Chronic Catarrh Of The Middle Ear | Operating Microscopes

Chronic Catarrh Of The Middle Ear
By EDWARD B. DENCH, PH.B., M.D.,
OF NEW YORK CITY.

THE term chronic catarrh has, in my opinion, led to a very general mis¬understanding among the medical profession in regard to the changes which take place in the middle ear in the disease under consideration. It would be much better to designate this affection as chronic non suppurative inflammation of the middle ear. The word catarrh is so universally associated with some affection of the upper air tract, that both the profession and the laity have come to look upon a chronic catarrhal otitis media as the result of an extension of an inflammatory process from the nose and aso pharynx into the tympanum by contiguity of structure. Catarrh is not a disease, but a symptom and from its derivation means a discharge. It may, therefore, result from various local lesions, and the idea. so commonly entertained that catarrhal inflammation of the middle ear is always due to the extension of an inflammatory process from the nose or naso pharynx is entirely unwarranted. The influence exerted by any affection of the nose or naso pharynx is usually purely mechanical 'thus, in the case of adenoid vegetations within the naso¬ pharynx, the middle ear may suffer either from the direct pressure of the lymphatic tissue upon the mouth of the Eustachian tubes, causing a rarefaction of the air within the tympanum; or this lymphatic tissue may interfere with the return circulation from the tympanum, thus causing a dilatation of the veins within this cavit y, and consequent congestion of the lining mem¬brane. The obstructive lesions of the nose and naso pharynx cause chronic middle ear disease chiefly through their influence upon the tympanic blood current. Etiology. Chronic Don suppurative inflammation of the tympanum may follow an acute inflammation of the middle ear, or may be the result of repeated mild attacks of acute congestion of the parts, each successive attack slightly impairing the function of the organ. On the other hand, the disease may be so insidiously progressive from its beginning as to give no symptoms until it has existed for many years.

Heredity is supposed to be an important etiological factor. From my own observation, I am inclined to attach less importance to heredity than do most writers. It is true that we often find impaired bearing in successive generations of the same family. When we examine these cases, however, we not infrequently learn that the impairment in bearing has Dot been due to similar middle ear conditions. The history is an unsafe guide in determining the etiological importance of heredity. The patient simply remembers that other members of the family have suffered from an affliction similar to his own, but can naturally give no information as to the nature of the local lesion. It would be absurd to suppose that a suppurative otitis media, causing impairment of bearing in one member of the family, should be at all responsible for interference with audition in successive generations. My own belief is that certain conditions of the nose and naso pharynx, such as enlargement of the pharyngeal tonsil, relaxation of the turbinal tissue, enlargement of the faucial tonsils, etc., are hereditary. Any of these conditions predispose to inflammation of the middle ear; yet, in many instances, they exist without producing this result.

Occupation exerts an important influence, in that those who are obliged to endure exposure to sudden and severe changes in the weather are more commonly affected than those whose vocation enables them to guard against such unfavorable conditions. For this reason we find that the disease is more common in males than in females.

The various general diatheses, such as the rheumatic or gouty diathesis, can scarcely be looked upon as influencing the occurrence of the affection. The habits of life are factors, however, in producing disease. The abuse of alcohol or tobacco, prolonged mental or physical exertion, or, in fact, anything which tends to lower the general condition, may act indirectly as a cause for the disease under consideration. In certain slowly progressive cases the local affection seems to be due to interference with the trophic nerve supply of the middle ear. This causes impairment in nutrition of the tissues, and certain structural changes follow which lead to either a perversion or impairment of function.

As before stated, a large proportion of cases are associated with some obstructive lesion of the upper air tract. This is particularly true where the chronic process follows repeated attacks of acute inflammation.

Of these local causes, the most important is probably enlargement of the pharyngeal tonsil. Enlargement of the faucial tonsils alone is seldom responsible for middle ear involvement. As enlargement of the feudal tonsils is almost invariably accompanied by a similar condition of the pharyngeal tonsil, the etiological importance of the former can hardly be determined with certainty.

Affections of the nasal cavities, such as hypertrophic rhinitis, nasal polypi, deformities of the nasal septum, etc., act essentially in the same way as does enlargement of the pharyngeal tonsil. These conditions either cause a rarefaction of the air within the tympanum, or interfere with the blood supply directly.

In atrophic rhinitis I am inclined to believe that the process within the middle ear is a simple concomitant of the nasal disease, and not a sequel to it. Atrophic rhinitis depends upon impaired nutrition of the lining membrane of the nasal chambers. A similar condition in the middle ear would be more probably due to a cause similar to that producing the nasal lesion than to this local disorder itself.

