PLATE 39.













1. Chronic Suppurative Otitis Media.-Drumhead opaque and retracted; round perforation behind the umbo. Mucous membrane of tympanic cavity reddened. Male, forty years of age; suppuration has existed four years. Whispered conversation heard at a distance of 1/2 m. Rinne absolute and partially negative up to c'. Weber in the right ear.Schwabach prolonged. Upper tone limit normal.













2. Chronic Suppurative Otitis Media.-Small reniform perforation below the handle of the malleus. Umbo projects into the perforation. In the posterosuperior quadrant the articulation between the incus and stapes is visible. Boy, twelve years of age. Suppuration has existed ten years.













3. Chronic Suppurative Otitis Media (Exacerbation). -Reniform perforation with granulating edges below the handle of the malleus. Mucous membrane of tympanic cavity reddened. Female, thirty-five years of age. Suppuration existed during childhood, but ceased years ago. Six weeks ago, after a bath, the suppuration reappeared.













4. Chronic Suppurative Otitis Media.-Large reniform perforation below the handle of the malleus. Girl, twelve years of age. Suppuration after measles in the second year.













5. Chronic Suppurative Otitis Media. -Destruction of all but a narrow peripheral strip of the tympanic membrane; the handle of the malleus projects into the perforation, In the posterosuperior quadrant one sees the articulation between the incus and the stapes in the postero-inferior quadrant the margin of the fenestra cochleae. Male, eighteen years of age. Suppuration began three years ago after scarlet fever.













6. Chronic Suppurative Otitis Media (Caries of the Incus and Floor of the Tympanic Cavity).-Destruction of all but a narrow peripheral strip of the tympanic membrane; extremity of the malleus is adherent to the promontory; in the posterosuperior quadrant the head of the stapes is seen; the long process of the incus is wanting. Small granulations are seen on the floor of the tympanic cavity. Female, twenty-four years of age. Aural discharge since childhood.













7. Chronic Suppurative Otitis Media (Handle of Malleus; Caries of Incus).- Nothing remains of the tympanic membrane but Shrapnell's membrane and a short stump of the malleus. The handle of the malleus and the long process of the incus have been destroyed. In the posteroinferior quadrant the margin of the fenestra rotunda, and in the posterosuperior quadrant the head of the stapes are seen. The long process of the incus is wanting. A blood-vessel is seen to pass over the promontory from below upward. Postscarlatinal suppuration of twenty years' standing.













8. Chronic Suppurative Otitis Media (Caries of the Tympanic Cavity).-Total absence of the tympanic membrane, the malleus and the incus Granulations on the floor of the cavity. In the posterosuperior quadrant the head of the stapes and in the postero-inferior the margin of the fenestra rotunda, are seen. Postscarlatinal suppuration of fifteen years' standing.













9. Chronic Suppurative Otitis Media. Polypoid Granulations (Caries of the Malleus and Incus).-Of the tympanic membrane nothing remains but Shrapnell's membrane and a small remnant of the malleus; the handle of the malleus is completely destroyed. On the posterior half of the wall of the tympanic cavity there is a spheric polyp with broad base. Male, thirty years of age. Running from the ear since childhood.













10. Chronic Suppurative Otitis Media. Polypoid Granulations. (Caries of the Malleus and Incus).-Nothing remains of the tympanic membrane but Shrapnell's membrane and a remnant of the Malleus. The handle of the malleus is completely destroyed. In the posterosuperior quadrant the long process of the incus, which is necrotic and drawn out into a point, projects into the cavity. The mucous membrane lining the tympanic cavity is covered with numerous granulations. Girl, eighteen years of age. The aural,discharge came on after diphtberia and has existed one year.














11. Chronic Suppurative Otitis Media; Cholesteatoma (and Nervous Deafness).- The drumhead is destroyed except for a narrow peripheral strip above and in front; the stump of the malleus is adherent to the promontory. The mucous membrane of the tympanic cavity is covered with epiderm, and in its postero-inferior portion with granulations. Above and behind cholesteatomatous masses arranged in layers project from the passage into the antrum. Female, thirty years of age. Has had running of the ear since childhood. Whispered conversation inaudible. Ordinary conversation heard at a distance of 1 m. Rinne absolute and partially negative up to c'. Weber in the head. Schwabach prolonged. Upper tone limit greatly lowered.














