CHAPTER VIII. FOREIGN BODIES IN THE EAR. (Part 2)

attempted to remove it, under chloroform, using for this purpose a small elevator. It is stated that half the button was removed in this way ; but the other half could not be dislodged. In a few days, the child having become very weak from the operation and the ansesthetic, from the chloroform, I was called in consultation. A careful examination was made. The mem- brana tympani was found to be gone, there was considerable swelling of the canal, but the button was not to be seen either by the physician or myself, although he thought he detected it with the probe. Another surgeon was called in, and he was not able to find a foreign body, and the child has been under treatment ever since for a chronic suppuration of the middle ear, the mem- brana tympani and the ossicula being gone, and the hearing irretrievably injured. I recite such cases in order to show what harmful conse- quences may result from the most conscientious attempts to remove a foreign body with instruments. No engravings are given in this volume of the numerous hooks, forceps, perforators, drills, picks, et id genus omne, that have been devised by surgeons, with more ingenuity than wis- dom, for the removal of foreign bodies from the ear, because I firmly believe that the vast majority of such instruments are very dangerous weapons ; while they are usually greatly infe- rior in efficiency to the use of the warm water and syringe. Cases will occur, however, in which syringing will not be suf- ficient ; but I should not hasten unduly, unless the body had become impacted in the tympanic cavity, or was causing unpleasant or serious symptoms. In such cases the ordi- nary armamentarium of the surgeon will contain instruments adapted for the individual cases as they occur. Let him remember, however, that once beyond the membrana tympani, he is dealing with parts whose injury becomes dangerous not only to hearing but to life. The ancient suggestion of Hippocrates and Du Yerney (see 172 REMOVAL OF FOREIGN BODIES. page 36), to detacli the auricle from the ear, will be found worthy of consideration when it is found impossible to remove a foreign body through the canal. It certainly cannot be a dangerous operation, and it is much to be preferred to any risk of serious injury to the cavity of the tympanum or the labyrinth. Dr. Lowenberg* reports an ingenious method by which he removed a small ivory ball, from the tip of a quill penholder, which had been forced into the ear of a boy nine years of age. Various attempts at removal, by other hands, wounded the canal, perforated the membrana tympani, and excited severe inflammation. After the inflammation had subsided, Dr. Lowenberg attempted to remove the body by syringing, by Valsalva's and Politzer's methods of inflating the ears ; but he failed. He then extracted the ball, by bringing the point of a small brush, dipped in joiners' glue, in contact with its outer surface, allowing the glue to harden, and then extracting brush and ball together. Dr. E. H. Clarke, who is quoted by Blake in the same report from which I have taken the description of Dr. Lowen- berg's method, once adopted a similar procedure with success. The foreign body was a hard, smooth ball, and it was ex- tracted by passing a thread through a small square of adhe- sive plaster, and bringing the latter, by means of a fine tube, into contact with the surface of the ball, when sunlight was concentrated upon it by means of a lens, until it softened and adhered, when it was easily extracted. These two methods are certainly to be commended as both ingenious and safe. It is possible that the reader is ready to believe, that I am attaching too much importance to this subject of the removal of foreign bodies from the ear : but I am sure that any one who has taken the pains to look over the literature of this subject, or who has seen many cases, will feel that too much stress cannot well be laid upon the necessity for skill and wis- dom in the management of these cases. I will, however, close the chapter by some statistics which * Report on the Progress of Otology, by C. J. Blake, Transactions Amerfr can Otological Society, 1872. FOKEIGN BODIES IN THE EUSTACHIAN TUBE. 173 have been carefully prepared by Dr. Mayer, of Munich, which illustrate this subject, and with the insertion of a painful case, from Mr. Pilcher's book on the ear, which is one I have been in the habit of repeating to my class, as a warning to those who try to extract from an ear what they have never seen. My distinguished countryman, Dr. J. Marion Sims, of this city, published an article, illustrated by three cases, in the American Journal for Medical Sci- ences, vol. ix., 1845, that very warmly and ably advocated the use of the syringe for the removal of foreign bodies from the ear, but which did not receive the attention it deserved. FOKEIGN BODIES IN THE EUSTACHIAN TUBE. Among the cases whose statistics will be given as reported by Dr. Mayer, two will be noticed where laminaria bougies were broken off in the Eustachian tube. Dr. Hecksher,* of Hamburg, relates an interesting case that belongs to this class. The patient was a principal of a college, who had been accus- tomed to treat his own ears — which were affected with chronic catarrh — by the use of the Eustachian catheter. Dr. Hecksher received a telegram one day from the patient, for whom he had occasionally prescribed, stating that he had got a foreign body in one of his Eustachian tubes. When Dr. Hecksher reached