of the outer, meatus, and that the anterior and posterior walls of the tube are flat and only slightly concave; a form that also partially obtains in the bone. It is clear, therefore, that when a circular tube is introduced into this oval-shaped meatus, it may press against the anterior and posterior walls, and yet leave a considerable space above and below it unoccupied. As a rule, therefore, it is impossible by means of this form of instrument to obtain a view of more than a small portion of the meatus and membrana tympani at the same time; and should the meatus be very small, the circular tube does not give passage to a sufficient quantity of luminous rays to enable the surface of the membrana tympani to be discerned. Another disadvantage of the circular speculum is, that the pressure of its convex surface against the anterior and posterior walls of the meatus,

A set of Specula for the purpose of examining the External Meatus.

which are nearly flat, is liable to produce pain, especially where the tube is small. It is therefore evident that the part of the speculum inserted into the meatus should be of an oval shape. This modification of the tubular ear-speculum was suggested by me in a paper in the Lancet, published in August, 1850; since which time most of these instruments have, I believe, been made of this shape, and have been found to answer every purpose for which a speculum auris can be required. In order to hold the speculum more firmly, it is desirable that the expanded portion should be somewhat flattened; and this flattening should be at right angles with that of the smaller extremity. A set of three or four specula should be in possession of the surgeon. It has been suggested that the tubular ear-speculum should be made

of glass silvered; but the thickness of the material would occupy too large a portion of the cavity of the meatus.

Mode of examination.-After the preliminary investigation has been conducted, the patient being as nearly as possible on a level with the surgeon, the latter, taking the lamp in one hand, should feel and inspect the external ear and the orifice of the meatus, without the use of the speculum. Having done this, a speculum adapted to the size of the meatus is to be taken in hand, and introduced into the orifice of the meatus, care being taken that the long diameter of each coincides. If the speculum enters very easily, and there appears to be room for a larger one, the next size should be selected, and the orifice fully dilated; for in all cases, the larger the speculum used the greater will be the quantity of luminous rays entering the tube, and the more complete the view of the meatus and membrana tympani. The speculum, having been introduced, is to be pressed slightly backwards, for the reasons I have mentioned, and then, by

FIG. 15.

The Surgeon examining the External Meatus by means of Miller's Lamp and the

Tubular Speculum.

means of the lamp in the other hand, the rays of light are to be directed successively on the several walls of the meatus and on the membrana tympani. The size of the different parts of the tube, the

quantity, color, and position of the cerumen, if present, should be noted; if absent, the state of the part of the tube in which it naturally exists, and the degree of vascularity of the dermis lining the inner half of the meatus.

A considerable degree of care is required in the examination of the meatus in the infant and child. The total absence of the osseous meatus in the former, and its very limited size in the latter, should always be borne in mind, or the surgeon, when he introduces the speculum, is apt to press upon the membrana tympani. In many cases it is necessary only to open the orifice of the meatus, when the membrana tympani is at once seen without the introduction of the speculum any further.

CHAPTER IV.

THE EXTERNAL MEATUS (continued).

ON FOREIGN BODIES AND ACCUMULATIONS OF CERUMEN IN

THE MEATUS.

FOREIGN BODIES IN THE MEATUS-MODE OF REMOVAL-CASES-CERUMINOUS GLANDS-
THEIR DISEASES-ACCUMULATIONS OF
CAUSES-TABLE OF TWO

CERUMEN-THEIR

HUNDRED CASES IN WHICH THE CERUMEN WAS REMOVED-SYMPTOMS-EFFECTSTREATMENT-MODE OF REMOVAL-THE SYRINGE AND ITS USE-CASES.

FOREIGN BODIES IN THE MEATUS.

FOREIGN bodies are frequently introduced into the outer meatus. Among those which have fallen under my own notice may be named beads, slate-pencil, leaves, a shell, a pea, sealing-wax, a percussioncap, a pin, a piece of paper, seeds of grass, tobacco, wool, cottonwool, human hairs, bacon, lint, camel's-hair pencil, and camel's hair. When a body is put into the meatus by design, it is either done by a child in play, or by an adult for the purpose of medical treatment, or an alleviation of the itching of the tube. When a patient is suspected of having a foreign body in the ear, the first step of the surgeon is to make a careful inspection of the tube in sunlight or with the speculum and the lamp, with the view of ascertaining whether there really is anything present. In a great number of cases, having explored the whole of the meatus, and seen the membrana tympani, he will be able to assure the patient or the friends that no foreign substance is there. For want of this pre-inspection, lives have been destroyed in attempting to extract from the ear imaginary bodies. which had never lodged there. Medical men are not generally aware of the impunity with which a foreign substance may continue for a time in the meatus. It is not uncommon to find a mass of hard cerumen in contact with the whole of the meatus and with the outer

surface of the membrana tympani, without causing any pain or inflammation; and I have frequently removed other substances, as beads, pebbles, &c., which had been either in contact with the membrana tympani or in its immediate vicinity, without causing any painful irritation. Nor is this remarkable when it is remembered that the meatus and outer surface of the membrana tympani are a continuation of the outer skin, and, like it, covered with a layer of epidermis. The meatus and membrana tympani are extremely sensitive when pressed upon by hard or rough substances; but soft, smooth bodies may be gently pressed against them without exciting pain. Thus the artificial membrana tympani, made of vulcanized india-rubber, is placed against the outer surface of a perforated membrana tympani without producing any unpleasant sensation.

When a foreign body has been detected in the external meatus, it should be removed as soon as possible. The syringe and warm water are, as a general rule, quite sufficient to remove all rounded solid bodies. I have succeeded in extracting beads and other hard substances which appeared to be impacted in the meatus, by means of the syringe only, though a good deal of time is occasionally required. It may at times be useful to move the body slightly by means of a probe a little bent downwards, so as to facilitate the passage of the water to the back of it; for the mode by which the syringe acts, is in forcing the warm water inwards behind the foreign body, and thus gradually expelling the latter outwards. Mr. Wilde and other writers recommend the use of the curette, spatula, or forceps, in the extraction of extraneous substances from the meatus: but I have rarely been obliged to use any of these instruments, and resort to them should be avoided if possible. Dieffenbach, who advocated the use of a curved director, or curette, must have met with cases showing the practice to be dangerous; for he says, "Should violent bleeding supervene, and there be no likelihood of completing the operation at one sitting, cold and afterwards warm applications are to be resorted to, to prevent suppuration." It is also almost impossible to pass a curette between the extraneous substance and the meatus without impelling that substance inwards, in which case it is very apt to be pressed forcibly against the membrana tympani, and cause inflammation. Cases are sometimes met with in which the most lamentable results have followed attempts at removing foreign bodies by instruments. Death itself has not unfrequently happened;