Pathology. Non suppurative inflammation of the middle ear may be either hypertrophic or hyperplastic in character. By the hyperplastic form I mean a condition ordinarily known as sclerosis of the middle ear, which may occur either as an idiopathic affection or as the result of a preceding hypertrophic condition.

Hypertrophic Inflammation. The mucous membrane within the tympanum is swollen, the blood supply is increased, and at length, actual tissue hypertropbv occurs. The Eustachian tube, forming as it does a portion of the middle' ear, participates in these changes. The mucous membrane is edematous, and the lumen of the tube is diminished in caliber. In the earlier stages the membrane of the tube is simply swollen, there being no tissue hypertrophy. This is particularly true of those cases which follow acute catarrhal otitis media, or where there have been recurrent attacks of acute congestion. If this engorgement continues, there is a development of new connective tissue within the walls of the tube, a no the passage gradually becomes more and more contracted. As a result, the intratympanic pressure is diminished, and the drum membrane and ossicular chain are forced inward toward the inner bony wall of the middle ear. The drum membrane is gradually stretched, so that when the caliber of the tube is restored, the drum membrane is much relaxed. Certain inflammatory changes take place in the middle ear, depending directly upon the displacement of the tympanic membrane and of the ossicular chain. The crowding of the ossicles against each other and against the internal tympanic wall aggravates the inflammatory process within the middle ear. As a result, adhesions are formed between the inner wall of the tympanum and the ossicular chain. The tensor tympani muscle gradually atrophies from disuse, the muscular fibers disappear and are replaced by connective tissue. After this has occurred, even if the Eustachian tube regains its normal caliber, the malposition of the ossicles and membrane persists owing to the rigidity of the atrophied tensor tympani. If the drum membrane is atrophic, it may bulge into the canal upon inflation beyond the plane of' the annulus, the ossicular chain remaining immovable.

We have spoken of the development of adhesions between certain portions of the ossicular chain and the adjoining bony walls of the middle ear. While this process may take place in any portion of the cavity, it occurs most frequently in the region of the oval window. The adhesions are most frequently found either between the posterior crus of the stapes and the corresponding wall of the oval niche or between the crura and inferior wall. Less frequently adhesions develop above the stapes or in front of it.

In certain instances the inflammatory process is exceedingly slow. It is in these cases that we often find a serous effusion in the tympanum, the engorged vessels unloading themselves of the fluid elements of the blood. Such an effusion may fill either the entire tympanic cavity or may be sacculated in the reduplications of the mucous membrane.

When the hypertrophic process changes to the hyperplastic variety, the cellular elements of the newly formed connective tissue are changed into dense fibrous tissue. In the Eustachian tube this transformation causes the stenosis to disappear, and the canal may become even abnormally wide. We frequently find, therefore, that although the tube is perfectly free, the bearing is greatly impaired. Where the process is hyperplastic from the first, the lining membrane of the middle car is gradually transformed into dense fibrous tissue.

Increased tension within the middle ear causes increased labyrinthine pressure; and in cases of long standing the perceptive portion of the auditory apparatus seldom escapes entirely.

The actual changes which take place within the labyrinth are sometimes the result of a chronic inflammatory process induced by this increased pressure. Where no pathological lesion can be demonstrated by microscopic examination, it seems that the function of the auditory nerve is to an extent ablated from disuse.

The disease in question is seldom unilateral, both ears, as a rule, being involved. Rarely, however, are both organs affected to the same extent, the disease usually beginning upon one side, and attacking the other at a later period. In the slowly progressive cases the disease may be so insidious as to entirely escape the patient's attention until the second organ is involved.

This secondary process seems to particularly affect the perceptive apparatus, although the middle ear does not entirely escape.

Symptoms. These depend upon the particular course pursued by the disease. Those cases following acute inflammation will naturally give a history of successive attacks of otalgia. In the slowly progressive cases, however, pain is not a prominent symptom, whether the disease is of the hypertrophic or hyperplastic variety. The symptom which first attracts the patient's notice is usually the appearance of subjective noises. These vary greatly in character in different cases. The patient will sometimes complain of a pulsation in the ear, synchronous with the cardiac pulsations. In other instances the noise may be described as a deep rumbling sound; again, it may be high pitched, and is often compared by the patient to the Sound of escaping steam. These noises may be constants or intermittent. They are usually exaggerated by physical or mental exertion, by a cold in the head, or by impairment of the general condition. Especially in the hyperplastic form of the disease the subjective noises may attract the attention of the patient before any defect in hearing is discovered; but sooner or later the impairment in audition will be recognized.

