EAR. 581 EAB. by tile iiiCroduelion of lluid through the Eusta- cliiau tube while batliing. In youug children the disear^e may appear suddenly at night, with a tem|)ei'ature ol lOJ^ to 104^, and a period of in- tense suH'ering, relieved bj' rupture of the drum, and pouring out of a little serous discharge that stains the pillow. Hise of temperature may con- tinue on the following day, together with deaf- ness and noises in the ear. As a rule, the cases terminate favorably without treatment. Sup- puration may occur involving the mastoid cells. The treatment i- directed lirst to relief of pain, by using a saline cathartic and an opiate. Local bloodletting by means of the artificial leech and the application of dry heat may abort an attack. If these measures fail to abort it. incision of the drum nnist be made, and the ear must be syr- inged, and dressed antiseptically. (3) Chrmiic catanhat ixfhniinialioii of Ihc middle ear is either of the hypertrophic or of the hyperplastic variety, in the hypertrophic variety there is a swelling of the lining membrane of the tym- panum due at first to chronic venous conges- tion, after which occurs hypertrophy of the ele- ments of the tissue lining the cavity. Fibrous layers appear and calcareous deposits may en- sue. The drum-membrane, the ossicles, the liga- ments and the walls of the Kustachian tubes share these changes. E.udate of scrum or sero- mucus collects in the cavity. Among the causes for this condition are repeated attacks of acute rhinitis, the presence of adenoid tissue in the vault of the pharynx, impairment of the gen- eral health, and the abuse of alcohol. The results are impaired hearing, whistling or buzzing or crackling noises in the ear. and occasional neu- ralgic pains, especially upon swallowing. Entire recovery can never be promised in these cases, but treatment by the aural surgeon, of a tech- nical and intricate nature, may cause vast im- provement, and avert total deafness. Chronic hyperplastic otitis media may develop from the hypertrophic form, and is characterized by an appearance of firm and fibrous new tissue, di- minished secretion, thickening of the walls of the supplying blood vessels, with a resulting sclero- sis. The symptoms resemble closely those of the hypertrophic variety, with (he addition of gid- diness in the early stages and a marked neur- asthenic or even melancholic condition, due part- ly to the temperamental state which invited the attack, partly to the fatigue of the higher cerebral centres resulting from repeated efforts to hear conversation. The prognosis for recovery is very grave, and the disease is less amenable to treatment than any other aural trouble. Treat- ment is directed by the aural surgeon toward the relief of the rigidity of the ossicular chain, by Inflation, exercise of the tubal muscles, the use of the Eustachian bougie, and of the myringotome and several operative procedures. Ilydrohromic acid or pilocarpine may be desirable for internal use. (41 Aoilr purulent otitis media most fre- quently follows an infectious disease, such as scarlatina. In qrippe, smallpox, cerebrospinal meningitis, pneumonia, etc. Pus forms behind the drum-head and may dissect its way into the neighboring soft parts or may invade the mas- toid. The prominent svanptoms are very severe pain deep within the ear. a temperature of 101° or 10:!°, severe general headache, and irreat de- pression. Invasion of a sinus may ensue, and pvirmia may result, accompanied by a higher temperature, delirium, convulsions, and paral- ysis. Immediate and vigorous operative meas- ures employed by an aural surgeon constitute the only treatment. (5) t'hroiiic purulent otitis media occurs as a sequel to the acute form, and, like it, is due to tissue necrosis. Discharge from the ear is the only prominent symptom, and one which should always suggest the necessity for competent medical advice. (0) Otitis media purulenia residua is a term applied to a class ot cases in which a former purulent inllamnuition has resulted in a permanent destruction of some of the tympanic structures. It may be either acute or chronic. The aural .surgeon alone can dillcrcutiatc this condition and advise regarding the antiseptic irrigation necessary or the re- moval of dead bone which may have become im- perative. Di.SE.^sKs OF THK Mastoid Prockss. Inllam- niation of this process may result from extension of a similar process from the middle ear. A chronic suppurative otitis nu'dia is the most fre- quent cause of acute mastoiditis. It may follow exposure to cold, a traumatism, or general tuber- cular or syphilitic infection. A destruction of the osseous tissue results. The most prominent symptom is intense pain over the mastoid bone, especially at night, a temperature of 99.5° to 101. .5°, difticulty in moving the head from side to side, and tenderness upon deep pressure over the tip of the mastoid. But slight constitutional disturbance is present. Involvement of a venous sinus with the production of an infectious thrombus may occur: emboli may develop and lodge in various viscera : dilTuse meningitis may complicate the disease, with resulting paralysis"; or the rarer cerebral abscess may follow. The diagnosis of mastoid disease is a matter of diffi- culty for any but an expert observer, although two signs are very reliable. These are. local tenderness upon deep pressure over the mastoid region : and a depression or sagging of the supero-posterior wall of the canal, close to the tympanic ring. Besides these signs, a localized tumefaction of the postero-sujierior canal wall (if it occur) is very indicative of mastoid in- volvement. Many other symptoms present them- selves, similar to those enumerated in the con- sideration of other diseases afllicting the car. The prognosis is always grave. The treatment consists in rest in bed, lluid diet, catharsis, ex- tensive incision of the drum-membrane, if .seen early, together with irrigation of the canal and the employment of the l.eiter coil, by which cold is applied to the whole mastoi<l portion of the temporal bone. Certain drugs are given to re- lieve pain. After 48 hours have passed without amelioration, operative interference is necessary. In such a case, the surgeon makes an incision through the soft parts back of the ear. commenc- ing over the middle of the mastoid insertion of the sternocleidomastoid muscle, about one-half inch below the tip of the mastoid process, cutting upward and forward close to the line of inser- tion of the auricle and following this line to a point directly above the meatus. This incision is carried down to the bone, and the soft parts are retracted, and the i)eriosteuni is raised from the bone. With nuillet and chisel an opening is made through the cortex into the mastoid cells, and all softened hone-tissue is removed with the sharp spoon. The mastoid antrum is entered and the entire pneumatic structure of the mas-
