In the case of a hard substance, repeated attempts may be made to dislodge it before resorting to further measures; but in the case of a soft vegetable substance like a pea, it must not be forgotten that moisture tends to make it swell and perhaps will necessitate almost immediate extraction by instruments. Extraction by instruments. =Indications.= (i) If inspection shows that the foreign body can at once be removed by a suitable instrument: for example, a percussion cap the edge of which may be grasped by a pair of forceps (Figs. 179 and 193); or a small boot button whose shank, if it faces outwards, may be caught by a small hook. (ii) If repeated attempts have failed to remove the foreign body by syringing. (iii) If previous attempts by others have failed, and the foreign body has been pushed in beyond the isthmus, and cannot be removed after prolonged syringing. (iv) If syringing produces violent giddiness, showing the probable presence of a perforation of the tympanic membrane. (v) If there be symptoms of acute inflammation of the middle ear or of pus being pent up behind the foreign body. [Illustration: FIG. 179. CROCODILE FORCEPS. Two-thirds size. A, Points of crocodile forceps, full size. B and C, Aural punch-forceps. D, Aural scissors. ] =Operation.= An anæsthetic may not be necessary in adults if the foreign body is not too deeply placed within the ear, if its removal appears to be a simple matter, and if the patient is of a placid temperament. Otherwise, unless contra-indicated for some special reason, a general anæsthetic should always be given in children, and it is also preferable in adults for the following reasons:--(1) Inability to remove the foreign body after repeated attempts by syringing usually means that its extraction by instruments will be a somewhat difficult matter. (2) The risk of injury to the meatal walls or tympanic membrane from involuntary movements of the patient during the operation is far greater than the risk of the anæsthetic. (3) If the foreign body cannot be removed through the meatus by means of instruments, the post-meatal operation is indicated. This, if necessary, can be done at once if the patient is under a general anæsthetic. If no anæsthetic is given the patient may sit up in a chair; otherwise, the recumbent position is advised. It is usually necessary to use an aural speculum, but if the foreign body be situated near the entrance of the meatus a sufficient view may be obtained by pulling the tragus forward and the auricle backward. Good illumination is essential. (i) _If the body be a soft substance_, such as a pea, the core of an onion, or a fragment of wood, it is best removed by fixing into it some form of sharp hook (Fig. 178, D). These hooks vary in shape. They may be curved, or shaped like a crochet-hook, or have the sharp point placed at right angles to the shaft of the instrument.