The hearing may be considerably impaired before the patient becomes conscious of the fact. For this reason, cases seldom present themselves in the very early stages of the disease, but only when the bearing has fallen considerably below the normal standard. Patients usually notice that, while in dialogue the hearing is fair ly perfect, they are unable to hear clearly when several are talking at the same time. Various sounds, such as the tick of a watch, the sound of the acoumeter, etc., may be perfectly heard, and yet the patient will be conscious of a certain deficiency in hearing, It often happens that the power of audition fluctuates greatly. At times the hearing will be excellent, while at other times the impairment will be quite pronounced. A common complaint is that the hearing becomes less acute whenever the patient has a '' cold in the head," and not infrequently that after each successive attack it remains less acute than before. It is not uncommon for the hearing to be greatly influenced by certain muscular movements ; thus, many hear less acutely while masticating the food than at other times. The acts of mastication and deglutition may also be accompanied by clicking or snapping sounds in the ear due to the separation of the walls of the Eustachian tube by the contraction of the palatal muscles.

Again, the hearing may vary with the position of the head. In the erect posture it may be perfectly normal, while on lying down or on tilting the head far back it may be greatly impaired. This symptom usually indicates the presence of fluia in the tympanic cavity. When the head is tilted backward, the fluid flows into the posterior portion of the tympanum and covers the oval and round windows, thus interfering with sound conduction. When, however, the head is bent forward or held erect, the fluid changes its position, leaving these regions free.

While vertigo is not a common symptom in these cases, it is occasionally met with, and may be very pronounced. This is particularly true where there is a collection of fluid in the tympanic cavity, the vertigo becoming very severe when the position of the head causes the fluid to cover the oval and round windows.

It must not be understood that the presence of fluid in the middle ear is the sole cause of tympanic vertigo. While dizziness is not a common symptom in these cases, it is by no means a rare one, and is sometimes exceedingly severe. The pressure upon the labyrinth, due to increased tension of the ossicular chain from the development of adhesions, is sufficient to cause the symptom. It may be said, in this connection, that the length of time which a vertigo has persisted is no indication that relief will not be obtained by relieving the middle ear condition. If examination by means of the tuningforks shows that the middle ear alone is involved, the results of treatment are usually satisfactory. It might appear that, in cases of long standing, relief of the increased labyrinthine pressure could be obtained by surgical measures only. This is not the case, however; and we often find that the restoration of the Eustachian tube to its normal caliber will immediately relieve the vertigo.

Most of these patients hear better in a noise than in a quiet place ; and, under the same conditions, the subjective noises are often less severe. This is explained by the fact that, when the ossicular chain is rigid, a certain amount of force is necessary to set it in vibration. When, however, the resistance has been overcome, very slight variations in this force are recognizable. For this reason, these patients usually hear better in a railroad train than does an individual with normal hearing (paracousis Willisii).

As the disease advances, the subjective noises, which at first have been distressing, may become less severe or disappear entirely. This is usually indicative of labyrinthine involvement, and is probably due to the fact that the portion of the perceptive apparatus concerned in the recognition of sounds of this particular character has been destroyed.

The appearance of tinuitus in the previously healthy ear should always be looked upon as a grave symptom. The sounds are generally of a high pitch, and probably depend upon certain changes in the cortical auditory area. As we know, each cortical auditory center receives fibers from both auditory nerves, but chiefly from the nerve of the opposite side. When the labyrinth of one side is involved as the result of chronic middle ear inflammation, the opposite cortical auditory center is affected, and, as the disease progresses, this cortical lesion interferes with the function of those fibers from the labyrinth of the same side, so that the disappearance of tinnitus in the ear first involved is usually followed by subjective noises in the opposite ear,

Diagnosis. Physical Examination. The changes visible upon speculum examination often give no indication of the degree of impairment of function. The drum membrane may appear fairly normal as regards position, color, luster, and structure, and yet the hearing may be very much impaired. On the other hand, fairly good hearing may exist where the drum membrane and ossicular chain give undoubted evidence of intratympanic inflammation. The most common change is displacement of the drum membrane inward. The handle of the malleus is fore shortened, and the short process is unduly prominent. The tympanic membrane itself may be thickened over certain are as and atrophic in other parts. A fore shortening of the handle of the malleus indicates displacement of the ossicular chain inward. In many cases this retraction is but slight, and yet extensive changes have taken place in the middle ear. Adhesions within the tympanic cavity may cause a rotation of the malleus upon its long axis, so that the manubrium may appear broader than normal. Here the direction of rotation is from behind forward. Rotation in the opposite direction is. accompanied by considerable retraction of the tympanic membrane, and the manubrium appears narrower than normal from the fact that the edge of the prismatic shaft is presented to view instead of the broader external border.

