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Foreign Bodies in the Ear.

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patient, his predisposition to cerebral affections, the nature of the foreign body, the degree of tumefaction, &c. &c. Thus, serious consequences have followed the movements of a flea in the meatus, and a roll of paper having penetrated the membrana-tympani, induced a fatal meningitis; while, on the other hand, Larrey and others relate examples of large bodies, such as cherry-stones, teeth, &c. remaining in the meatus without causing the slightest pain.

Treatment.-Nowhere is the aphorism of Hippocrates, sublata causa tollitur effectus, more applicable than here, provided it be enforced promptly. A great variety of means of extraction, according to the nature of the foreign body, have been resorted to. In all cases we should at once inject oil or some emollient fluid, which relieves the pain, facilitates the future extraction, and if the body be an insect it may cause its removal. M. Latour describes the various instruments which have been used in ancient and modern times. He speaks highly of the probe in the form of an earpick employed by M. Begin. When the body is forcibly fixed, he believes the use of a small wimble may be sometimes advantageous. A variety of forceps have been employed, and they answer excellently for pointed, angular, &c. bodies. Rounded bodies they seize with difficulty, and retain with as much, unless their extremities are concave. To be truly useful, each branch should be separately applied to the body and then locked like midwifery forceps.

Of foreign bodies which are developed within the ear itself, the indurated cerumen is the most common. The meatus in the young and in the adult is much moister than in the aged, in whom these concretions generally occur. These may vary much as respects consistence, colour, form and dimensions. If the concretion is soft it may be removed by an ear-pick; but if indurated, the membrana-tympani might be injured by this procedure, and injections are to be preferred. M. Latour prefers oil to any other fluid, as partly dissolving the cerumen and facilitating the expulsion of the rest. Many cases of deafness, attributed to other causes, and long treated by other means, may, in this simple manner, be relieved.

Insects entering the ear at first cause a disagreeable sense of tickling, which is eventually converted into most dreadful pain, which may give rise to severe nervous symptoms, and even endanger the patient's existence. The earwig is considered by M. Latour, as well by other writers upon the subject, as the most dangerous of the insects which infest the ear. Many means have been recommended for the expulsion of insects. Various forms of probes and forceps have been contrived, the points of which are to be smeared with some sticky substance to secure the animal. Fluids for the purpose of impeding its respiration or poisoning it have been injected, such as sweet oil, milk, warm water, bitter almond oil, decoction of peach leaves, soap and water, essence of turpentine. Lastly, substances have been held at the external ear to tempt the insect out. "As to a little insect," says Ambrose Paré, "we may extract it by laying half a sweet apple at the orifice; for the little creature in attempting to nibble it, may be seized hold of." Laschevin says the half of a potatoe is a special antidote in this way for the earwig. M. Berard and other surgeons have obtained the exit of the larvae of flies by employing a piece of meat; and, according to M. Velpeau, milk attracts the earwig. All these means are

desirable to be known, as in an emergency we may not have access to that one which we prefer; but, in the majority of cases, a simple injection of oil is all the treatment required.

We need not follow the author through the details he enters upon according to the nature of the obstructing body. He relates some interesting cases in illustration of the length of time foreign bodies may have remained in the ear prior to extraction. In two of these they excited more or less ptyalism, and in one lachrymation.

GUY'S HOSPITAL REPORTS. Second Series. Edited by Drs. Barlow and Birkett, and Messrs. Cock and Poland. Vol. IV. 8vo. pp. 498. Highley: London, 1846.

THE present volume contains papers by Drs. Addison, Lever, Williams, and Hughes, and by Messrs. France, Hilton, King and A. Taylor; besides two Reports, one Medical and the other Surgical, of the Clinical Society connected with the Hospital. We shall notice them seriatim.

I. ON THE FALLACIES ATTENDING PHYSICAL DIAGNOSIS IN DISEASES OF THE CHEST. By Thomas Addison, M.D. &c.

After a glowing eulogium on the rare merits of Laennec and the distinguished services which he has conferred upon medicine, by the introduction of Auscultation into the art of diagnosis, Dr. Addison very judiciously remarks that this great discovery has, on the whole, been more injured by indiscreet and indiscriminate advocacy of its claims than by the most determined and open hostility.

