unnoticed for years. But the most serious damage not infrequently results from unskillful attempts at their removal by persons (even physicians unused to instrumental work on the ear) who are driven to immediate and violent action on the false supposition that instant interference is called for. Insects, it is true, should be killed without delay by dropping into the ear sweet oil, castor, linseed, or machine oil or glycerin, or even water, if the others are not at hand, and then the insect should be removed in half an hour by syringing as recommended for wax (p. 35).

To remove solid bodies, turn the ear containing the body, downward, pull it outward and backward, and rub the skin just in front of the opening into the ear with the other hand, and the object may fall out.

Failing in this, syringing with warm water, as for removal of wax, while the patient is sitting, may prove successful. The essentials of treatment then consist, first, in keeping cool; then in killing insects by dropping oil or water into the ear, and, if syringing proves ineffective, in using no instrumental methods in an attempt to remove the foreign body, but in awaiting such time as skilled medical services can be obtained. If beans or seeds are not washed out by syringing, the water may cause them to swell and produce pain. To obviate this, drop glycerin in the ear which absorbs water, and will thus shrivel the seed.

EARACHE.-Earache is due usually not to neuralgia of the ear, but to a true inflammation of the

middle ear, which either subsides or results in the accumulation of inflammatory products until the drum is ruptured and discharge occurs from the external canal. The trouble commonly originates from an extension of catarrhal disease of the nose or throat; the germs which are responsible for these disorders finding their way into the Eustachian tubes, and thus into the middle ear. Any source of chronic catarrh of the nose or throat, as enlarged and diseased tonsils, adenoids in children, or nasal obstruction, favor the growth of germs and the occurrence of frequent attacks of acute catarrh or "colds." "colds." The grippe has been the most fruitful cause of middle-ear inflammation and earache in recent years. Any act which forces up fluid or secretions from the back of the nose into the Eustachian tubes (see section on Deafness) and thus into the middle ear, is apt to set up inflammation there, either through the introduction of germs, or owing to the mechanical injury sustained. Thus the use of the nasal douche, the act of sniffing water into the nose, or blowing the nose violently when there is secretion or fluid in the back of the nose, or the employment of the post-nasal syringe are one and all attended with this danger. Swimming on the back, diving, or surf bathing also endangers the ear, as cold water is forcibly driven not only into the external auditory canal, but, what is more frequently a source of damage, into the Eustachian tubes through the medium of the nose or throat. In this case the plugging

of the nose with cotton would be of more value than the external canal, as is commonly practiced. If water has entered the Eustachian tube, blowing the nose and choking merely aggravate the trouble. The wiser plan is to do nothing but trust that the water will drain out, and if pain ensues treat it as recommended below for earache.

Water in the ears is sometimes removed by jumping about on one foot with the troublesome ear held downward, and if it is in the external canal it may be wiped out gently with cotton on the end of a match, as recommended in the article on treating wax in the ear (see p. 35). In the treatment of catarrh in the nose or throat only a spray from an atomizer should be used, as Dobell's or Seiler's solutions followed by menthol and camphor, twenty grains of each to the ounce of alboline or liquid vaseline.1

Exposure to cold and the common eruptive diseases of children, as scarlet fever, measles, and also diphtheria, are common causes of middle-ear inflammation. In the latter disorders the protection afforded by a nightcap which comes down over the ears, and worn constantly during the illness, is frequently sufficient to ward off ear complications.

Although earache or middle-ear inflammation is common, its dangers are not fully appreciated, since the various complications are likely to arise, and the result is not rarely serious. Extension of the in

1 See p. 49.

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. 35).

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