breast, and when both ears are affected to throw the head backward and roll it from side to side, it is not unusual to find the child dull and drowsy with an occasional awakening to a sharper pain.

These symptoms are easily explained-the occurrence of pain after a period of sleep is due to the fact that the child is no longer swallowing and making other movements which favor the opening of the Eustachian tube, the blood stasis from the pressure contact of the swollen walls of the tube and the serous exudation which follows the primary congestion cause an increasing pressure within the tympanic cavity, and especially upon the membrana tympani-that this is the cause of the symptom is in part proved by the fact that the pain with which the child awakes is often readily relieved by the gentle use of the Politzer air-douche; this procedure opening the Eustachian tube and permitting the escape of a part of the contained fluid into the throat, thus relieving the intra-tympanic pressure.

That the more continuous pain, which comes later on, is not similarly relieved is due to one or more of several causes: 1. There may be serous effusion into the tissues of the membrana tympani itself, causing an intrinsic pressure, which it is evident would not be relieved readily by inflation of the middle ear. 2. The greater swelling of the mucous membrane lining the Eustachian tube may have rendered that passage impervious to air. 3. The deeper implication of the lining of the tympanic cavity may give rise to pain characteristic of periosteal inflam

mation.

In very young children the burrowing of the head is an instinctive search for the relief afforded by warmth; were the pain due to an inflammation of the lining of the external auditory canal, pressure would be avoided.

The co-ordinate movements of the head and the drowsiness are due in part to intra-labyrinthine pressure consequent upon congestion and upon the secondary pressure resulting from the retained secretion in the middle ear, and sometimes to a corresponding meningeal congestion.

A similar drowsiness may be induced in very young children. artificially, by making very gentle continuous pressure upon the membrana tympani by means of a cotton-tipped probe.

When the disease is allowed to run its course fully, in the majority of cases, nature's remedy finally occurs in a spontaneous perforation of the membrana tympani with purulent or

muco-purulent discharge and speedy relief from the pain and concomitant symptoms; this usually does not occur, however, until the little patient has been much prostrated by pain, and until a degree of destruction has resulted in the sound transmitting structures of the middle ear, which can be measured only by its after effects.

To relieve the pain by the internal administration of opiates is but a superficial treatment, since it leaves the inflammatory process to run its course unchecked, and the remedies employed should be those directed rather to a forestalling of the evident efforts of nature for relief.

In the early stages the child should be made, if possible, to frequently gargle the throat, as aside from any therapeutic value which a gargle may have, it acts mechanically to assist in opening the Eustachian tube.

The air douche should be used frequently, especially if there is complaint of pain, and the parents should be instructed in its use; any rubber bag with a nozzle which can be inserted in the nostril will answer the purpose, or, in default of this, air may be blown from the mouth through a tube.

If the child cannot be made to swallow at the moment of inflation, it may be made to blow forcibly against the hand held tightly over the closed lips; if it is too young or too intractable to blow, it can be made to cry, which answers very nearly the same purpose. In very young children the forcible inflation without the accompaniments is often abundantly sufficient.

The common practices of instilling warm oils and opiates and of covering the ear with a poultice are decidedly objectionable; the former relieve only temporarily as a rule by their warmth, and obscure a field in which it may be necessary subsequently to operate, and the latter gives relief at the expense of a possibility of a swelling of the outer parts, especially of the lining of the external auditory canal, which makes subsequent operative interference very difficult, if not impossible, with safety. The instillation of a mixture of glycerine and water, warm, two or three parts to one, and the covering of the ear with a dry, warm cloth often answer the immediate purposes of relief, and, when there is serous infiltration of the membrani tympani, there is, with this thicker fluid without, to a certain extent an exo8mosis, which tends to relieve the pressure within.

In the later stage, with an accumulation of pus under pressure in the middle ear, as evidenced by yellowish-gray color and

bulging of the membrani tympani, the evident remedy is a puncture of this membrane preferably at its most prominent portion. This simple operation should be performed only under good illumination and with a due recognition of the anatomical relationships of the parts. The best instrument for the purpose is the lance-headed paracentesis needle; in default of this a narrowbladed bistoury, a broad suture needle, or a three-cornered saddler's needle held at an angle in a fixation forceps.

