noid growths are responsible for a large percentage of cases of deafness in children, forgetfulness, inattention, mouthbreathing, snoring, night terrors, etc., and that in order to cure these conditions we must begin at the front of the nose and go back. Then only can we have any permanent results. If we begin at the throat it is uphill work and we accomplish nothing.

What Can We Do to Relieve Deafness Due to Chronic Middle-Ear Catarrh?

BY C. P. LINHART, M. D., COLUMBUS

Deafness due to chronic middle-ear catarrh is one of the common afflictions that come for relief to the busy practician. There is at best not a very encouraging outlook for this class of cases, but if we can do anything to stop the progress of the disease we may receive the commendation of the grateful patient.

Before beginning the routine treatment the primary cause of the difficulty should be removed. Very often there will be found a spur extending out from the septum blocking the way to the free passage of air through the nose, and interfering with the drainage; accompanying this deformity is sometimes found a deflection of the septum. The spur, if sufficient to cause trouble, should be removed and the deflection corrected. In cases in which there is hypertrophy of the turbinals they should be reduced by surgical or medical treatment.

In examining the nose and ears I have noticed that there was a congestion of the drum membrane corresponding to the side of the nose that was occluded, even when occlusion was only temporary from a congested turbinal. At times when the nose is occluded on one side the opposite ear will be found affected. In the latter case it would seem that the current of air passing freely through the unaffected side makes a whirlpool of air in the vault of the pharynx which cools and dries off one part and causes a congestion in another which eventually leads to a chronic

thickening of the mucous membrane and underlying tissue. When the way is made clear through the nose the mucous membrane covering the turbinals should be cleaned with some spray or douche every day until the secretion of the mucous glands becomes normal. This the patient can do at his home, coming to the physician two or three times a week, as is necessary, to receive applications of some medicated lotion, such as nitrate of silver 10 to 20 grains to an ounce, or menthol and camphor, each a dram to an ounce of iodin to stimulate the parts to their normal functions. It will be found that this preliminary treatment will greatly aid in clearing up the congestion in the Eustachian tube and middle ear, even if no other treatment is used.

Usually one ear becomes affected first, then after a time the other begins, and the progress of the disease in the second ear is much more rapid than the first. This is presumably on account of the nerve disturbance. This disturbance of the equilibrium of the auditory nerve facilitates the progress of the disease in the second ear. Often the patient does not know of his progressing deafness until the second ear becomes affected, and complains of deafness on this side when on examination the other ear will be found in a worse condition. When one ear is so deaf that it is of no practical use it should be treated the same as the other, for it is hard to improve one ear without improving the other.

For the treatment of the Eustachian tube and middle ear there is perhaps no better medication than an application by means of the air douche of a stimulating vapor from the combination mentioned above of menthol, camphor and iodin. This when done through the Eustachian catheter and Dench vaporizer, not only medicates the parts by the stimulating vapor, but acts as a massage, particularly in the middle ear, loosening the adhesions and tending to cause an absorption of the thickening of the mucous membrane in the tube and middle ear. In case there is difficulty in introducing the air through the Eustachian tube it has been my

custom, after a month's treatment, to open the tube by means of the electrolytic bougie as devised by Duel. Sometimes one application of the bougie will be found adequate to make the tube sufficiently patulous for the free entrance of air. It does more than this; it stimulates absorption and tones up the mucous membrane and surrounding tissues of the ear.

The progress in these cases is usually slow. Patients will need encouragement, tests with mechanical instruments ought to be made once a month, and the improvement noted so that the patient can see by the examination that he is making a gain, or at least is not losing anything. His friends who expect a great deal of a physician in a short time will tell him that he is not hearing any better, and he will require constant watching and encouragement. You all know that we who hear well, hear much better than we need to for ordinary conversation and that our hearing varies much from day to day; by hearing so well we do not notice this daily variation. These unfortunates are susceptible to every atmospheric change. When the air is damp and heavy the mucous membrane of the nose, Eustachian tubes and ears becomes thickened, it is then that their hearing is duller than usual, for at best they must give close attention to hear ordinary conversation. Then it is fair to presume that people do not talk with the same degree of loudness every day of their lives, so that if the speaker happens to be feeling indisposed his voice weakens and the unfortunate listener is blamed for not hearing so well when it is not his fault at all.