"Books and essays without number, and of great value, have been written for the purpose of adding favourable testimony to the merits of the stethoscope; to increase its utility, and extend its application; whereas, so far as I know, not a single individual has deemed it right, or desirable, to pursue the opposite course, of expressly publishing to the world the manifold difficulties and fallacies attending its use. The publications alluded to, by the semblance of a too exclusive advocacy, have, according to my humble belief, placed the stethoscope and its pretensions in a false position; they have awakened in the minds of many a vague notion of infallibility; they have led the profession and the public to expect too much; and, by suppressing or concealing the real imperfections of a favourite expedient, have put it in the power of hostile parties to inculpate the stethoscope for the errors of the stethoscopist."-P. 3.

No sensible physician will ever substitute Auscultation for other means of diagnosis; but he will gladly employ it as a most useful auxiliary. He will not lean upon it as a crutch, but only use it as a staff with which to explore his way. Never will he omit to obtain a full and complete history of every case of disease which comes under his care. It is not the knowledge of one symptom, or of one set of symptoms alone, that he is > be satisfied with; and how can he hope for such information unless by

1847] Dr. Addison on the Fallacies of Physical Diagnosis. 91 putting into requisition every means in his power of interrogating Nature? The too exclusive stethoscopist will unquestionably be oftener at fault, at least in his treatment, than he who refuses to avail himself of physical diagnosis altogether; but surely the abuse of a thing can be no reason, in the eyes of a man of sense, for the total neglect of it. As a matter of course, the acquisition of any new method of investigation pre-supposes an expenditure of diligent attention on the part of the student. Dr. Addison says: "unfortunately, in the medical profession, all truly valuable and practical knowledge, is only to be obtained by a proportionate sacrifice of time and labour."-Why unfortunately? It would be much better, alike for the public benefit and the credit of our profession, if the art of medicine-we do not say, of mere prescribing-were not so easily attained. Dr. A. has cast his observations into the form of distinct propositions, appending remarks to each of them. We shall select those which strike us as the most important.

1. Many persons, whilst under examination, fail to perform the respiratory act efficiently, either from mere nervousness, or from not knowing how to do it; they merely heave the chest up and down, instead of freely inhaling and expelling the air.

This may lead to the erroneous belief that the respiratory murmur is deficient or even absent, while the lungs are perfectly healthy. The best way of preventing this source of fallacy is to desire the person to cough, and instantly afterwards to inspire forcibly, in order to cough a second The two sides of the chest should also be examined and compared together at the same time, in order to guard against error.

time.

2. Whatever lessens the freedom, mobility, or elasticity of the ribs, renders the sound or percussion more dull.

Hence, in rickets, old age, &c., the signs afforded by percussion, and in many instances by auscultation also, are often little to be relied upon. The chest is imperfectly resonant, the respiratory murmur is apt to be unusually feeble, and the impulse of the heart to be much weaker than it would be, if the ribs were more free and elastic in their movements.

3. When there is a lateral flattening of the ribs, with projection of the sternum, as is usually the case in a rickety patient, the action of the heart is liable from slight causes to beat with such violence, and to have its sounds and impulse so extensively diffused, as not unfrequently to have led to an unfounded apprehension of serious organic lesion of that organ.

The physician must, moreover, be more than usually cautious in his diagnosis and treatment of acute pulmonic disease under such circumstances; as the violence of the symptoms is often quite disproportionate to the extent and severity of the existing disease, and may therefore suggest unnecessarily active treatment.

4. When exploring the chest in a case of recent disease, we may be misled by the permanent effect of an ancient Pleurisy, or Pneumonia. It is well known that an old pleurisy or pleuro-pneumonia will often cause very considerable contraction of the affected side of the thorax.

This deformity is generally observed at the lower part of the chest, either anteriorly or posteriorly, or both. As we might expect, there is usually dulness on percussion over the seat of a Pleuritic contraction, also feebleness or absence of respiratory murmur, constrained movements of the ribs, and dry crepitating or crackling sounds heard chiefly during the act of inspiration. In the same manner, there may be dulness on percussion, bronchial respiration, bronchophony, and a sub-mucous crepitation discoverable in a fever patient from an old attack of Pneumonia, which has left a larger or smaller part of the lungs more or less completely hepatised. In either of these cases, it may be scarcely possible for the physician to determine, at least by mere physical examination, whether the consolidation be of recent or of ancient date.

As a matter of course, the existence of these signs might seriously mislead a physician in the diagnosis of recent disease, if he were not aware of their long standing. Hence the necessity of making minute enquiries as to the past history of a patient.