In measles, as has been said, there are two types of middle ear disease fairly distinct in their inception. In the first, resembling the acute inflammation which is the frequent cause of the too common and too commonly neglected "catarrh" in children, there is as a rule a general congestion of the tympanic mucous membrane with rapid serous effusion into the tympanic cavity. The remedies referred to in the early stages in scarlet fever are equally if not more successfully applicable here; when they fail of effect, however, and the serous effusion is excessive, I have resorted, with advantage in many cases, not to paracentesis of the membrana tympani for the purpose of freely liberating the retained fluid, but to the simple procedures of acupuncture and drainage. In the preliminary stage of the inflammation, when resolution is still possible, the violence done to a delicate tissue by a free incision has seemed by its increased irritation to precipitate the condition which it is intended to avoid; the free evacuation of the tympanic cavity, moreover, by taking away the counteracting pressure upon the walls of the engorged bloodvessels permits a greater degree of serous exudation and of accompanying tissue destruction.

Since in many of these cases but a slight and continuous relief from pressure is required, the acupuncture best answers this purpose. In want of a better instrument, a large needle may be firmly held in a pair of forceps and two or three punctures made, preferably in the lower portion of the membrana tympani, a roll of absorbent cotton wick is then inserted, its inner end in contact with the membrane, its outer end projecting from the ear; as soon as this wick becomes moist throughout, a fresh one should be substituted; the wick serves a double purpose by favoring the gradual withdrawal of the serous fluid, and by keeping the lining of the canal dry and so preventing its maceration. So long as there is a serous discharge the ear should not be syringed; syringing and astringent instillations are to be resorted to only when the discharge becomes muco-purulent.

The second, and less common, form of ear disease under consideration, is characterized primarily by a sudden congestion of the membrana tympani, principally at its upper part, without a corresponding congestion of the tympanic mucous membrane. This usually occurs coincidently with the eruption on the face, and gives rise to very sharp pain, not relieved by the use of the air-douche.

In many of the cases which have come under my observation, I have seen the upper portion of the membrana tympani con gested with serous exudation into the tissues of the membrane confined to its upper part, the remaining portions of the membrane transparent or but slightly congested, and with no evidence of serous accumulation in the middle ear. The explanation given by Woakes of a similar condition accompanying the presence of carious teeth in children will answer here, the localized congestion in these cases being due to inhibition of the vaso-motor nerves controlling the tympanic branch of the carotid artery, the irritative impulse being afforded by the eruption upon the face. Cases of this kind sometimes resolve spontaneously, the congestion diminishing with the disappearance of the facial eruption; in many, however, the congestion tends to increase, includes the tympanic mucous membrane, and the conditions described in the first type of inflammation of the middle ear become established.

In addition to the instillation and dry warmth, acupuncture of the swollen superior portion of the membrana tympani may be resorted to with good effect, and in two cases in which the congestion was evidently rapidly progressing I made a "dry puncture" of the lower portion of the membrane with subsequent slight serous discharge through the opening and a speedy relief from the congestive symptoms.

Of the general treatment of these cases it does not become me here to speak. In the acute congestive stages, however, the - bromides would seem to be especially indicated. Their after treatment locally is sufficiently described in the excellent textbooks of Roosa, Burnett, and Buck; one or other of these works should be in the hands of every general practitioner, because the acute inflammations of the ear in childhood immediately furnish or lay the foundation for a large part of our aural material, and because the prevention of disease is the first duty of the profession.

THUMB SUCKING.

By D. H. GOODWILLIE, M.D., D.D.S.,

NEW YORK.

THE following case will serve to illustrate this bad habit and its treatment:-

Floura J., of Augusta, Georgia, aged 4 years, was brought to me by her parents in April, 1877, for treatment of nasal catarrh and a deformity of the nose. On making inquiry of the mother as to the habits and care of her child, she acknowledged her ignorance, and referred me to the colored nurse. Her story only served to show what is too frequently the case, that through bad management and defective alimentation children are brought up in a state of physical starvation, though they may be living in the midst of affluence. This child was pale and anæmic in appearance, tissues soft, expression listless, running at the nose, constipated, cross and impatient, arms and legs bare, and no flannel on the body while the weather was quite cold. A good portion of time, during sleeping hours and often during the day, its left thumb was in its mouth. It went to sleep sucking its thumb, and often in the night would wake up and continue this bad habit. When this left thumb was in the mouth, the index finger was brought over the bridge of the nose, pressing it over to the right, while the middle finger pressed down upon the cartilaginous portion of the nose.

When the process of sucking was going on, pressure was brought to bear on the superior incisor teeth by the thumb, and, at the same time, the fingers on the nose pressed it down, and, to a certain extent, prevented respiration through the nose. The incisor teeth were forced outward, and malformed the anterior front of the mouth. The upper lip was not so well developed in proportion as the under one, and had a pouting appearance. Left thumb reduced in size as compared with the right.

Under an anesthetic the nasal cavity was thoroughly exam