When the Eustachian tube is patulous and there is much thickening of the drum membrane, external massage by means of the Delstanche masseur may be used with benefit.

In some cases I have found, after six months or a year's constant treatment, that there comes a lull in the improvement. I then advise the patient to quit for three or

six months and then return, and usually find that after this rest the ears are susceptible to further improvement.

By sticking to these patients and encouraging them it is surprising how much benefit can be gotten out of some such routine work as is described above. Even when the hearing cannot be materially improved if the progress of the disease can be stopped a great deal of good will have been accomplished.

You all know that in deafness due to chronic middleear catarrh there comes a time with some people when without any treatment on the part of the physician the progress of the disease ceases. At times there is even an improvement in hearing. If this occurs without any special treatment on the part of the physician, surely it is reasonable to presume that the medication and treatment of this disease will stop its progress and hasten the period of improve

ment.

DISCUSSION

Dr John H. McCassey, Dayton: The Doctor has chosen for his paper one of the most difficult affections in the whole field of medicine with which we have to deal. The progress is slower and the clinical results fewer in the treatment of this condition than in almost any other. I· find in the treatment of the ear affections one of the best things to do is to put the nose and throat anatomically in as perfect condition as possible, for instance, removing any vestige of tonsils, adenoid growths or obstructions. I find that any harsh measures in meddling with the Eustachian tube is often attended with bad results, and for fear of doing more damage by the introduction of catheters, etc., setting up and intensifying the inflammation, I resort to these measures with great caution. As I said a few moments ago about four-fifths of all the cases of ear troubles are due to troubles in the nose and throat, and in the remedying of these conditions lies our great hope. When these cases come on at first the patient will come to you with the Eustachian tube partly occluded by temporary inflammatory conditions which give rise to an exclusion of air pressure from the inside, and they will complain of a heaviness or dulness in the ear. They will tell you that by put

ting a finger in the ear it causes this disagreeable feeling to disappear This is due to the fact that by so doing they exclude the air pressure from the outside, and this gives them relief. This is perhaps the reason why so many people with a little stricture of the Eustachian tube go about with a little piece of cotton in the ear, this serving to equalize the pressure of the air inside and outside the ear Now of course by using the Eustachian catheter you free the canal from any obstruction and thus give relief, and in this way bringing about a cure.

Dr B. F. Entrikin, Findlay: I have often seen ear troubles thoroughly disappear on cleaning out the nose and throat. I wish to ask this question: What method do you use in introducing your Eustachian electrode? I tried it on some of my patients and they would not stand it at all.

Dr John M. Ingersoll, Cleveland: The Doctor has outlined the treatment for these conditions of the ear very completely and concisely. He also mentioned a point which is very frequently overlooked, but one which should always be considered, that is, the variation of normal hearing. A little careful observation and testing will show that our hearing-power varies considerably and that the average individual may lose nearly one-third of his hearing-power before he notices that his hearing is less acute for conversation and ordinary sounds.

After this point is passed, the loss of acuteness becomes proportionately greater and the deafness seems to develop much more rapidly. I think that it is a good practice when patients come into the office complaining of any nasal trouble to test their hearing. I keep a record of such tests and if I find that the hearing is below normal I always tell them that sooner or later they are liable to have some ear trouble, and that they should have their hearing tested once or twice a year.

Referring to adenoid growths in this connection the chances for serious deafness are very great unless this condition is relieved. The most advantageous time to treat these conditions, just the same as in any other pathologic condition, is in the beginning. The earlier we can begin our treatment the better the results of that treatment will be.