On the Removal of Foreign Bodies from the Ear. 343

Balfour calls particular attention to in cases of aneurism) markedly stronger than that of the heart, although it was quite as strong, and the pulsation was not as distensile as might be expected of an aneurism of such position and dimensions.

3. The sounds of' the heart were audible in the tumour (with the first a well-marked bruit), but there was no accentuation of the second sound (Walshe), nor was the bruit of a booming character (Hayden), or confined to the turnout.

4. The ccdema of" the neck and thorax decidedly preceded that of the arms and hands by many days--the reverse of what would occur in pressure upon the superior vena cava by an aneurism.

5. The constantly rapid pulse--owr 130--for two months and half.

6. The temperature being always sub-febrile. 7. The hydro-thorax, with collapse of the left lung, the result of

obstruction to the pulmonary veins.

ART. X H L - - O n the Removal of Foreign Bodies from the JEar. By ROBERT T. COOPER, M.D., Univ. Dubl.

MR. F. H. WARD, in a letter in the Correspondence section of T]~e British Medical Journal, of January 27, 1877, thus expresses his opinion upon the operation of syrin~ng as a means of extracting foreign bodies from the ear : - -" I think," says he, " the main point to be observed to obtain success in the operation is to draw the pinna well upwards, in order to alter the relation of the meatus to the unyielding body which it contains, and so give a space for the entrance of the fluid. I f this precaution be not observed, or t]~e stream be caused to impinge directly on the foreign body itself, one can almost be induced to believe that all the syringing in the world would fail to move the mass in the slightest degree."

We can cordially acquiesce in the idea that causing a stream of water to play directly upon a foreign body, firmly impacted in the external auditory canal, will fail not merely to shift it, but to slfift it in the proper direction, for this qualification is a very necessary one. And yet it remains an undeniable fact that, however syringing be performed, it has proved itself, if we are to judge by our own experience, and by the expressions of approval with which it is everywhere received, a fairly successful means for removing foreign bodies from the meatus. And this arises, I am forced to believe,

344 On the Removal of Foreign Bodies from tile Ear.

more from the happy natural construction of the auditory canal, as well as from the comparatively small size of the bodies that find their way into it, than from the skilful manner in which the operation of syringing is usually performed. The operation must necessarily, under any circumstances, fail in such cases as that reported by Mr. Dalby, where some of the ccmeilt used in taking a cast of a person's face found its way into the meatus, and there was allowed to set. "The calibre of the passage is smallest about the middle. The outer opening is largest from above downwards, but the inner end of the tube is slightly widest in the transverse direction,"" so that the seat of impactlon of a foreign body is, naturally, where the calibre is least, and therefore midway in the passage. A jet of water playing upon a foreign body in this situation will have the effect of driving it inwards, and therefore to where the tube is wider from side to side. There will necessarily, therefore, be room sufficient for the water to in- sinuate itself between the offending body and the sides of the canal. In this way a welling-up of fluid will take place behind the foreign body and between it and the tympanic membrane, and which will, in proportion as the water accumulates, exercise pressure outwards upon the body, and in this way lead to its expulsion from the canal. Very often the bodies most firmly impacted are peas or beads; these being generally round will be found, when driven in, to revolve in the inner extremity of the passage, until the mass of water behind them, being at each stroke of the syringe forcibly agitated, drives them vigorously beyond the narrow portion of the canal.

This, I take it, is the rationale of the operation, the membrana tympani being saved--firstly, by the mass of water insinuating itself behind the foreign body and so interposing between it and the membrane; secondly, by the slanting position in which the mem- brane is thrown across the canal; thirdly, by the tortuosity of the meatus which contributes, in many instances at all events, to break the force of the stream of water; and, fourthly, by the generally unirritating surface of the bodies that find their way into the meatus.

But it is quite within comprehension that were an irregularly- shaped irritating foreign body, such as a cockroach, to find its way into the furthest extremity of the canal, or were there to be im- pacted in the canal a body large enough to fully occupy its entire

�9 Quain'~ Anatomy. Eighth edition. Art., "The External Auditory Canal."

