the catheter which I think of sufficient importance to mention. While the patient is holding the catheter in the proper position, I apply to its extremity the soft rubber tube that is connected with my warm spray producer (Fig. 2), and allow the air and spray to pass into the catheter, but without touching it. Certainly, much of the air thus thrown into the catheter comes back, but I use sufficient pressure to cause full inflation of the middle ear. By so doing the inflation can be accomplished with the least possible injury to the mouth of the Eustachian tube.

I always spray the nasal and pharyngo-nasal cavities before inflating the middle ear, that the mucous membrane may be thoroughly cleansed, thus preventing the possibility of blowing secretion into the Eustachian tube or tympanum in the act of inflation. I use this warm spray producer, principally on children, without the Eustachian catheter, simply inserting it into one nostril while the patient closes the other nasal opening and repeats the word "what," and holding on to the "t," which prolongs the compressing effect of the operation. In this way warm air and spray of vaseline are forced into the Eustachian tube.

POLITZER'S METHOD OF INFLATION.

Dr. Adam Politzer, of Vienna, deserves and no doubt receives the sincere thanks of the medical profession of the entire world for giving us his method of inflating the middle ear. It has prevented the death of hundreds, and the deafness of thousands, every year since its promulgation. It is nearly impossible to overestimate the benefit derived from its discovery.

FIG. 3.-Illustrating the degree of compression of the ruober bulb to inflate the Eustachian tubes. The compression of the bulb (2 by 21⁄2 inches) to the extent of one-half of its diameter is all that is required.

His manner of inflation is to direct the patient to swallow a little water, and during the act of deglutition to force air from a soft rubber bulb (Fig. 3), through one of the patient's nostrils, the other nostril being closed. As the avenue down the throat is closed by the soft palate during deglutition, the air must enter the Eustachian tubes and thence into the middle ears.

The nozzle of the inflator should be large enough to completely fill the nostril (Fig. 4), and the opening through it should be so large that the air will enter suddenly in a gust and not in a small continuous stream.

If the compression of the rubber bulbs be continued during the act of swallowing, air will be forced into the tympanum cavity, not because deglutition

performs the office of opening the Eustachian tube, but because this act causes certain muscles to cut off the escape of the compressed air by way of the fauces. As the closure of both nostrils prevents its escape through those passages, it must go through the Eustachian tube, though sometimes it passes through the lachrymal canals also.

FIG. 4. Glass nasal tube (half size) for inflating the Eustachian tubes through one of the nasal passages.

It seems to me that this accounts sufficiently for the escape of the condensed air from the nasal cavities through the Eustachian tubes into the middle ears; but all works on the ear that I have examined seem to be impressed with the necessity of accounting for the entrance of the air into the middle ear by other means than by pressure alone, i.e.: by the levator and tensor palati muscles opening the tubes at the same instant that deglutition is performed, this opening giving the air an opportunity to pass through to the tympanum. I am well aware that I am contradicting high authority when I assert, as I most respectfully do, that the relation of these muscles to this canal in the healthy subject is such that they cannot open the passage to the middle ear, and that it has never been proved that they do. It is by no means a difficult undertaking to demonstrate that these canals are never open in the healthy subject, that is, using the word open as it is used by Toynbee, Tröltsch, Roosa, Hinton, Dalby, Knapp, Turnbull, Herman, Foster and others.

That the Eustachian tubes are always permeable to air in the healthy individual is true; but that they are ever so open that air may freely enter and leave the middle ear during deglutition, or any other act I know cannot be proved. I know that I stand alone in this.

That deglutition closes the mouth of each Eustachian tube may be demonstrated on individuals who have lost the septum nasi.

This demonstration I have frequently made on quite a number of patients under my care. To make the observation I passed a reflector (Fig. 5) through the nasal passage, reaching to the posterior wall of the pharyngo-nasal cavity. On this reflector I directed a strong light, which illuminated the parts under observation so perfectly that their image was reflected to my eye distinctly. I could see the muscles acting on the organs under inspection during the various motions of the parts, which were made by the patient at my request. I thus made inspections during deglutition both of solids and fluids, during vocalization, and forced and natural respiration. During deglutition, the soft palate was pushed back against the posterior wall of the pharyngo-nasal cavities by the alimentary bolus; it then ascended until its upper surface closed and covered the mouth of each Eustachian tube. These observations I made a number of years ago, and recorded them in the St. Louis Medical and Surgical Journal under the head of "Functions of the Uvula." During the act of phonating, the sounds that pass through the mouth alone, the soft palate was raised, and a portion of its lower border was pressed against the posterior wall

of the pharynx. No sound or combination of sounds that any of the patients could make caused the velum to rise as high as it did during deglutition, and no effort on their part, but the momentary one of swallowing, closed and covered the mouth of each Eustachian tube.

FIG. 5.-Antero-posterior section of the head through nasal passages, showing the position of the mirror reflecting the upper surface of the soft palate, base of the tongue, epiglottis and vocal cords. E, t, mouth of the left Eustachian tube; R, reflector introduced through the left nostril; S, P, soft palate; U, uvula; Ep, epiglottis.

These facts are within the reach of any one to demonstrate on any individual who has one large, straight nasal passage. Place such a person before the window and allow the sunlight to fall into the open nostril; let him make any sound or combination of sounds, and it will readily be seen that, while so doing, he is unable to cause the velum to cover the Eustachian tubes; but request him to swallow a little saliva, and then the velum will instantly raise and completely hide from view these openings. This prepares the way for the consideration of Gruber's modification of Politzer's method.

GRUBER'S MODIFICATION OF POLITZER'S METHOD.

