Two other affections of the external ear make up Much of the 25 per cent of diseases in volving this part — the diffused and the circum scribed inflammations of the canal. The first may be broadly called eczema — the latter furunde or boil. Gout and many general condi tions can predispose to the eczematous inflam mation, which by its heat and moisture makes the ear a hot-bed for the growth of the molds and bacteria which maintain or increase the trouble; and it may have an intensity verging into erysipelas. The milder, chronic forms are generally responsible for ?uruncles, for they furnish the itching which leads to scratching and the germs which punish this. °What did you scratch it with?* will generally bring con fession of a hairpin or a match-stick according to the sex ; and boils are more common on the right-hand side. The suffering caused by a boil may be extreme, sometimes keeping the patient walking the floor all night. They are rarely serious matters, but each tends to cause others, so they cannot be made light of. They consist of an infective inflammation of the glands of the skin lining the canal and are apt to be trivial when the superficial sebaceous glands are in volved, but more severe if a deeper cerumen gland is the seat. These glands extend into the subcutaneous tissue, possibly into the periosteum, so their inflammation can excite a periostitis pressing the ear out of place and perhaps strongly suggesting mastoid inflammation. Pres sure or motion of the parts, as in chewing, is acutely painful ; but firm pressure on the bone can be comfortably borne if all motion of the canal be avoided. Hot douching (110° F.) is usually comforting and if fully used has an ex cellent tonic effect ; warmth and moisture often increase and renew the trouble. The infection should be fought by mercurial oxide ointment and, if bearable, a firm plug covered with it should be passed into the swollen canal where it will exercise pressure, secure a useful massage from each jaw-motion and continue throughout the day and night the rubbing in of the salve.
Bony outgrowths of the walls sometimes narrow or close the external canal and less often cancerous growths involve it and the external ear. The bony growths are curiously common in the ears of ancient Peruvian and Mound builders' skulls and in modern times in Hawaii and in England. The London surgeons among their private patients see and remove more of these bony outgrowths than are reported from all the hospitals of the world. Their causes are not clear, and bathing has been suggested as influencing their formation. As seen in other than Englishmen, the great majority seem due to long-continued discharge from the ear; and this suppuration must be cured or the growth removed, lest the confinement of pus may lead to serious or fatal complications.
The suppurative inflammations of the middle ear form the most important phase of our sub ject, not only because of their malign effect in producing deafness and deaf-mutism, but from their serious menace to the life. Thousands are known to die annually from ear-diseases, and the records of large numbers of post-mortem examinations show that a large --proPortion usually escape recognition durifm life. The prevalence of influenza for manyYeass past has hugely increased the frequenerfof serious out comes, as WeU as served to biitis tittok to notice ; but even the rer was long grim. All e eruptive fev ; especially latina, measles and Ayphoid, are apt o involvement of the ears. These shobId, t fore, be closely watched and generally guarded in some measure by coverings, especially in chil dren, who may never call attention to their ears and yet if they lose hearing are prone to become deaf-mutes.
It is well known that discharge from the ear is apt to lessen or cease at the onset of serious extension and that bottling up of the flow may give rise to such results; but the somewhat prevalent view that such suppuration should be alone and it will be outgrown" is as mis taken as is the idea that it is dangerous to bring it to an end. To "stop it up" is wholly different
from stopping it by cure; and the chronic cases of slight discharge, often hardly noticeable, are those from which fatal diseases such as brain abscess, premia and sinus-clotting are generally recruited. Few good insurance companies will have anything to do with a man having a long standing running ear — the risk for the indi vidual may not be very frightful, but it is enough in any large aggregate to consume all the profit of insuring lives.
Suppuration of the middle-ear is ushered in by pain, and the severity of this "ear-ache" is at times some measure of the seriousness of the attack. The onset may he insidious or mislead ing, however, and relief may be sought of the dentist; while in children the fever, delirium or convulsions may draw attention away from the ears. Stains on the pillow or visible moisture in the canal may be the first indications that the ears are involved. But every such case, how ever stormy or mild its beginning, may go on immediately or remotely to the worst of issues; and it is our duty to take reasonable precautions from the start, lest we have reason later to reproach ourselves. Mere external protection as by ear-tabs or a night-cap may conserve the recuperative powers; gentle hot douching with clean water may relieve the pain by reducing the inflammatory congestion ; and spray and gargling may strike at the root of the trouble in nose and throat. However ill the patient may be in other respects, it is mistaken kindness to withhold these simple yet often effective meas ures of treatment. The tendency is to a "gath ering in the ear," which may be watery or mucous or may be purulent and infective. If the simple measures named, with dry heat from a salt-bag or hot water-bottle fail, there is need for surgical aid. Drainage by the natural Eustachian channel can only sometimes be gained; but after good cleansing of the nose and upper throat, it should be gently attempted by the Politzer method or the catheter. Abuse of these means is rightly condemned; so only the expert can maintain his right to use them if ill results follow— in spite rather than because of them. If they fail and the drumhead is seen to be bulging, especially with yellowish fluid, it should be delicately cut along its back margin to furnish a free escape for the collected fluid. If the swelling is marked at its upper portion, the knife should be carried up into this region, coming out in a sweep to the bone along the upper back wall. Free bleeding may be en couraged by warm douching and is more effec tive from such a cut than from external leech ing; yet since much of the blood-exit from the drum-cavity is along the front wall of the canal„ leeching in front of the ear may be almost as, good, but should remove not less than four to eight onnces. A wick of gauze or absorbent cotton, dry or moistened with carbolic or boric glycerine, should be inserted deep into the canal and the protective covering replaced. "But if you cut the drumhead you destroy the hearing!' is a fallacy which is still repeated. The opening of the drumhead is a delicate operation, often very painful so as to require ether or other anaesthesia and capable of doing injury to the structures beyond it; but it only forestalls the opening which would occur spontaneously, makes a free and well-placed opening and really saves a drumhead from ulcerating through. Far more important is its influence for good in relieving the injurious pressure in the drum cavity and it may be really life-saving in pre venting fatal extension of the suppuration.