12. Chronic Suppurative Otitis Media.-Entire absence of the drumhead, malleus, and incus. The mucous membrane of the tympanic cavity is covered with epiderm except for a few granulating areas. Woman, sixty years of age. Has had aural discharge since childhood. Whispered conversation inaudible; ordinary conversation heard at 3/4 m. Rinne absolute and partially negative to c2.














13. Chronic Suppurative Otitis Media. Double Perforation.-Perforation in front of and behind the handle of the malleus. Patient was a girl sixteen years old, of tubercular diathesis. Suppuration had existed three months.














14. Chronic Suppurative Otitis Media. Perforation in Shrapnell's Membrane (Caries of the Incus).-Small perforation behind and above the small process of the malleus. Male, twenty years of age. Aural discharge since childhood.














15. Chronic Suppurative Otitis Media. Perforation in Shrapnell's Membrane. Polypoid Granulations (Caries of the Attic). -Perforation above the short process of the malleus. Defect in the osseous portion of the attic. A spheric polyp projects downward from the defect in the bone into the perforation. Male, forty years of age. Aural discharge since childhood. Whispered conversation heard on the right side at 1 1/2 m. Rinne partially negative to cl. Weber in the diseased ear. Schwabach prolonged. Upper tone limit normal.














16. Chronic Suppurative Otitis Media. Cholesteatoma.- Destruction of Shrapnell's membrane and the osseous portion of the attic. The cholesteatomatous masses project from the perforation into the auditory meatus. The drumhead is opaque, and granulations are seen at the handle of the malleus. Woman, thirty-eight years of age. Aural discharge since childhood.














17. Remains of a Chronic Suppurative Otitis Media. Dry Perforation. -Reniform dry perforation. Behind and below in the opening of the perforation the margin of the fenestra rotunda is visible. A bloodvessel passes over the promontory. Female, twenty- three years of age. Had aural discharge in her nineteenth year. The discharge ceased two years ago.














18. Remains of a Chronic Suppurative Otitis Media. Dry Perforation. Calcareous Deposits. -In the posterosuperior quadrant a perforation in which the margin of the fenestra rotunda and the articulation between the incus and stapes are visible. In front and above a remnant of drumhead containing calcareous deposits. Male, twenty-four years of age Had aural discharge fifteen years ago.














19. Remains of a Chronic Suppurative Otitis Media. Adherent Cicatrix.- Drumhead retracted. In the antero-inferior quadrant a scar adherent to the wall of the promontory. Female, twenty years of age; aural discharge, during childhood. Whispered conversation heard at 1 m. Rinne partially negative up to c'. Weber in the right ear. Schwabach prolonged. Upper tone limit normal.














20. Remains of a Chronic Suppurative Otitis Media. Adherent Cicatrix.-Of >the handle of the malleus only the short process is visible. The anterior half of the drumhead contains a depressed scar adherent to the opposite wall of the tympanic cavity. Female, twenty-five years of age. Aural discharge in childhood.














21. Remains of a Chronic Suppurative Otitis Media. Calcareous Deposits. Cicatrix.-The anterosuperior and posterosuperior quadrants contain calcareous deposits. Below the handle of the malleus there is a reniform, slightly movable sear. Male, fifty years of age. Aural discharge in childhood. Whispered conversation heard at 2 m. Rinne partially negative up to c. Weber in the head.














22. Remains of a Chronic Suppurative Otitis Media. Adherent Cicatrices.-The drumhead distorted by cicatrix. The handle of malleus immovably adherent to promontory. Female, thirty years of age. Aural discharge in childhood. Whispered conversation inaudible on the right side. Ordinary conversation heard at I m. Rinne absolute and totally negative. Weber in the right ear. Schwabach prolonged.














23. Remains of a Chronic Suppurative Otitis Media. Cicatrix and Calcareous Deposit.- crescent-shaped calcareous deposit surrounds the handle of the malleus. Above and behind is a cicatrix loosely adherent to the bone, so that the margin of the fenestra rotunda and the articulation between the malleus and stapes are distinctly seen. Female, twenty-four years of age. Aural discharge in childhood. Whispered conversation heard at 1 1/2 m.














24. Scar from Fig. 15 after Politzer's Procedure. -Vesicular bulging of the scar.The characteristic points on the inner wall of the tympanic cavity have disappeared. Whispered conversation heard at 6 m.