As it is a fact that during deglutition the velum rises high enough to cover the mouths of the Eustachian tubes, and that no sound that the patient can make will cause the velum to rise as high as the tubes, we can readily see the advantage that Gruber's modification has over Politzer's. I have had a large number of patients claim that more air passes into the middle ear during inflation by Gruber's phonation method than during inflation by Politzer's deglutition method. If this is so, it is another proof that the Eustachian tubes are not opened during the act of deglutition, as asserted by every auth or on otology. Gruber's modification consists in preventing the air from passing into the fauces, not by deglu

tition, as done by Politzer, but by directing the patient to pronounce the word "hick" forcibly, which completely closes the passage leading from the pharyngonasal cavity to the fauces.

In the Monatschrift für Ohrenheilkunde for October, 1875, we find his method detailed. He advises that the patient, whose middle ears are to be inflated, should pronounce the word "hick" in a forcible manner, just as the surgeon in the act of compressing the India rubber air bulb. The effort to pronounce this word plainly, forcibly and distinctly, causes the tongue to press the velum upward and backward against the posterior wall of the pharynx, and thus, as in deglutition, cut off the communication between the pharyngo-nasal cavity and the fauces. But, as before stated, the pronunciation of the word "hick" does not cause the velum to rise so high that it will close or cover the Eustachian tubes, whereas deglutition does both, nor does the act of phonation call into play either of the muscles connected with the Eustachian tubes.

When water is swallowed the velum closes both the tubes, and thus retains the condensed air above them, nor can this air enter the mouths of the tubes until the soft palate has descended far enough to uncover them; then the air, as it becomes rarefied by the falling velum, enters. When the word "hick" is pronounced the mouths of both the tubes, not being closed or covered, are ready to allow the air to be forced into them at once; and it really enters them with more force than during deglutition, and, as I said, without the aid of the tensor or levator palati muscles to open the way into the middle ears. There is also more time for the air to pass into the Eustachian canals, for the reason that a longer time may be given to pronouncing the "hick" than the time that is occupied in swallowing some water, as it is only in the last portion of this act that inflation can take place, whereas the patient can "hang on" to the "k" of "hick" comparatively indefinitely.

During the first year I used this method (1876) I made frequent comparative trials upon the same patient, trying successively the deglutition and then the phonation method. I inflated the middle ears of several patients who had perforation of the membrana tympani by means of my warm spray producer (Fig. 2), an instrument which throws a steady stream of spray and warm air at a uniform pressure. The nozzle of the instrument was inserted into one nostril, the other being closed, by the patient. In the ear, having a perforated drum-head, I inserted a manometer. By it I could very accurately observe the passage of air into the middle ear, and through the perforation of the membrane. It was quite manifest, both to the patient and myself, that the liquid in the manometer was moved far less by inflation, during the deglutition method, than it was during the pronunciation of the word "hick." With one patient, during deglutition, only two small bubbles of air were forced into the cup of the manometer; while in inflation during pronunciation of the word "hick," the patient retaining the tongue in such a position as to maintain a continued closure of the pharyngo-nasal cavity: very nearly all the fluid was blown abruptly out of the cup, so great was the rush of air through the Eustachian tubes into the tympanum, and out of the perforation of the drum-head and external auditory meatus, and yet no muscular effort was made to open the tubes.

During these experiments the spray from the instrument was thrown with the same degree of force in each case. Now, it is manifest that if the Eustachian tube was opened by or during the act of deglutition, as contended by authors of otology, the air should have passed through the Eustachian tube into the middle ear, and out through the manometer with far greater force than it did while pronouncing the word "hick," but the opposite is the fact.

A very important advantage that inflation during phonation has over inflation during deglutition is that the pressure on the middle ear may be continued during quite a number of seconds. This continued pressure may usually be maintained indefinitely, almost, by the use of the catheter, especially on adults; but we more frequently desire a continued pressure on the ear of a deaf child on whom it is difficult to use the catheter. Then, too, a child would repeat the word "hick" a half dozen times, while it would not be willing or able to swallow as many mouthfuls of water.

There are times when the middle ear cannot be inflated either by Politzer's or Gruber's method without causing a painful sensation in the other ear. In such a case, measures must be adopted that will force the air into the ear that is desired, and leave the other undisturbed. This unilateral inflation is usually accomplished by the catheter, but since 1872 I have adopted a measure that prevents the pain from inflation, and obviates the use of this instrument in all cases of this kind, in both old and young, and is as follows:

I direct the patient to close the auditory meatus of the ear that will be painfully affected by the inflation, by pressure upon the tragus with the forefinger, when inflation can be performed without the least pain to the ear so closed. This prevents the outward movement of the drum-head, which is the cause of the pain, by condensing to a considerable degree the air on the external side of the membrana tympani.

I have frequently observed that the hearing of my young patients is very greatly increased by the first puff of air forced into the middle ear. Also, that the patients in whom the greatest improvement in hearing is made are those in whom the secretion in the Eustachian tube is so abundant that in a short time the hearing will rapidly pass away; but if inflation be repeated in ten or fifteeen minutes afterwards, the hearing is again restored. Six years ago (1878) I treated a young patient, whom I retained in the office nearly two hours at each visit, making an inflation once in every ten or fifteen minutes. In young patients, the secretion closes the Eustachian tube, and a part of it is driven into the middle ear by the first inflation. It soon accumulates again, and requires another removal. If the inflation is not frequently repeated, the recovery of such a case will be greatly retarded; while at the same time, it is of the utmost importance that the catarrhal inflammation of the mucous membrane of the tube should be subdued as speedily as possible.

With older patients, chronic catarrh causes the flow of secretion to lodge in the Eustachian tubes, which frequently, instead of closing the passage, causes the tubes to remain too open, allowing too much air to enter the middle ear. This condition is denominated patency of the Eustachian tubes. The closure of the tubes from the accumulation of mucus happens most frequently to the