged 30, consulted me April 22, 1901. Patient's family history good. He had recently returned from the Southern states where he suffered with malaria, had lost weight and was rather anaemic. Had subacute pharyngitis and suppuration of right and middle ears of several days' duration. Was some tenderness over left mastoid. Patient's hearing had been failing for the past three weeks. Made an incision in the left membrane, as the perforation gave insufficient drainage. Patient was treated on general principles; was given tonics in addition to the local treatment of his ear. He improved very much. Owing to a death in the family, patient returned to his home in Idaho the last of May. He reported that he was still improving a few days later. June 14 I received word that the patient had suffered a relapse, and concluded from symptoms given that he had facial paralysis with a serious involvement of the mastoid. Examination of the patient on the 21st found the above opinion correct. He had lost flesh very rapidly, and it was found that the patient was suffering with an active tubercular involvement of the lungs, also a tubercular laryngitis. The ear and mastoid complication was probably of the same origin. I hesitated to do a mastoid operation, as the lung complication pointed to a fatal termination at a comparatively early date. The temperature reached 1041⁄2 with symptoms of infection on the 23d, and on the following morning I operated on the mastoid. The antrum and cells were filled with pus, and a large amount of diseased bone, extending to the mastoid tip, was removed. The patient stood the operation well, improved rapidly and left for home eleven days after the operation. The wound was healing rapidly when I received the last report some days after his arrival home. I learned that the patient subsequently died from the tubercular involvement of the lungs. 4.—G. R. S., aged 24, was referred to me September 10, 1901. Patient was here for his health. Tubercle was suspected, but its presence was not proven. Patient complained of dis charge from left ear, more or less constant since infancy. For the last three years there had been an offensive odor to the discharge. Examination showed a perforation in the posterior part of the membrane, involving about one-sixth of that structure. Abundant granulation tissue could be seen through the perforation. The ear was cleansed frequently, the granulations cauterized a number of times, and treated on general principles. The discharge slowly but gradually lessened and in two months it had almost ceased. Patient is rather susceptible to climatic changes, and upon taking cold he still has a slight irritation of the ear, with a very little moisture in the middle ear. While the case appears to be practically cured, the tissues still remaining in a susceptible condition, however, such that they might easily become inflamed, yet a positive opinion as to cure or resolution could only be given after the lapse of a considerable time. ETHICS.* Ethics Treats of Right Conduct and Character. Medical Ethics Treats of the Physician's Duty to His Patients, the Public and Himself. By W. J. ROTHWELL, M.D., Professor of Medicine, Gross Medical College, The statement is often made that gentlemen do not need. a code of ethics for their guidance, since every real gentleman adopts the golden rule as the measure and guide of his conduct. But human judgment is fallible, and, therefore, the inherent right of private opinion free from the restraint of some generally accepted authority cannot be maintained either in public or private life. Two persons may differ in opinion upon any debatable question, but neither has the right to use phy *Read before the Graduating Class of Gross Medical College, May 15, 1902. |