tion of the meatus. If the speculum is introduced without first illuminating the canal, unnecessary pain is often inflicted, and morbid conditions, such as furuncles, for instance, may be overlooked. The introduction of the speculum is painless, although it occasionally excites cough, rarely vomiting and syncope, by irritating the auricular branch of the pneumogastric. Bringing the speculum forcibly against the bony margin of the auditory canal gives rise to pain and produces excoriations. The largest speculum that can be introduced is selected ; a fresh one should always be used for each patient, otherwise an opportunity may be afforded for observing an epidemic of otitis externa. The speculum is held in place with the thumb and index-finger of the left hand, the pinna being at the same time steadied with the middle and the index-finger of the same hand, leaving the right one free to handle the instruments. The examiner should bring his eye as closely as possible to the patient's ear. If he is myopic or hyperopic, he uses his ordinary glasses or a correcting lens attached behind the central opening of the mirror. The light reflected into the auditory meatus through the speculum produces a bright illumination of the deeper portions of the meatus and drumhead. The extent of the illuminated and visible portion depends on the width of the canal and the degree of convexity of the inferior and anterior walls. If the floor of the canal, for instance, has a strong convexity, it will be impossible to see the antero-inferior half of the drumhead, as it is impossible to dilate the bony portion of the meatus with the speculum. The deepest portion of the meatus cannot always be seen, and foreign bodies contained in it may, therefore, escape the surgeon's eye. As it is possible to see only as much of the drumhead as corresponds to the lumen of the speculum, the different portions of the meatus and drumhead must be brought into view by successively lifting, depressing, and moving the speculum from side to side. The posterosuperior wall of the meatus, which is often the seat of fistulæ, has a uniform pale white color; it is often the first thing seen on introducing the speculum, and must never be mistaken for the drumhead. The drumhead occupies the antero-inferior portion of the canal, and under normal conditions presents a peculiar color and certain characteristic details. If the introduction of the speculum does not suffice to displace the scales of epidermis or cerumen contained in the meatus, but, as occasionally happens, merely scrapes them away from the walls, so that they FIG. 25.-Aural forceps FIG. 26.-Foreign body forceps (after Hartmann). obstruct the lumen and thus prevent a good view of the drumhead, then the surgeon must first proceed to cleanse the canal. This is done by syringing, or, if the operator possesses the necessary skill, by scraping with an ear curet, with a pair of forceps bent at an obtuse angle (Fig. 25), or with the ear forceps (Fig. 26), always under illumination. These instruments must be so constructed that they can be opened within the smallest speculum. Syringing is the safest plan. It is done with a large aseptic piston syringe (Trautmann) or an india-rubber aural syringe with a glass tube that can be removed and sterilized by boiling (Fig. 27). A specially devised glass vessel (Fig. 28) or a kidney basin is held under the ear to catch the water. The ear is drawn backward and upward, and the point of the syringe applied-not too deeply-to the posterosuperior wall of the meatus, whereupon the stream of water will flow horizontally along the roof of the canal to the ear-drum, thence downward into the deepest portion of the meatus, so that the return current will wash out the obstacle. Very little pressure should be used at first. Water at 28° C. (95° F.), sterilized by boiling, is used. If the pressure is too great or cold water is used, vertigo, tinnitus, or syncope may result. If the drumhead is perforated, the water may run into the throat. Instrumental removal of obstacles in the external auditory canal should be attempted by experts only, as much damage may result from unskilful manipulation. Sterile water should always be used, since, if a perforation is present,-as, for instance, after an explosion,-it may be covered up with cerumen, and irri gation with non-sterilized water might infect the tympanum. Before introducing the syringe it should be held with the bulb up so as to remove any air-bubbles contained in the water. After the irrigation is completed the pinna should be dried with cotton. The auditory meatus is wiped out with a cotton-wound applicator (Fig. 29) by moving it up and down and from right to left. Rotary movements within the auditory canal are unpleasant to the patient. After the passage has been cleared in this way, the funnel-shaped, retracted drumhead-is seen in the antero-inferior portion of the meatus. It presents the following landmarks (Plate 38): (1) Above and in front (in the right ear to the right, in the left ear to the left) is a yellowish prominence, the short process of the malleus; (2) from this point the handle of the malleus extends backward and downward as a yellowish-white streak; (3) the handle ends a little below the middle of the drumhead, at a point where the membrane is retracted-the umbo; (4) in front of and below the umbo is a triangular cone of light, the apex corresponding with the umbo. This cone of light extends nearly to the periphery of the drumhead, and is sometimes divided longitudinally or interrupted at the center. In front of and above the short process of the malleus lies the somewhat depressed Shrapnell's membrane, bounded below by the anterior and inferior folds; it contains the superior fold (Fig. 6). By the help of these landmarks the drumhead is readily divided into anterosuperior, posterosuperior, antero-inferior, and postero-inferior quadrants. The drumhead presents for observation the following characteristics : (a) Color and Transparency.-The color is complex, being a mixture of the grayish color of the membrane itself, and, owing to its transparency, of the color of the tympanic structures or wall of the promontory. The normal color of the drumhead is grayish, a little darker in the anterior than in the posterior half. In children and aged individuals the color is a yellowish white. The annulus tendineus forms a whitish streak most conspicuous in the posterosuperior quadrant. Changes in the color of the drumhead may be produced by changes in the membrane itself, as in inflammation, or by changes in the color of the contents of the cavity, which becomes yellowish in the presence of a yellow exudate or of the color of the wall of the promontory (reddening). The introduction of the ear speculum often produces congestion of the handle of the malleus, owing to irritation of the artery of the external auditory meatus. The normal contents of the tympanic cavity may sometimes be seen through the transparent membrane. Thus the long process of the incus, the stapes, the pouches of Trölt, the chorda tympani, and the margin of the fenestra rotunda may be visible (Fig. 6). When, owing to a scar in the posterosuperior quadrant, for instance, the ear-drum is thinner than normal, the incudostapedial articulation is sometimes so plainly seen that it appears to be uncovered (Plate 39, 23). When the membrane is perforated, the various structures of the tympanic cavity complicate the image. In total absence of the drumhead the wall of the promontory appears (Plate 39, 7) and, when the bone in the osseous portion is defective, the attic may be seen (Plate 39, 15). The normal transparency of the drumhead may be impaired by thickening of the membrane, calcareous deposits, maceration of the epidermis, or infiltration (Plate 38, 9). An opacity around the umbo is normal. (b) Luster, Inclination, and Convexity.—The covering of fat that the drumhead receives from the ceruminous glands gives its surfaces a glistening appearance. In the living subject the membrane presents a light reflex which, owing to the funnel shape of the ear-drum and the convexity of the antero-inferior quadrant, appears triangular (Trautmann, Politzer); in addition there is often a reflex in front and below, in the tympanic sulcus (Bezold) and in Shrapnell's membrane (Plate 39). The triangular reflex depends on the inclina |