The presence of adhesions can be demonstrated by the use of the Siegle speculum. Examination with this instrument will show that the drum membrane and ossicular chain no longer move outward as a whole, when the air in the canal is exhausted. With each act of rarefaction, certain portions of tile drum membrane will be drawn outward, while the ossicular chain will either remain immovable, or more frequently the handle of the malleus will seem to rotate upon its long axis, motion outward being prevented by adhesions to the internal tympanic wall.

In the hyperplastic variety of the disease, atrophy of the tympanic membrane is commonly present. This may be so marked as to render the structures in the middle ear clearly visible. In the upper posterior quadrant the descending process of the incus, the posterior crus of the stapes, and the tendon of the stapedius muscle can frequently be recognized. Owing to the tenuity of the membrane it is often found to be relaxed as the result of sudden and violent changes in the intratympanic pressure.

Catheterization in the hypertrophic cases shows a narrowing of the Eustachian tube, most marked upon the more affected side. If there is fluid in the tympanum, its presence will be characterized by bubbling or crackling noises as the air enters the cavity. Extensive adhesions within the tympanum will occasionally produce creaking and strident sounds upon catheter inflation.

In the hyperplastic variety of the affection the Eustachian tube will be found abnormally wide, air entering the middle ear very freely. Sometimes one tube will be abnormally patent, while the other is narrow. This simply means that the process has advanced farther on one side than on the other, and that in the ear first affected the hypertropbic process has changed to the hyperplastic form.

Functional Examination. In investigating the hearing, we have to deal first, with quantitative, and, second, with qualitative, audition.

By quantitative audition we mean the distance at which any given sound, such as the tick of the watch, the click of the acoumeter, or the sound of the human voice, is beard, as compared with the distance at which the same sounds are perceived by the normal ear. Qualitative audition, on the other hand, is the perception of all sounds of the musical scale between the certain limits these limits being known as the lower tone limit and the upper tone limit. The lowest musical tone perceived by the human ear is one in which the sounding body makes sixteen double vibrations per second, and the highest musical note recognizable is one in which the vibrations are repeated not less than 32,500 times per second. All intermediate notes between these limits are perceived under normal conditions. Obstruction to sound conduction is characterized by the imperfect audition of particular notes in the musical scale, no matter whether this obstruction is located in the external auditory meatus or in the middle ear. The conducting mechanism is chiefly concerned in the transmission of the lower notes of the musical register, and in disease of the conducting apparatus hearing is first impaired for the lowest notes of the scale.

(1) Quantitative Examination. In the disease under discussion, tests will show a diminution in the hearing distance, both for sharp sounds, such as the watch or acoumeter, and for the human voice. Of these two means of testing, the human voice is always preferable, and for purposes of comparison the whisper should be used. The patient should not be allowed to become familiar with particular words or sentences, and, therefore, numbers of two figures are commonly employed in testing. In examining one ear the patient should be directed to close the other with the finger, and to close the eyes also, in order to avoid the possibility of lip reading. The patient is then requested to repeat whatever is whispered to him. In addition to numbers, it is also well to employ short sentences. The average distance at which tile various test numbers and sentences are heard should be taken as the whispering distance.

It will be found that these patients hear sharp sounds relatively better than they hear the human voice.

(2) Qualitative Examination. To determine the limits of audition, vibrating tuning forks of various pitch are held close to the ear to be tested, the opposite ear being closed with the finger. The lowest fork heard marks the lower tone limit. In chronic non suppurative otitis media the lower tone limit will always be elevated, the lowest notes of the scale not being perceived. It is noticed, however, that the elevation of the lower tone limit bears a certain relation to the whispering distance; that is, where tile whispering distance is much reduced, the lower tone limit will be very high; while, if the impairment in function is slight, the lower tone limit will be more nearly normal. The upper tone limit may be determined with a fair degree of accuracy by means of the Galton whistle. In cases where the labyrinth has not been involved secondarily, the upper tone limit will be normal; any appreciable reduction at this end of the scale is indicative of labyrinthine involvement. In uncomplicated cases bone conduction will be relatively or actually increased, and Ranne's test will be negative. The vibrating tuning fork Placed upon the forehead will be usually referred to the poorer ear, although this is not an invariable rule. This test is of less value in cases of long duration than in those that have existed for a shorter time. It is well known that in cases of long standing the bearing may be better upon the side first affected than upon the opposite side; in other words, the progress of the disease is much more rapid in the organ involved secondarily. In such cases, Weber's test might be negative; but would still indicate the side upon which the intratympanic changes were more marked.