the patient, he gave the following history : He had introduced through a metallic catheter a whalebone probe into the tube. On the end of this probe was fastened with a silk thread a raven's feather, which he used for the purpose of washing away mucus from the tube. One evening as he was using the apparatus, he drew back the probe with- out the feather, and he found that he had left it in the tube. It caused so much pain that he could not sleep. Attempts were made by a physician to remove the foreign body, but they failed. Dr. Hecksher then attempted to remove the body, but the parts were so swollen that he could not practice rhinoscopy, and see the feather, and he failed with various kinds of forceps to remove it. So much inflammation ensued that he was obliged to desist, and use anti- phlogistic treatment ; but the patient finally removed the feather hiniself by the aid of the catheter introduced in the usual way, and his finger passed behind the uvula. CASES. Dr. Ludivig Mayer f has collected the cases of foreign bodies in the ear that he has been able to find in the litera- * Monatsschrift fur Ohrenheilkunde, 1870, No. 1. f Monatsschrift fur Ohrenheilkunde, Jahrgang IV, No. 1. 174 STATISTICS OF FOREIGN BODIES IN THE EAR. ture of the fifty years preceding 1870. The whole number is 77. Of these persons 16 were between 1 and 10 years of age. 10 " " 10 " 20 " 10 " " 20 " 50 " 1 was over 50 " " The age of the remainder is unstated. In 6Q cases the foreign body was in the auditory canal, 8 were in the cavity of the tympanum, and 3 in the Eustachian tube. Of the three cases in the Eustachian tube, two were at the pharyngeal orifice. In the third case, a barley-corn pro- jected from the pharyngeal orifice, and at the post-mortem section — it is not stated of what disease the patient died — the foreign body was found to reach into the osseous tube. In two of the cases the foreign body was in the ear but twelve hours before seen by the surgeon who reported them. In only 12 of the cases was the foreign body in but a short time, varying from days to weeks. In the remainder, they were in for years. Four were in for four years, two for twenty years, one for forty-five, and one for more than sixty years. The substances found were — a needle, carob beans (6), beans (3), cherry pits (6), living larvae (4), peas (1), a wisdom tooth of the upper jaw, a grain of coffee, a snail, pearls (2), point of a glass syringe, a glass ball, wads of cotton (6), a carious tooth, a piece of hard coal, a wad of paper, a gun cap, a piece of bone, a piece of bread, a bit of lead, laminaria bougies in the tube (2), a millet seed, a piece of coral, a barley-corn in the tube, and an agate stone. Dr. Mayer finds, on an analysis of these cases, that the attempts to remove the foreign bodies had usually caused much more trouble in the ear than their presence. In 48 of the 77 cases, functional and pathological changes are said to have occured as a result of the presence of the foreign bodies. In 11 of the cases it is reported, that the attempt at removal caused these disturbances. Pain in the ear was generally the disturbing symptom in those cases in which the foreign body caused any trouble. This was chiefly due to the irritation of the lining membrane CASES OF FOKEIGN BODIES IN THE EAE. 175 of the canal, which is so closely allied to periosteum in it3 nature as to be subject to intense pain. Besides, as shown by F. E. Weber, the pain in the cartilaginous portion of the canal is severe on account of the fact, that the fibrous tissue of the cartilaginous canal is fastened to the squamous portion of the temporal bone, above and behind, by tense fibres. As has been shown, the canal is very richly supplied in nerves, and this serves to explain the severe pain experienced when a rough body is in the ear, or when the canal is abraded by attempts at the removal of a smooth and harmless one. Polypi arose five times in consequence of the inflammation of the ear. Severe hemorrhage occurred five times, and always in consequence of attempts to remove the foreign bodies. In one case there was delirium, and in three cases suppu- rative meningitis, and once a cerebral abscess, with, of course, a fatal result. The membrana tympani was perforated, and the cavity of the tympanum inflamed, from the efforts at extraction in the three cases in which meningitis resulted. In one case the patient, a child, attempted to push the foreign body — a piece of flint-stone — out through the other ear. Suppurative meningitis occurred, and death resulted in a few days. The stone was so firmly fixed in the mastoid cells that trouble was experienced in removing it, even at the post- mortem examination. In one case on the section, a wad of paper was found in a cerebral abscess which communicated with a collection of pus in the tympanic cavity. It had probably been forced there by the attempts to remove it. The disturbances of the nervous system were considerable in some cases, and they throw light upon the influence of chronic aural suppuration upon this part of the organism. In three cases there were general convulsions ; there was paralysis of one side of the face in five cases, atrophy of the arm in two cases, twice there was anaesthesia of the whole of one side of the body. There were two cases of epilepsy. The facial paralysis was caused by a continuation of the inflammation to the Fallopian canal and the facial nerve. 