5. Distension of the abdomen from Ascites or from enlargement of the Liver or Spleen, &c., in short whatever tends to push up the diaphragm and to prevent the free expansion of the lungs, may have the effect of producing dulness upon percussion and feebleness of the respiratory murmur in the inferior part of one or of both sides of the chest; and may thus give rise to the suspicion of a Pleuritic Effusion being present, when all is right within the throax.

The position of the patient, according as this is upright or horizontal, will necessarily have the effect of modifying the extent and degree of these abnormal signs just mentioned.

6. Of all the sources of fallacy to be encountered in the physical diagnosis of diseases of the lungs, Bronchitis is by far the most prolific of mistakes and oversights.

The co-existence of this disease is exceedingly apt to obscure the auscultatory symptoms of Phthisis, Pneumonia, and Pleurisy, as well as various forms of chronic pulmonary disease.

The value of the following remarks, on the complication of bronchitis with tubercular disease of the lungs in its early stage, will be appreciated by every practical physician :

"It is under such circumstances that the too exclusive stethoscopist is liable to be beaten in diagnosis by those who reject physical examination altogether; for, the latter enquires carefully into the history of the patient and of his family, he observes attentively the patient's general aspect, and the character and order of the general symptoms; all of which are wont to be too much disregarded by the stethoscopist. Nevertheless, if the stethoscopist do his duty, he has greatly the advantage: he will institute an equally careful enquiry; added to which, he will observe whether the bronchial obstruction is limited to the apex of the lung; he will repeatedly, and for some minutes at a time, apply the stethoscope, or, what I prefer, the naked ear, to the upper part of the chest: he will desire the patient to breathe freely, to cough, and, if possible, to expectorate. He will, by so doing, often succeed in removing the obstructing mucus, and thereby develop, however slightly, some degree of bronchial respiration, or bronchophony, or both; signs strongly confirmatory of phthisical disease in doubtful cases. Ac

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cording to my own experience, the individual symptom, which, without being decisive, above all others increases the apprehension of phthisical disease, is occasional slight hæmoptysis just sufficient to tinge or streak the sputa.”—P. 9.

We are inclined to attach more importance than Dr. Addison seems to do to the character of the sputa. In simple Bronchitis we never observe those fragmentary boiled-rice-like particles floating in the water (in which the sputa have been received) and gradually settling down to the bottom of the vessel, which are almost uniformly seen in cases of genuine Phthisis. The streaked yellow appearance too of the expectorated matter, as well as the globular or nummulated form which it so often assumes, are phenomena nearly peculiar to the latter disease. Moreover, careful percussion will often serve most materially to aid the diagnosis. A firm or forcible tap over the site of a tubercular deposit very generally occasions, if not actual pain, a sense of uneasiness, which is not experienced by the patient at the corresponding spot on the opposite side of the chest; this uneasiness often extends through to the back of the shoulder.*

7. In every case of suspected Phthisis, the patient should be made to breathe and cough with some degree of violence, the physician having his ear applied all the while to the chest; as the bronchi opening into a tubercular cavity are apt to become occasionally obstructed with mucus, so that the characteristic auscultatory phenomena may not be perceived during gentle respiration. It is necessary, therefore, that the obstructing mucus be dislodged, before these phenomena can be distinctly recognised. From want of the simple precaution just given, many errors of diagnosis have been committed.

8. Dr Addison remarks, with great truth, that "a person may have a violent tearing cough, lasting for weeks or months, attended with slight mucous expectoration, occasionally even streaked with blood, and causing pain to be felt throughout the whole chest; as well as an appearance of constitutional distress; whilst neither auscultation nor percussion can detect any morbid change in the chest."

Such a case may result from a very simple cause-one that is very often overlooked in practice-we mean, a relaxed Uvula. It may depend, in the female, on Hysterical irritation. We have seen it in several instances in persons of Gouty diathesis, and found it yield to the use of antacids and of an anti-arthritic regimen, when it had resisted every other plan of medication. The existence of old pleuritic adhesions, or of limited pulmonic consolidation always, as might be expected, aggravates the severity and obstinacy of such coughs.

"9. When Pneumonia occurs in its simplest form, i. e. with little or no bronchial complication, there is sometimes no cough and consequently no expectoration;

* We may here remark, en passant, that the application of a single leech every night or every second night, for a week or two at a time, over this uneasy locality -followed, it may be, by small blisters of the size of a half-crown or so--has in our hands been generally attended with very marked benefit.