kull. More commonly,
perhaps, the membrane is ruptured from indirect violence due to great
condensation of the air in the external auditory meatus, following
blows upon the ear, heavy artillery reports, or diving from a height.
The injury is followed by pain in the ear, often by considerable
deafness and tinnitus, and bleeding is frequently observed. If early
examination of the ear is made, coagulated blood may be found in the
meatus or upon the membrane, or ecchymosis may be visible on the
latter. A rupture in the membrane following indirect violence is
usually lozenge-shaped. During inflation by Valsalva's method the air
may be heard to whistle through the perforation. In all such injuries
the hearing should be carefully tested, and the possibility of an
injury to the labyrinth investigated by means of the tuning-fork test.
Prognosis as regards hearing should be guarded at first. As a rule the
rupture heals rapidly, and no treatment is necessary save the
introduction of a piece of cotton-wool into the meatus. Syringing
should be avoided unless suppuration has already occurred, in which
case treatment for this condition must be adopted. As these injuries
frequently have a medico-legal bearing, careful notes should be made.

#Acute Infection of the Middle Ear.#--This usually arises in
connection with infective conditions of the throat and naso-pharynx.
It varies considerably in its severity, and may run a mild or a severe
course. It is characterised by pain in the ear, deafness, and a
certain degree of fever. In children the symptoms may simulate those
of meningitis. When the tympanic membrane is examined in the mild
forms of the affection or in the early stages of the more severe type,
the vessels about the handle of the malleus and periphery of the
membrane are injected, and possibly a number of injected vessels may
be seen coursing across the surface of the membrane. In the later
stages the whole membrane presents a red surface, the anatomical
landmarks being indistinguishable, the membrane bulges outwards into
the meatus, and, if an abscess is pointing, a yellowish area may be
visible upon it. The sudden cessation of pain and the appearance of a
discharge from the meatus indicate perforation of the membrana
tympani.

The _treatment_ of acute otitis media varies with the severity of the
attack. The patient should be confined to the house or to bed, alcohol
and tobacco should be forbidden, and the bowels must be fre