flammation to the bone behind the ear may necessitate chiseling away a part of the skull to liberate pus or dead bone in this locality, and the occurrence of abscess of the brain will necessitate operation.

The use of leeches in the beginning of the attack is of great value, and though unpleasant are not difficult or painful in their application. One should be applied just in front of the opening into the ear (which should be previously closed with cotton to prevent the entrance of the leech), and the other behind the ear in the crease where it joins the side of the head and at a point a little below the level of the external opening into the ear. A drop of milk on these spots will often start the leeches immediately at work, or a drop of blood obtained with a pin prick. When the leeches are gorged with blood and cease to suck, they should be removed and bleeding encouraged for half an hour with applications of absorbent cotton dipped in hot water. Then clean, dry absorbent cotton is applied, and pressure made on the wounds if bleeding does not soon stop or is excessive.

The after treatment of the bites consists in cleanliness and the use of vaseline. The patient must stay in bed, and the hot-water bag be constantly kept on the ear till all pain ceases. If the drum perforates, a discharge will usually appear from the external ear. Then the canal must be cleansed, once or more daily, by injecting very gently into the ear a solution of boric

acid (as much of boric acid as the water will dissolve), following this by wiping the water out of the canal with sterilized cotton, as directed for the treatment of wax in the ear (p. 49).

The syringing is permissible only once daily, unless the discharge is copious, but the canal may be wiped out in this manner several times a day with dry cotton. It is well to keep the opening into the ear greased with vaseline, and a plug of clean absorbent cotton loosely packed into the canal to keep out the cold. Excessive or too forcible syringing may bring about that complication most to be feared, although it may appear through no fault in care, i. e., an implication of the cavity in the bone back of the ear (mastoid disease). Germs find their way through the connecting passage by which this cavity is in touch with the middle ear, or may be forced in by violent syringing. When this happens, earache, or pain just back of the ear, commonly returns during the first or second week after the first attack, and tenderness may be observed on pressing on the bone just back of the ear close to the canal. Fever, and local redness and swelling of the parts over the bone in this region may also occur. Confinement to bed, and constant application of a rubber bag containing cracked ice, to the painful parts must be enforced. If the tenderness on pressure over the bone and pain do not subside within twenty-four to forty-eight hours, surgical assistance must be obtained at any cost, or a fatal result may ensue. The

opening in the drum membrane, caused by escape of discharge in the course of middle-ear inflammation, usually closes, but even if it does not deafness is not a necessary sequence.

The eardrum is not absolutely essential to hearing, but it is of great importance to exclude sources of irritation, dust, water, and germs which are likely to set up middle-ear trouble. More ordinary aftereffects are chronic discharge from the ear following acute inflammation and perforation of the eardrum, which may mean at any time a sudden return of pain with the occurrence of the more dangerous conditions just recited, together with deafness. Bearing all this in mind it is advisable never to neglect a severe or persistent earache, but to call in expert attention. When this is not obtainable the treatment outlined below should be carefully followed.

Symptoms. Pain is severe and often excruciating in adults. It may be felt over the temple, side and back of the head and neck, and even in the lower teeth, as well as in the ear itself. The pain is increased by blowing the nose, sneezing, coughing, and stooping. There is considerable tenderness usually on pressing on the skin in front of the ear passage. In infants there may be little evidence of pain in the ear. They are apt to be very fretful, refuse food, cry out in sleep, often lie with the affected ear resting on the hand, and show tenderness on pressure immediately in front or behind the ear passage.

Plate II

ANATOMY OF THE EAR

The illustration on the opposite page shows the interior structure of the ear. The concha and Meatus, or canal, comprise the external ear, which is separated from the middle ear by the Drum Membrane. Wax is secreted by glands located in the lining of the meatus, and should be detached by the motion of the jaws during talking and eating. If it adheres to the drum membrane it causes partial deafness.

The internal ear, or labyrinth, a cavity in the bone, back of the middle ear, consists of three parts: the Cochlea, the Semicircular Canals, and a middle portion, the Vestibule. The middle ear is connected with the throat by the Eustachian Tube.

Sound vibrations, which strike the drum membrane, are conveyed by means of a chain of three small bones through the middle ear to the nervous apparatus of the internal ear. The Eustachian tube and middle ear are lined throughout with mucous membrane, and any severe inflammation of the throat may extend to and involve the tube and the middle ear, causing deafness.