By DR. COOPER. 345

inner half, a forcible jet of water playing directly upon this body would have no other effect than to drive it right in upon the furthest extremity of the canal, and in this way cause undue pressure upon the membrana tympani itself, and even if it did not rupture the membrane, at least occasion a great deal of pain by pressing upon the chain of ossicula auditoria. Such does not occur, I am prepared to concede, in every case of removal of large quantities of cerumen, bodies that correspond pretty much to this description, but even here it is quite possible that without being in full view of the ceruminous mass upon which wc are acting, injury may be done to the delicate membrana tympanl. Besides, even in such cases, I know from experience, wc can materially expedite matters, and can render our interference much less risky, and much less uncomfortable to the patient, by working with a speculum, and so being enabled to direct the stream of water upon such part of the body as is seen to be giving way.

Again, without actual view of the body, we will often, especially if unpraetlsed operators, undo with one stroke of the piston what we have effected with the immediately preceding ones. And hence, even in the case of impacted cerumen, a much longer time is occupied in removing it than is at all necessary, while with more irritating varieties of fbreign bodies absolute danger may be in- curred,

Taking into consideration, however, that the shape of the ordi- nary ear specula, as we find them in the instrument-makers--to wit, Toynbee's, Wilde's, and Gruber's--would be extremely incon- venient for such purpose, being with difficulty held should the syringe-piston be stiff' or the syringe itself be too large to manage conveniently with the one hand alone, I have devised an instru- ment with a handle attached to it, such that while the syringe is being held with the right hand it can be steadied, while the surgeon is syringing, upon the joint of his left thumb flexed upon the handle. In this way we can play steadily upon any part of the foreign body we s to be insecure so as to get the stream of water well behind it, or, if it be necessary from the nature of the impacted mass, as sometimes happens with cerumen firmly clinging to the sides of the canal, we can concentrate our efforts upon such portion of it as seems from its fixedness to require detaching from the sides of the meatus.

As is well known it sometimes takes a long time--where, for example, the cerumen is unusually hard--to detach it, but generally

346 On the Removal of Foreign Bodies from the Ear.

speaking if we can loosen the outer portion of the mass, hardened and dry from contact with the external air, the remainder, which is usually soft, having been protected from the external air, comes away easily. Toynbee" insists, and very correctly, " that the ear should be drawn backwards so as to straighten the tube; and if this cannot be effected on account of the left hand of the surgeon being otherwise engaged, the posterior part of the meatus should be pressed backwards by the point of the syringe." But let any- one try and press backwards the wall of the meatus in the way indicated, and he will find it all but impossible to do so without influencing the direction of the stream of water coming from the syringe. This is not the ease when we use pressure backwards with a speculum, as the orifice of the speculum, completely corres- ponding to the calibre of the auditory canal, allows of the jets of water being directed upon any one point.

Another consideration having reference to the patient's comfort, and a very necessary one, is to avoid wetting their clothes when we are syringing. Toynbee guards against this misadventure by means of his "ear-spout." " The use of an ear-spout is very serviceable during the process of syrin~ng. I t consists of a spring to pass over the head, at one end of which is a funnel to fit under the ear, down which the water can run into the basin." He then gives us a plate of his well-known and eminently useful "ear-spout " fitted on the head2 The objections I find to Toyn- bee's ear-spout are, that if the spring is not strong enough to cause it to remain sufficiently close under the ear, some drops will now and then find their way down the patient's neck, and so defeat

�9 Diseases of the Ear, p. 52. London. 1868. b Lor c/t, p. 53.

By DR. COOPER. 347

the object for which the spout was intended; while another, and the principal objection I urge to it, is its constituting an un- necessary addition to the requirements of the surgery---one at ]east that, as we shall show, may very well be dispensed with. Others use a specially constructed basin (Wilde), others an ordinary drinking tumbler half filled with the fluid to be injected, and direct the patient to press it well in undcr the ear; but this is objection- able, as a nervous patient, instead of pressing it tightly in under the lobule of his ear, very often will jerk it from him the moment the operation of syringing begins, and so allow space for the stream of water to flow down his neck.

