any part of the upper respiratory tract. Cold winds striking the ear, bathing, getting wet, pouring or sniffing cold fluid into the nose, and the entrance of soap and water into the auditory meatus are frequently responsible for this affection. It not unusually follows the introduction of fluids into the middle ear through the eustachian tube. The presence of pus in any locality depends upon a necrotic process of adjacent tissues, and the organism producing this must possess a certain amount of virulence. One of the most common causes of suppuration of the middle ear is some acute, infectious disease, scarlatina and measles being the most frequent, although it often follows la grippe, pneumonia and other diseases. During the epidemic of la grippe of 1891, I observed a large number of cases of this affection. In these cases of suppuration, there is perhaps usually an invasion of the middle ear by micro-organisms through the eustachian tube; in some cases they may gain entrance through a perforation in the drum head. Bezold found the diplococcus pneumonia in suppuration of the middle ear in pneumonia. In acute suppuration streptococci or pneumococci are usually found followed by the staphylococci pyogenes.

The first stage of the process consists of a hyperaemia. of the membrame of the middle ear, which may be seen through the translucent drum head. This period of congestion is followed rapidly by a transudation of the fluid elements of the blood, and this is followed by necrosis, the tissues breaking down with the formation of pus. The drum head bulges from the presence of the accumulated fluids, becomes softened and finally ruptures. The whole tympanic cavity becomes involved, and the purulent fluid may find its way into the mastoid antrum and cells. Sometimes, owing to the swelling of the soft parts, there is little or no communication between the upper part of the middle ear and the rest of the cavity. This may occasion a very marked bulging of the upper part of the membrane-the membrana flaccida. Dench mentions a case in which this bulging was so extensive that the membrane protruded from the meatus and might easily have been mistaken for a polypus. Occasionally the pus will burrow the entire length of the meatus, passing between the cartilage and bone, dissecting up the soft parts and appearing in the post-auricular region as a soft fluctuating swelling. This is more frequently seen in children, where the soft tissues are less firmly attached to the parts beneath. Involvement of the mastoid cells nearly always occurs in these cases,

Infection of the intracranial structures may take place through necrosis of the squamous portion of the bone.

Symptomatology.-Usually, in an acute purulent otitis, a severe, deep seated pain comes on suddenly and increases in intensity until it is almost unbearable. Attending this is a decided elevation of temperature, ranging from 101 to 103 degrees; headache, constipation, and in children delirium and convulsions frequently occur. In adults the pain is usually not so severe. The pain is more or less intermittent and is generally more severe during the evening and night and is increased by coughing and swallowing. The affection is often accompanied by subjective sensations of hearing, such as ringing, roaring or hammering sounds. Hearing is more or less affected in the early stage to a slight degree, which becomes more marked as the exudation appears.

Course and Issue.-The course of acute suppuration of the middle ear depends principally on its cause, on the intensity of the process, on the constitution of the patient, and on the external circumstances. Perforation of the membrane often occurs on the third or fourth day, although it may take place in a few hours, or in protracted inflammations sometimes only after two or three weeks. When the pressure has been relieved by an incision or a perforation and the pain is much less severe, a decrease of the inflammation may be inferred. The suppuration often lasts from ten to twenty days, although in some cases the discharge may cease in two or three days and in others may continue for a number of weeks. After the perforation is closed, its site is usually indicated by a slight depressed cicatrix, although sometimes this cannot be distinguished and no trace of a past inflammatory process is observable on the membrane. In some cases cicatrices, calcareous deposits, opacities and partial atrophies result, which may or may not occasion a disturbance of hearing. An irregular protracted course often occurs from scarlatina, la grippe and in cachectic persons. These cases are often associated with involvement of the mastoid, where the perforation has closed before the suppuration ceased.

The results of acute purulent inflammation of the middle

ear are:

I-Cure, with the hearing completely restored.

2. Transition of the purulent inflammation into serousmucous catarrh.

3-Permanent disturbance of hearing, due to connective tissue adhesion in the tympanic cavity or in consequence of extensive losses of the drum head, with or without destructive changes in the ossicles.

4. Inflammation of the mastoid cells. This is frequent in children, and the perforation of the abscess often takes place externally with exfoliation of a necrotic portion of the bone.

5.-Death may occur from pyaemia, meningitis or cerebral

abscess.

6. Acute purulent inflammation may result in chronic purulent inflammation of the middle ear.

Diagnosis. It is not always possible to make the differential diagnosis between acute purulent inflammation of the middle ear and an acute inflammation of the middle ear that has not resulted in the formation of pus. After perforation has taken place the discharge may be seen in the meatus; or if very scanty, by inspection of the drum head. The perforation may usually be seen after merely cleansing the meatus and drum head, and after inflating the middle ear. In children an examination of the membrane is more difficult. The perforation is rarely visible on account of the great swelling and narrowing of the external meatus and the discharge of the secretion. A diagnosis between a purulent inflammation of the middle ear and a purulent inflammation of the meatus can generally be made by inflation of the middle ear by Politzer's bag. In the former case pus will be forced into the meatus. If the secretion is scant the auscultation tube may be used when the sound of a perforation is very apparent. A localized swelling of the canal, indicative of mastoid involvement, is situated upon the posterosuperior wall of the meatus close to the drum membrane. Tenderness, upon deep pressure, over the mastoid is an indication. that the bone is involved, while tenderness on pressure about the ear around the fibrocartilaginous portion of the meatus, points to a circumscribed external otitis of a simple character.

Prognosis. After the formation of pus and its evacuation, the perforation may heal and the parts restored to a normal condition. This termination is rare, however, as a destruction of the membrane over a greater or less area may be expected. Large cicatrices of the drum head may exist; cicatricial tissue causing more or less adhesion of the ossicles is not uncommon. When the membrane is mostly destroyed a dry, glazed condition of the internal wall of the middle ear may be observed.

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 1ather 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