Prognosis. The prognosis in these cases varies according to the age of the patient, the station in life, occupation, environment, and the duration of the disease. The prognosis is better in the hypertrophic than in tile hyperplastic variety. In the hypertrophic form the condition of the upper air passages is also an important factor in determining the course which the tympanic inflammation will pursue. Where the disease appears late in life the progress is much less rapid than where it affects children or young adults. The station in life is of importance, in that the disease will be less likely to advance in a patient so situated as to he able to guard against exposure to inclement weather, and to avail himself of the advantages of a favorable climate, than in one by whom these precautions cannot be taken. While I do Dot believe that it is possible to secure permanent improvement in these cases by a temporary change of residence, there can be no question that, if a patient can live permanently in a dry and equable climate, be will be able materially to retard or possibly to stop the progress of the disease.

The length of time that the disease has existed affects to a great extent the prognosis. If of long duration, certain structural changes have probably taken place in the tympanum which cannot be removed by treatment. On the other hand, in the. early stage of the disease, when structural changes are less marked, proper treatment may restore the parts to a more normal condition, and will at least stop the further progress of the inflammatory process.

The rapidity with which the affection has advanced must be considered in giving a prognosis. Where the progress has been rapid and both ears have become involved in a short time, a much less favorable opinion can be given than where the same changes have taken place only after many years. In women any increase in the symptoms at the time of the menopause always warrants a guarded prognosis.

The condition of the upper air passages exerts an important influence upon the progress of the disease within the middle ear. In many of these cases we find either hypertrophy of the turbinal tissues or a chronic inflammation of the naso pharyngeal mucous membrane. In the younger patients the pharyngeal vault is often filled with adenoid vegetations. All of these obstructive conditions tend to aggravate the pathological process within the tympanum ; and no treatment will be efficacious that does not include the relief of the upper air passages.

Hyperplastic otitis is but little influenced by nasal and naso pharyngeal conditions, and very little can be expected from treatment of the throat or nose. Most of these patients give little history of catarrhal trouble. It is quite possible that some pre existing condition of the nose or naso pharynx may have induced the aural affection, but in the atrophic stage this influence is no longer active.

Treatment. The treatment depends upon the local condition found on physical examination in connection with the information obtained by a careful functional examination. The measures to be employed are radically different in the hypertrophic and hyperplastic variety of the disease.

It must be borne in mind that the general 'condition influences the progress of any local inflammation. Therefore, the patient must be kept in the best possible general condition; excessive mental and physical exertion must be avoided, as well as indiscretions in diet, the abuse of alcohol, tobacco, etc. In many of these cases the aural symptoms are aggravated by colds; certain hygienic measures should be adopted, therefore, to render the patient less susceptible to sudden changes in temperature. To this end the daily use of the cold bath should be advised, as well as the complete protection of the body by woollen undergarments.

In the hypertrophic cases one of the first objects of treatment should be to relieve any obstructive lesion in the upper air passages. Adenoid growths in the naso pharynx should be removed by operation, and normal nasal respiration should be secured by the correction of nasal obstruction. I do not mean by this that slight deformities of the septum must be corrected by surgical interference. It is only where the abnormality prevents free respiration that surgical interference is necessary.

Regarding the treatment of the middle ear, we find in these hypertrophic cases that the Eustachian tube is narrow. This must be restored to its normal caliber, in order to secure the proper ventilation of the tympanum. While manv obtain satisfactory results by inflating with the Politzer bag, I freely confess that in my bands this instrument, as compared with the catheter, has been of little value in chronic cases. By inflation we not only restore the intratympanic pressure, but are able to medicate both the tube itself and the lining membrane of the tympanum by the introduction of various vapors. The current of air acts as a mechanical stimulant to the mucous membrane, both of the tube and tympanum, and this stimulating effect may be increased by the introduction of various vapors, a , of menthol, eucalyptol, camphor, benzoin, iodin, etc.

The introduction of stimulating vapors causes an increased flow of blood to the parts, thus favoring the absorption of any recent inflammatory deposits or relieving chronic congestion due to the lack of vascular tone. When any stimulating vapor is used, it is wise to inflate first with air, until the tube is fairly patent, and to then introduce the vapor. In this way comparatively little of the vapor escapes into the throat, and irritation of the air passages is avoided. The particular vapor to be used is largely a matter of individual preference. I have employed for a long time, with considerable success, the vapor given off by the following mixture:

A pledget of cotton saturated with this mixture is placed in the middleear vaporizer. This instrument enables the operator to inflate first with air and then with the vapor, without disturbing the catheter.