:For these reasons the speculum, of which we give a woodcut (vide p. 346), is constructed with a spout-handle, an appendage that perfectly answers its two-fold requirements of a handle and a spout. We have termed this a spout-speculum, and feel convinced that any one who once uses it will not care to syringe after the old fashion, and, besides this, it has the not inconsiderable advantage, in these days of unnecessary costly instruments, of being as inex- pensive as any ordinary ear speculum, and quite as useful as any of them for the purposes of an optical instrument. I may explain that my speculum is constructed in vulcanite ; specula of which, as :Pollitzer says (at least he is speaking of much the same material, namely, " rubber"), have the advantage " o f being much lighter, and are, therefore, borne in the meatus by the patient, without support, far more easily than the many metallic cones, and, more- over, do not occasion the unpleasant cold sensation caused by a polished metal surface. The dark ground of the inner surface favours a clear definition of the illuminated parts far more than does the slight reflection of light from the polished metal, which increases the brightness of view at the centre. ''�9

Vulcanite is a material especially adapted for the requirements of a syringing speculum, which at any moment, on a sudden move- ment being made by the operator, might be forcibly pressed against and, if of metal, might injure the sides of the meatus. My speculum, as will be observed from the woodcut, is bevelled off at the end, so as to spoon away the mass of foreign matter as it is making its exit from the meatus. This, of course, is not absolutely necessary, though it really is advantageous. With a bright arti- ficial light and a laryngeal mirror on the operator's forehead, and

�9 PoUitzer on the Memb. TympanL Trans. by Mattewson and Newton. New York. 1869.

348 On the Removal of Foreign Bodies from the Ear.

an indla-rubber tube fitting closely over the spout of the speculum, through which will run the out-going stream of water into an adjoining basin, one can syringe for any reasonable time with this instrument, with the greatest possible comfbrt to oneself and the least possible inconvenience to one's patient.

To turn now to another consideration regarding the removal of foreign bodies from the ear--namely, the relative advantage of the ordinary ear-scoop and the syringe for this purpose.

Mr. Walter Rivington, in The British Medical Journal, March 18th, and again in that of December 16th, 1876, expresses his belief that " the ear-scoop should be banisl~ed from the surgical armamentarium." We agree most cordially with this opinion; the ear-scoop is an awkward, unsatisfactory, and dangerous instru- ment, but how can we pretend to displace our instruments unless we come forward with efficient substitutes; and this, so far as I am in possession of the facts, has not been done by this very intelligent surgeon.

Those who have followed us thus far will perceive that the principles upon which syringing, as a means tbr removing foreign bodies from the meatus, are based, are that the column of water from behind will drive the foreign body outwards, and that, there- fore, if the water cannot insinuate itself between the sides of the meatus and the impacted body, the syringing alone cannot possibly effect its object, and that the hitherto very general favour in which it is held is owing to the difference in shape between the inner extremity compared with the middle region of the auditory canal-- so much so that in syringing, as we generally perform it, a foreign body impacted midway in the canal is at the commencement of the operation driven further in, prior to the pressure of the column of water from behind it acting so as to impel it outwards. Now, if these premises be true--and any practical surgeon, not to say aurist, will know that they are so--lt follows that our chief aim in syringing ought to be to get a mass of water behind the impacted body, so that by exercising pressure upon it from inside, the force of the water will drive it out along the auditory canal. To accomplish this object effectually, I have suggested the construction of a syringe-nozzle, made somewhat in the shape of an ordinary dressing-case ear-scoop (vide woodcut, p. 349), the ribbon- shaped opening of the bore of which is placed above and somewhat short of the semi-flattened scoop-like extremity, with the object of directing the stream over the scoop-end, so that it may pass at first