176 CASES OF FOREIGN BODIES IN THE EAE. The convulsions and the epilepsy were probably caused by reflex action through the medulla oblongata, due to peri- pheric irritation of the fifth pair of nerves. The cases of atrophy of the arm and anaesthesia of the body are so imperfectly reported, that Mayer does not attempt any explanation of them. Our limits do not allow of a complete transcription of the cases which Dr. Mayer has collected with such care ; only a few of the more curious or important ones, can receive a fur- ther allusion. In one case a horse coughed some oats into the ear of a man as he was going by the animal. Deleau, Junior, removed a foreign body from the cavity of the tympanum, an agate stone, by an injection of water through the Eustachian tube. The reader will find this case fully reported in Lincke's collection of Monographs on the Ear* The case of atrophy of one arm, epilepsy, anaesthesia of one-half of the body, is the famous one of Fabricius Hildanus, quoted by Von Troltsch.f The patient, a young woman of 18 years, is said to have been cured of all these symptoms by the removal of the foreign body, a glass ball, eight years after it was inserted. Handfield Jones X saw a case in which hemiplegia with convulsions arose from the presence of insects in the ear. Wederstrandt § reports a case in which molten lead was poured into the right ear of a drunken man. The pain was not severe ; the hearing power was gone. The patient was able to leave the hospital in eight days. The lead was not removed, and severe suppuration occurred. Seventeen months after he was in the same condition, with paralysis of the right orbicularis palpebrarum muscle ; a polypus had grown over the lead. In three of the cases death occurred, and in all of them it may properly be said to have been caused by attempts to * Lincke's Sammlung, Bd. I, p. 154. f Text-book, American translation, p. 490. X Sydenham Society Year-book, 1861. § American Journal of the Medical Sciences, vol. ix. FATAL ATTEMPT TO EEMOVE A FOEEIGN BODY. 177 remove foreign bodies, which, whatever disturbances of the system they might have produced, would not probably have led to death. Mr. Pilcher, in his work on the ear,* reports a very in- structive case in full in which surgeons of a London hospital attempted to remove from the ear of a child of seven years of age, the head of a nail, which they never saw, but which they felt with a probe. The first surgeon to whom the child was brought said he saw the head of the nail, but he did not attempt to remove it because four men could not hold the boy's head still. A director, dressing forceps, which were both bent in the forci- ble efforts, forceps with hooks were used, and they were also bent straight, but the nail conld not be removed. An incision was then made behind the auricle, and the meatus was ex- posed. A search was then made for the nail, with forceps and an elevator. . Tooth forceps were then used ; three pieces of metal, which appeared to be pieces of the nail, were removed by these delicate instruments. The malleus bone was then removed by the forceps. The patient was now so exhausted that "his pulse could scarcely be felt, and his skin was bedewed with cold per- spiration." The operator then stated that he had used " more force than was warrantable." He thought, however, there was now a large opening (sic) through which pus might escape, and yet he feared that a portion of the petrous bone might exfo- liate, and that meningitis and abscess of the brain might occur. He stated that he had seen three or four cases which had terminated in this manner. Of course the little victim died, and that too on the third day after these operative attempts. The post-mortem examination revealed softening of the base of the brain, and of the anterior part of the hemispheres. Not a vestige of the bony part of the external auditory canal remained, it having been removed during the operation, * Treatise on the Ear, American edition, by George Pilcher. Philadelphia, 1843. Reprint. 12 178 FATAL ATTEMPT TO REMOVE A FOREIGN BODY. and the floor of the tympanum was also wanting. There was considerable pus in the tympanic cavity. " The nail not being in the tympanum, sections were made through the cochlea, vestibule, semicircular canals, and mastoid cells ; but there was no nail to be found.'''' The fact has already been alluded to in this chapter, that persons sometimes suppose there is a foreign body in the ear, when there is actually none in it, and when there probably never has been one there. At times mental delusions occur on this subject. I have seen several cases of the kind which are quite remarkable. Two cases I saw at the New York Eye and Ear Infirmary, where the patients, who were women of the lower class in life, supposed that pins were in the auditory canal. No amount of reasoning, nor the subterfuge of pretending to remove a pin from the ear, by syringing, could satisfy these females. In another case a woman brought her son to my clinic in the University of New York, and stated that he was passing pieces of anthracite coal from the external meatus. She had quite a quantity of coal in a handkerchief, which she said had been passed from the ear. Some of these pieces of coal were larger than the auricle. The boy agreed with his mother in her insane statements. I am sorry that they passed from my observation before I could fully investigate the cause or mo- tive for the delusion. In another part of this work* allusion will be again made to the cases, not uncommon, in which patients with chronic dis- ease of the middle ear, and persons who