If the obstruction in the Eustachian tube is of long standing, it will scarcely yield to inflation alone, and mechanical dilatation by means of Eustachian bougies will be necessary. Bougies of celluloid, whalebone, cat¬gut, etc. are objectionable, as they cannot be rendered aseptic by boiling. They are also liable to break during the operation, thus leaving a foreign body in the Eustachian tube. For the last few years I have resorted to the following device: A piece of No. 5 piano wire, two or three inches longer than the Eustachian catheter, is selected, and at one extremity is bent so as to form a small hook about one sixteenth of an inch long. The book is then flattened upon the longer portion of the wire so that at this end the wire is doubled upon itself for a distance of about one sixteenth of an inch. The wire is then passed through the Eustachian catheter until this doubled portion protrudes beyond the tip of the instrument for the distance of an inch and a half. The other end of the wire is then bent at right angles as it leaves the conical portion of the catheter, so that its further passage through the instru¬ment is impossible. Both the catheter and the wire are boiled to render them aseptic. A little cotton is then wound tightly about the doubled extremity of this wire, which is then drawn backward into the catheter, so that the cotton¬ tipped end protrudes just beyond the mouth of the instrument. The catheter is then introduced into the mouth of the tube in the ordinary way, and the cotton tipped bougie is gradually passed through the Eustachian canal until it is felt to enter the tympanum. As the isthmus of the tube lies about an inch beyond the pharyngeal orifice, resistance is felt when the bougie has been introduced about an inch. This resistance is perfectly normal, and should remind the operator that he is approaching the tympanic cavity. A moderate amount of pressure forces the instrument through the bony portion of the tube and into the tympanum. As the Eustachian canal varies somewhat in length in different subjects, great care should be used in the final stage of the operation. If the wire is so bent that it cannot be introduced more than an inch and a half beyond the mouth of the catheter, it is practically impossible to do any damage. It is sometimes necessary to carry the instrument a little further, in order to be certain that it has entered the tympanum. If this operation is performed carefully, it is impossible to do any harm. The operator usually recognizes by the sense of touch that the bougie has entered the tympanum. Frequently the cotton tipped extremity of the bougie can be seen in the tympanic cavity, through the drum membrane, on speculum examination. The tip of the bougie, under these conditions, appears as a white, opaque object, just behind and a little below the short process of the malleus. Pressure upon the bougie causes the drum membrane to move slightly outward, as can be easily recognized by the observer.

One of the advantages of this device is that, when the cotton is tightly wound upon the wire and introduced into the tube, it absorbs a certain amount of moisture from the membrane, and thus becomes larger; an additional amount of dilatation is secured in this way. Another advantage is that there is but slight friction between the wire and the catheter, and any resistance to the passage of the instrument must certainly be due to an obstruction in the Eustachian canal.

It is frequently of advantage to saturate the cotton pledget with a solution of nitrate of silver of strength of from ten to sixty grains to the ounce. In this way the tube is medicated as well as subjected to mechanical stimulation. In hypertrophic cases of long standing, the careful use of the bougie is attended by the most gratifying results.

The injection of fluids into the middle ear through the Eustachian tube has been attended with doubtful benefit. Personally, I have no experience with this method of treatment. There is no reason why solutions should not be introduced into the middle ear in this manner, if both the solutions and the instruments are aseptic. It has always seemed to me to be more simple to medicate the middle ear directly through an opening in the drum membralle, rather than to inject the fluids through the tube.

When the tympanum contains fluid an attempt should first. be made to evacuate this by means of catheter inflation. During the procedure the patient's head should be flexed on the chest, and, at the same time, should be inclined toward the opposite side. The current of air entering the middle car will then displace the fluid and force it out through the Eustachian tube into the naso pharynx. The use of stimulating vapors in these cases is also of advantage in hastening the absorption of the effusion.

As the persistence of an effusion depends usually upon some obstructive lesion of the nose or naso pharynx, these parts must be put in the normal condition before permanent relief can be hoped for. If these measures fail, the fluid must be evacuated by incising the drum membrane. The incision should lie in the posterior segment of the tympanic membrane, close to its periphery, and should extend from below the tip of the handle of the malleus upward to the posterior fold. The term so often used, of “puncturing" the tympanic membrane to evacuate fluid, is responsible for many unsatisfactory results. A small opening allows but little of the fluid to escape, and does not empty the cavity. A free incision is necessary in order to secure the desired result. In "Performing this operation it is well also to incise the mucous membrane over the inner tympanic wall, thus depleting the engorged vessels and rendering recurrence less probable. Such incision is absolutely free from danger if the canal is sterilized before the operation, and if the instruments and the hands of the operator are aseptic. Moreover, the procedure cause , but very little pain if a sharp knife is used.