By DR. Coorr, a. 349

between the latter and the wall of the meatus. In this way, the small scoop-like extremity having been insinuated a little way between the foreign body and the upper (generally) wall of the meatus, on forcing in the water with the syringe, the stream passing over the scoop-end of the nozzle will be directed into the fundus of the auditory canal, without at all impinging upon the foreign body, all the while steadied, if need be, by pressure of the scoop upon it. The possible objection that may be urged to

this is that insisted upon by Mr. Rivington, in opposition to the ordinary ear-scoop, in his paper of 16th December, 1876, where he says : - -" I t occupies a great deal of space, and it must be insinuated by the side of the foreign body, and reach its posterior part, to be of any service at all." In the first place, our scoop does not occupy nearly so much space as an ordinary ear-scoop, and it need not pass further than a very little way beyond the line of impaction ; it is enough if it can get sufficiently far in to allow of the water passing to the far side of the foreign body, and to enable us to use gentle pressure from above upon the foreign body, and so prevent its sliding inwards during the act of syringing ; for it is not difficult to believe that with the foreign body steadied, and the force of the stream of water directed against the upper wall of the auditory canal, our dependence being upon the three gained by the column of water welling-up from behind, the stream will, without injurious disturbance of the foreign body on the one part, or of the mem- brana tympani on the other, cause pressure to be made, a true vis & tergo, by the column of water pushing from behind as it accumulates against the impacted body ; and this--the operator taking care to lift off the pressure from the body by gently directing the nozzle up from off it, when he knows the water has well accumulated-- will allow of the water from behind driving the body outwards. But if the body impacted be composed of a hard, non-resisting material, and be firmly wedged in, we cannot, it may be urged, obtain even the small space required for the practical carrying out of these principles. This can hardly be so, for if we give a thought to our anatomy we will find that " the whole cartilage" [of the ear] "may be looked upon as an elongated plate, the lower part of

350 On tlze Removal of Foreign Bodies from tile Ear.

which is folded round in front so as to bring it nearly into contact with the upper part. ''a So that by taking advantage of this carti- laginous deficiency in the upper wall of the tube, we are enabled, however impacted a body may be, to insert, in certainly the great majority of cases, our scoop-nozzle far enough to allow of the stream of water passing on to the tympanic extremity of the canal. More than this, if the foreign body be irregular in outline, and be cal- culated, by reason of its irregular formation, to do injury to the tympanum, if brought into contact with it, the being able to steady this body by the aid of our syringe-tube, and so to prevent the impacted mass gett ing further into the canal, is a very obvious advantage--such a body as a cockroach, which formed the subject of discussion between Mr. Rivington and Dr. Alford Nicholls, of Dominica, would be. Certain I am that with our scoop-nozzle and spout-speculum it would be, indeed, an extraordinary mass of cerumen, which would baffle all efforts at dislodgment " f o r twenty minutes or half an hour," and this "wi thou t removing any particles, or even causing the water to be clouded" (Toynbee) .

I may add that these instruments are to be had of the well- known surgical instrument makers, Messrs. Arnold and Sons, Smithfield.

MET.~LLOT]f~ERAPIro

AT the Socidt6 de Biologle r M. Charcot related some interesting experi- ments Jn the employment of metals~ In the case of one hysterical woman, who had lost sensibility of one side r if three or four pieces of gold be applied to the affected side r and kept in their place by a piece of ribbonr at the end of a short time sensibility will return to an extent of from five to eight centimetres above and below the points of applica- tion. Often this sensibility will persist the entire day, and coincident with its return there is an elevation of temperature and an increase of dynamometric force. Sometimes one piece is enough to produce these phenomena. Other metals r such as zinc and copper, have been tried with like results, but some patients are more susceptible of the action of one than of the others. By the same method of procedure similar results were obtained in the case of two persons suffering from loss of sensibility in one side of the body arising from organic cerebral disease r and the sensibility r which was in these two eases restored by the action of the metals r lasted longer than when the malady was only hysterical

S .W. �9 Quain's Anatomy.