All these manipulations are used for chronic catarrh in the inner ear, for adhesions in the auditory chain of bones and in "sclerosis" in the middle ear, because in one way or another they set in motion the tympanum and small bones. It is attempted in this way, and to some extent successfully, to improve hearing and diminish the singing noise and other subjective symptoms in the ear. To influence catarrh in the ear it is of course necessary to treat the nose, throat, and Eustachian tubes.

The work of specialists in this department seems to me on the whole very useful, but far from complete.

One must be careful not to make too big vibrations (over 2 mm.) so as to produce injury to the tympanum, or to the articulations between the small bones, or between the stapes and fenestra ovalis. The treatment should not be painful. Contra-indications to such treatment consist of all acute inflammatory processes in the middle ear, of all conditions where there is normal hearing, and of atrophy, adhesions, and indrawing of the tympanum (Ostmann).

The internal ear massage described above may be assisted by external ear massage, which is also used alone for many external diseases of the ear.

It is also possible, as Politzer has done, to massage the tube by frictions immediately under the external ear between the mastoid process and the ascending ramus of the lower jaw.

In slight chronic catarrh of the middle ear Hommel orders the patients to give themselves vibratory treatment by means of the air in the external ear passage four to six times a day for a minute or two, by pressing the tragus against the external opening at the rate of 120 to 150 times a minute.

Reinhard and Ludwig, Zaufal and others use neck effleurage, with downward stroking from the mastoid region, in a similar manner to that performed by Ling and later by Gerst, for its beneficial effect upon absorption of acute and chronic exudations in the middle ear. The neck effleurage in these cases should include the region in front of the tragus, by means of which a considerable emptying of the veins takes place. Finally, one is able, as Dr. Stangenberg of Stockholm tells us, in such cases and in all chronic catarrh to use vibrations with advantage (with any vibrator) outside the ear in the mastoid fossa and all round the external ear. Under this treatment Stangenberg states that the usual noises in the ear are in many cases considerably diminished.

In suppurative otitis media during the acute stage the only suitable form of massage is neck effleurage, which is used for its antiphlogistic effect, and after the usual treatment and the removal of the pus to assist healing and prevent the disease becoming chronic. Even in this latter case, in Gerst's opinion, one may with advantage use neck effleurage several times daily for long periods.

Massage has been tried in cases of pure neuroses of the ear* Politzer (in his "Lehrbuch d. Ohrenheilkunde": Stuttgart, 1887, p. 425) says: "In many cases when (in otalgia) pain attacks the whole region of the ear and specially increases with pressure on the region between the ramus of the lower jaw and the mastoid area, corresponding to the course of the cartilaginous part of the tube, I noticed, after repeated massage for several days, a considerable improvement, even a complete disappearance of the otalgia."

Stangenberg recommends vibrations given with a vibrator on the outside of the ear in these cases. In similar diseases one ought specially to massage over the auriculo-temporal nerve; it is also useful to treat the supra- and infra-orbital nerves (Urbanschitsch).

Hematoma of the ear was treated with massage first by W. Meyer, then by Blake and Urbanschitsch.+

When haematoma of the ear arises in mentally healthy persons (or in those of the insane, e.g., the demented, who are not excited Politzer, however, states that with small painless haematomata healing should be left to nature; that painful blood tumours ought not to be treated with either bandages or massage, and that in other cases one ought only with the greatest care after three to four weeks to make use of the latter treatment, which otherwise may cause fresh haemorrhage.*

* I would call attention to the difficulty and necessity of making oneself sure of the diagnosis. One must particularly exclude disease of the teeth and ulceration in the throat, and examine for tenderness to pressure over the auriculo-temporal, great auricular, and small occipital nerves.

+ W. Meyer, in "Arkiv. f. Ohrenheilk.," 1880; Blake, in "Zeitschr. f. Ohrenheilk.," 15. xiii by the treatment) massage, to judge from the results of the above-mentioned doctors, seems to be equally indicated, as it promises quite as good results as bandage, compress, painting, or surgical treatment, and, possibly to a greater extent than these, may prevent further deformity of the ear.

Zaufal massaged away thickening in the external ear after chronic eczema.

Diffuse external otitis has been successfully treated by Gerst by neck effleurage for ten minutes three times daily.

Urbanschitsch orders massage (alternating with tampons) by means of strokings over the affected part for circumscribed external otitis (= boil in the external ear passage).

* "Lehrb. d. Ohrenheilk." : Stuttgart, 1887.