After incising the tympanic membrane, it is often wise to inflate by means of the catheter to completely evacuate the fluid; and in some cases, where the effusion is viscid; it is well to wash out the tympanic cavity, with normal salt solution, through the Eustachian catheter. The incision heals in from twenty four to thirty six hours if aseptic precautions have been observed. At the end of twenty four hours, if the margins of the incision have become agglutinated, it is well to guard against the accidental rupture of the freshly formed adhesions by means of a paper disk applied to the surface of the drum membrane so as to cover the line of incision. The disk need not be removed by the surgeon, as it will be discharged spontaneously by the outward growth of the epithelium covering the tympanic membrane. It may be removed, however, at any time by the use of the ear syringe.

A favorite plan of treatment in chronic catarrhal otitis media has been the systematic use of passive motion for the purpose of either breaking up or of stretching adhesions which have developed between the ossicles themselves or between these bonelets and the inner tympanic wall.

Lucael has met with considerable success in these cases by the use of the 11 pressure probe." The device consists of a small tube, through which a rod terminating in a cup like extremity passes. Within the tube is a small spiral spring pressing against the other end of this rod. The shaft of the instrument is introduced into the canal, and the cup shaped extremity is applied to the short process of the malleus. By a rapid to and fro motion of the instrument the short process is pressed inward and then allowed to spring outward, the amount of pressure being regulated by the tension of the spring. In this manner it is claimed that the adhesions within the tympanum are stretched, and that the function of the ear is, in manv cases, improved. I have had no experience with this method, and can, tfierefore, give no personal opinion as to its efficacy. The procedure is somewhat painful, and has. never seemed to me to be free from danger. This I believe to be especially true where the process within the middle ear is not quiescent. Any attempt to forcibly manipulate the ossicles must cause a certain amount of mechanical irritation, and, therefore, must aggravate the condition which it is intended to overcome. This same criticism applies, I think, to modifications of Lucae's method of massage, advocated by Lester' and by Garnault,' who employ a small electric motor for actuating the masseur.

Systematic massage of the ossicles by alternately condensing and rarefying the air within the external auditory meatus, either by the method of Hommel, by pressure in front of the tragus, or by the use of either the Delstanche masseur or the Siegle otoscope, has also been looked upon with much favor by some. Experience has not taught me that valuable results are obtained by these methods.

As the motions of the ossicular chain under the normal conditions are caused by aerial vibrations, it would seem reasonable that the most proper method of employing massage would be through the agency of some sounding body, and within the last few years various vibrometers, vibrophones, etc. have been devised. All instruments constructed for this purpose have, I think, been useless and worse. There is no question, however, that in certain cases the systematic exercise of the ear by means of the human voice may be of great benefit in improving the function of the organ, and the method has been successfully used by Urbantschitsch.' In employing this method it has been my practice to have an attendant read to the patient for a period of from five to fifteen minutes in a voice sufficiently loud to enable him to understand distinctly. Where the impairment of hearing is very marked the conversation tube may be used, although this should be avoided if possible. It is advantageous, in case the patient understands more than one language, to read in different languages on succeeding days, to accustom the patient to recognize sounds varying widely in character. Such a method is tedious, but is often attended with excellent results. It is particularly advantageous where the ear has been practically useless for a long time and has then improved somewhat from local treatment. Under these conditions the auditory nerve seems to have suffered from disuse, and, although perfectly healthy, requires a certain amount of education before it can again perform its function. Here, of course, the procedure is one not only of massage, but, to a certain extent, one of education, familiarizing the patient with the significance of imperfect auditory impressions conveyed to the cortical centers.

Intratympanic Operations. I have endeavored to detail briefly the various methods at our command for the treatment of these cases. When seen in the early stages, inflation, the use of the Eustachian bougie, and the treatment of the upper air passages often yield excellent results. We frequently, however, meet with cases in which all of these measures fail, the middle ear charges being so advanced as to render absorption of the new tissue impossible. The Eustachian canal is perfectly patent, the upper air passages are normal, and the patient is suffering either from the result of a previous inflammatory condition or from a profound trophic disturbance within the middle ear.

