They can be softened better by means of glycerin than by bicarbonate of sodium solution. When difficult to detach and requiring the use of instruments, it is well to fill the ear with carbolated glycerin, both for maceration and protection against infection. A tooth-pick dipped into a concentrated solution of caustic potash may be thrust carefully into the center of the plug in order to macerate and soften it. By the use of a blunt ear spatula, blunt broad forceps, blunt, sometimes even sharp, scoops, these plugs can be gradually picked out in the course of a few days if necessary. If the skin of the meatus appears macerated or inflamed after removal of the plug, it should be brushed with nitrate of silver solution (10 per cent.) until healthy. When this is done, epidermis plugs are not so likely to recur as wax plugs.

CHAPTER XXXIV.

DISEASES OF THE EXTERNAL EAR.

FOREIGN BODIES. OPERATIVE DETACHMENT OF THE AURICLE. TUMORS. STENOSIS OF THE MEATUS. INJURIES. MYRINGITIS.

326. Foreign bodies, such as beads, peas, wads of paper, and the like, get into the external meatus mainly through the pranks of children. Cotton and gauze are sometimes forgotten and left. A variety of small objects, sticks of wood, and so on get in by accident, and insects -for instance, bedbugs and the larvæ of flies-have been found at times. As long as the foreign body is not sharp its mere presence causes no annoyance beyond, perhaps, a feeling of fulness, and it leaves no consequences. It is the traumatism, especially from unskilful attempts at extraction, which is to be feared. The inexperienced physician cannot be warned too emphatically that it is safer to leave a foreign body in the meatus for the time being than to take the chances of wounding the walls or the drumhead. No attempt to remove a foreign body should be made unless the latter is seen. If it be covered by wax, the removal of the wax is in order. If it is so sinall as to be hidden in the deep sinus of the meatus next to the membrana tympani, it will probably drop out when the head is turned to the side. Hence leisurely inspection through the speculum with a good light should establish the diagnosis before any therapeutic action is attempted. Prompt action is only required if traumatism, either incidental or due to former attempts at extraction, has led to complications. These may be diffuse inflammation of the walls of the meatus or inflammatory involvement of the middle ear. In the latter case extensive traumatism involves the risk of extension to the brain.

The safest way to remove a foreign body is by patient syringing with warm water. In the case of peas or beans, which swell when moistened with water, oil or alcohol may be used for syringing, unless they are freely mobile and can be made to drop out by turning the head. Live insects may be dislodged by tobacco smoke or chloroform vapor. Impacted objects which do not budge on syringing should be seized with the utmost care with a small sharp hook or a flat curet, with its blunt edge turned toward the wall, or the snare. The surgeon should always remember not to push the object deeper into the canal. Forceps of any kind are apt to do this. Good illumination is indispensable. In the case of an unruly child anesthesia may prove necessary. If the attempted extraction fails, it is sometimes better to desist for the time as long as there are no urgent symptoms. Under the use of carbolated glycerin moderate swelling of the meatus may recede sufficiently to permit an easier extraction a day or two later.

327. When other methods fail and urgent symptoms indicate prompt interference, the auricle and cartilaginous meatus are to be detached from the osseous canal in order to gain access to its depth. The typical operation is done as follows:

Vertical (slightly curved) incision down to the bone, 5 mm. behind the auricle from the tip of the helix to nearly the tip of the mastoid process. Compression or torsion of bleeding vessels. Detachment (by means of an elevator) of the periosteum and of the cartilaginous meatus from the bone. Transverse (vertical) section through the posterior cutaneous wall of the osseous meatus with the tenotome. By pulling the auricle forward, the cartilaginous meatus is almost entirely lifted out of the osseous canal, which is now accessible. Good illumination without reflecting mirror is all that is required. If the foreign body cannot be removed by reason of impaction, the osseous meatus is now enlarged by chiseling away its posterior wall with small concave gouges. After

completion the cartilaginous meatus and auricle are replaced and the external wound is sutured. If the posterior wall has been chiseled, the integument of the meatus is slit longitudinally for the purpose of better coaptation. The meatus is then packed with iodoform gauze. The operation is rarely required, except in the case of complicating inflammation of the middle ear or shot wounds. 328. Tumors of the external ear or of any part of the ear are not common. The most frequent growth of the auricle is the fibroma or keloid, sometimes the consequence of irritation by an ear-ring. Keloids are more often seen Sebaceous cysts occur mainly on the concave side of the auricle. Cancer and lupus are rarely seen here. All these morbid processes present no peculiarities different from those in other localities.

in negroes.

In the meatus polypi are often seen, but they rarely spring from the walls of the meatus, mostly from the middle ear, and will be treated in connection with chronic suppurative otitis. The few polypi which originate from the walls of the meatus must be considered in the same manner as those extruding from the middle ear. The most frequent neoplasms of the meatus are exostoses. They may grow sufficiently to occlude the canal. Sometimes they are multiple. They are of ivory hardness, and must be removed by chiseling through the healthy bone around them. Their discussion can be combined with that of stenosis or atresia of the external meatus.

329. Narrowing or occlusion of the canal may be due to various lesions. Besides circumscribed exostoses, a diffuse hyperostosis of the osseous wall or at least of a part of it is sometimes seen, especially in connection with. old chronic suppuration of the middle ear. Cicatricial contraction may follow an ulcerative process, such as corrosion by chemicals or burns or lupus, or, very rarely, diphtheritic inflammation of the meatus. It may also follow faulty healing after a radical mastoid operation with partial removal of the posterior wall of the meatus. Total occlusion of the canal is sometimes seen as a con

genital condition, either in the form of a membranous diaphragm, or as total obliteration of the caliber. The former condition is recognizable by the yielding to the probe, while hardness of the obstruction shows it to be bony.

interfere.

Narrowing of the meatus requires surgical attention if it either interferes with hearing or with the escape of the secretion of a diseased middle ear. The latter indication is imperative. Otherwise it may not be necessary to Mechanical dilatation and small operations are useless. Drilling by means of hand drills or burrs run by a dental motor or chiseling is permissible only on the anterior wall and only within the length of the meatus. Any encroachment toward the drumhead involves risk. In the case of exostosis or diffuse hypertrophy of the posterior wall the proper method is chiseling after detachment of the auricle. The hard growths can be shelled out by gouging through the normal bone. When working on the posterior wall it must be remembered that in the vicinity of the drumhead there is danger to the facial nerve and semicircular canals. Congenital occlusions are easily dissected out if membranous. In the case of total obliteration of the canal an operation is risky and of questionable utility. It should not even be considered unless tests with tuning-forks establish the integrity of the internal ear on that side beyond ques

tion.

330. Under the head of accidents to the ear frost-bites must be mentioned as the most common. Congelation of the helix or of the lobule causes a blanching, followed by persistent lividity. The popular practice of rubbing frozen ears with snow in order to thaw them gradually is probably founded on experience. The congestive reaction after a frost-bite may last a long time and is apt to return upon slight exposure. Nothing can be done for it beyond. protection in cold weather.

331. The most frequent injury to the ear is that resulting from a blow. It may lead to ringing and slight deaf