It is impossible to foresee how mild or serious any case is going to prove; and without panicky fighting of shadows, it is only reason able to press home all due precautions. The patient is best in bed, especially if feverish, and all exposure and stimulating diet should be avoided. Constipation must be relieved, for straining of every sort is not only painful but increases the congestion.
With the opening, artificial or spontaneous, of the there is generally relief of the pain; yet this is almost sure to recur, especially at night, but with lessening severity, duration and frequency. The fever, which is commonly marked in children, declines and some of the lost sleep is made up. The tension within the drum-cavity is lessened by the escape of the "gathering" and obtains continued relief by the persistence of the discharge. This is thin and bloody at first, then thicker and prob ably stringy. Its amount is often surprising, so that hourly cleansing is needful, and it may excoriate the skin in and about the canal, call ing for protective ointments. The ideal treat ment is thoroughly to cleanse before cutting the drumhead and thereafter as frequently as the flow demands to change the sterile wicks of cotton in the canal. If these are prepared by the hundred, each wrapped in a waxed paper and the package of them baked, the patient can readily remove the moist plug and substitute a clean one without contaminating it. Practi cally, frequent syringing with boiled water at 110 F. or more and a clean soft-rubber bulb, better relieves the pain and cleanses the deeper parts of the canal. The heat can penetrate where the water cannot and is the best astrin gent and stimulant. After two or three weeks the discharge should cease, and another week or two should bring cure; but the cardinal fact in these cases is the infected character of the inflammation, which endangers serious destruc tion in the drum-cavity and adjacent more vital regions. Often worse than the destruction is the scarring which results from nature's effort at repair. An opening in the drumhead gener ally heals and may leave no visible scar; in an important minority of cases the edges are skinned over, preventing its closure and graft ing skin upon the mucous surfaces within.
Nature is prepared to sweep away fluid waste material in the drum-cavity, but skin-flakes forming there are difficult of removal; they tend to collect and by their presence excite more exaggerated scaling. Onion-like masses may thus form, constituting "cholesteatomal or pearly tumor, and these can do much dam age by their pressure as well as maintain or renew the suppuration. The bony walls and the little ear-bones may be destroyed by pres sure or decay; and while an exit may thus be made for the cholesteatoma-mass, it too often works inward instead of outward, dam aging the labyrinth and may carry the infective process into the brain-case. Just under the thin floor of the drum-cavity is the head of the jugular vein, its intracranial part is equally vulnerable just behind, and an even thinner roof alone protects the brain-membranes above, It is not surprising, then, that symptoms of brain-inflammation are not unusual in ear diseases ; and while these may be merely irri tative and transitoiy, they are at times of deadly meaning. Where the bone suppurates and decays the mastoid-projection just behind the ear is apt to be involved, forming a °mas toid abscess," and may need to be chiseled open to give exit to the matter and dead bone. Even without this, the inner wall of bone can decay and an abscess-collect?on form on the outer surface of the brain-membrane. Yet this is strong and firm and may thicken to better pro tect all within; so such 'extra-dural abscesses" have but a fraction of the danger of a collec tion upon or in the brain itself. Even this can now be often recognized in time by its subnor mal pulse and temperature, and located suffi ciently by its symptoms to permit of surgical relief ; and nearly 50 per cent of the reported operations have been followed by cure. The infection can penetrate the adjacent great blood-vessels and cause clotting within them, with general blood-poisoning and formation of abscesses in the lungs or other parts of the body; but the septic clot can be recognized and safely removed in many cases even when ex tending down almost to the heart.