I am aware that I stand almost alone in advocating surgical interference in these cases. My opinion is the result of my own personal experience, which has, perhaps, been extensive enough to warrant the position which I take. Where other methods fail, and where careful functional ex amination shows that the perceptive mechanism is not greatly involved, I believe that it is always wise to do an exploratory tympanotomy. Cocain anesthesia suffices to render the procedure painless, and at the same time is free from the objections attending ether or chloroform narcosis. For purposes of exploration, the tympanic cavity is best entered in the posterior and upper quadrant. In order to gain access to the middle ear, a flap of the drum membrane should be reflected downward and forward, so as to allow inspection of the incudo stapedial joint and of the regions of the oval and round windows. When done under local anesthesia, the hearing can be tested at various stages during the operation, and if it improves the surgeon may complete the operation. On the other hand, if, after the stapes has been liberated by the division of adhesions in the oval niche and by disarticulation at the incudo stapedial joint, there is DO improvement in the bearing, the flap of the membrana tympani can be replaced and retained in position by means of a paper disk. Under aseptic precautions this operation is absolutely free from danger. If liberation of the stapes improves the hearing, the operator may proceed at once to remove the membrana tympani, malleus, and incus to secure permanent improvement. Excision of the two larger ossicles is performed with perfect ease under cocain anesthesia. I have not infrequently operated upon both ears in the same patient at different times. Had the operation been painful, the patient would scarcely have submitted to a second operation without general anesthesia.

One of the advantages of the procedure above mentioned is its value as a diagnostic measure. There are certain doubtful cases in which functional examination does not enable us to exclude labyrinthine involvement, and yet in which the condition in the middle ear seems to be sufficient to account for the functional impairment. An exploratory tympanotomy enables us to determine exactly how much improvement can be expected from removal of the drum membrane and of the two larger ossicles. If the exploratory operation gives negative results, the flap can be replaced leaving the ear in the same condition as before operation. We are then certain that the impairment of function is due to some lesion of the perceptive apparatus. We often find, however, that we have underestimated the effect produced by the middle ear lesion the hearing improving beyond our expectations after the stapes has been liberated. In these cases completion of the operation yields very gratifying results.

Middle ear inflammation upon one side usually leads to impairment of audition on the opposite side. We have to consider, therefore, not only the possible improvement in the ear operated upon, but also the effect of the procedure upon the opposite organ. From a number of my own cases I am convinced that the relief of increased tension in the conducting apparatus upon one side either checks or retards the involvement of the opposite o an, and in manv cases improves the ear not operated upon. I should attach no importance to these cases, had they not been so frequent and the fact confirmed by other observers, notably Urbantschitsch.

Operative procedures of this character have been fairly satisfactory in my own practice, and after stating plainly to the patient that improvement cannot be absolutely promised, but that an operation offers the only chance for improvement, and that in a large proportion of the cases this is obtained, I still continue to perform these operations. My own results under cocain anesthesia are as follows: of 64 cases operated upon, 32 were greatly improved, 24 moderately improved, and 8 unimproved. In three of the above cases in which no improvement followed the operation, 1 should say that I did an exploratory operation only. The functional examination had seemed to demonstrate that the labyrinth was seriously involved, and operation was undertaken only as a forlorn hope. Disarticulation at the incudo-stapedial joint and liberation of the stapes being followed by no improvement, the flap of tympanic membrane was replaced and the ear left in its original condition. In one instance, where functional examination also seemed to show extensive labyrinthine involvement, the hearing was notably improved, not only in the ear operated upon, but also in the opposite ear. The improvement in general audition was so noticeable as to be remarked upon by the patient's friends.

A certain number of cases have been operated upon under ether anesthesia, and the results have been reported in my recent work.' For the reasons already stated, I always prefer to operate under cocain anesthesia.

Concerning the efficacy of constitutional treatment in chronic catarrhal otitis little can be said. Measures for improving the general health of the patient will naturally suggest themselves to the medical attendant. Where the labyrinth has been involves secondarily, the internal administration of pilocarpin may be tried. The results, however, are much less satisfactory than in cases of primary labyrinthine disease. In neurasthenic patients general medication and attention to hygiene will often do much to improve defective audition. Here strychnin in large doses and long continued is particularly valuable. I ordinarily begin with 1/40 grain three times daily, and gradually increase the dose until the patient is taking 1/20 grain four times daily. A fact which is often lost sight of is the fatigue which impairment of hearing causes, the patient making every exertion and fixing his whole attention in order to overcome his affliction.

Certain drugs have been recommended for the relief of tinnitus. My own experience has been that all are usually unsatisfactory. We may except, perhaps, large doses of hydrochloric acid, which afford sometimes relief. Naturally, if the general condition of the patient indicates the necessity for certain medication, such medication may incidentally relieve the subjective noises; but where the general condition of the patient is normal, very little relief can be obtained by internal medication.

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