But epidermis is not soluble in water or any other available material. When the impaction consists largely of lami nated epithelium, especially if really a cholesteatoma-mass working out from the middle ear, no such easy task is to be anticipated. Prolonged syringing, aided, perhaps, by skillful use of the probe and forceps, must be employed to remove such a mass, and prudence may dictate adjourning the completion of the matter to a second sitting. The canal walls are often excoriated beneath such a mass, and exfoliating, but not yet fully detached, epidermis may anchor it to tender surfaces, from which it should not be violently torn away. But in true cerumen-impaction there is little or none of this. Delay in soaking or otherwise trifling with the plug only increases any irritation from its pressure. The patient, if put off, may never return to the sur geon whom he truly says made him worse instead of better. Dizziness or fainting may compel a suspension of the sitting; but if the patient has been warned to an nounce the first sensation of the sort, this can generally be forestalled; and an eye should generally be kept open for any clammy sweat on his brow. Pressure upon the tympanic structures is a com mon cause; and suction with the squeezed Politzer bag fitted in the canal will often undo the mischief and give instant re lief. If not, the patient should be laid flat by tilting his chair back until the head is on or near the floor and induced to lie still until feeling right again; when the chair can be raised again and we can proceed in a few moments without repe tition of the disturbance.
After this and all other syringing, the canal should be gently dried with ab sorbent cotton on a delicate carrier and the air shut out by a light flake in the exit; otherwise there will be chilling from the evaporation of the trace of moisture left, with possibly unpleasant reaction. Any excoriated surfaces should be dusted with boric acid or aristol; and any needed treatment given to the nose, throat, and middle ear.
In the removal of cerumen instru ments such as probes, hooks, etc., should be absolutely avoided.
The syringe should be thoroughly sterilized and capable of containing about three ounces and a quarter of liquid. The extremity should be very fine and perfectly cylindrical. It is well to attach a soft-rubber tube a centi metre long to the end, to prevent injury to the passage. Water that has been heated to OS° F. should be used, but it must not be applied too hot. In admin istering the injection, the end of the syringe should be directed along the upper wall of the meatus. The first in jection should be made very gently. in order not to cause vertigo. If no symp toms occur, from 5 to 6 syringefuls may then be injected.
If the cerumen does not become loosened, violent syringing must not be resorted to. The cerumen must then be softened. and the following solution is recommended:— 13 Sodium bicarbonate, 15 parts. Glycerin.
Water, of each. 300 parts.
Six drops of this solution are to be warmed and dropped into the ear three times a day; a tampon of cotton is placed in the ear after each instillation.
At the end of forty-eight hours fresh injections may be repeated, and, if the lump is still immovable, the instillations are again resorted to.
After the extraction, the ear should be thoroughly dried and a small tampon of cotton placed in the entrance and allowed to remain there for two days. Laurens (Presse MCA., Feb. 19, '96).
Foreign bodies in the ear are not com mon or important except as furnishing to incompetent and rash attendants op portunity for improper and sometimes most injurious interference. Let alone, none but gunshot missiles or living in sects can often occasion the slightest damage, except as forming nuclei for subsequent collections of cerumen.
Case in which the point of a knife, apparently after a stab, was wedged in the posterior wall of the meatus twelve years before causing any reaction. The
foreign body was removed by operation to recover from the ear affection. mann (Dent. med. Woch., No. 46, '96). It is the injury inflicted in efforts to remove them that is responsible for numerous untoward results, occasionally fatal. Rarely will any such object be thrust primarily beyond the cartilaginous portion of the canal, whence its tion by any competent method should be easy. It is only after family or friends or incompetent medical man has pressed it deeper and too often wounded or tated to marked swelling the tissues about it, that the condition assumes any importance. Then the panic which sumes that it "will certainly go to the brain" must first be allayed; the patient quieted to bear examination, which vious abuse has taught him to dread; and the ground clearly taken that the truding mass will be at once removed only if this can be safely done. To sel delay afier failure is apt to seem a reason for immediately seeking another and more vigorous attendant. Careful examination should first be made to termine the presence of the alleged eign body, and this should begin with the other ear, not only that the configuration of the parts may be noted, but because in the excitement one ear may be receiv ing attention belonging to both or to the other alone. If there is, in fact, a body to be removed, the syringe and water of about 105° F. should be used as above directed, and, unless there has been very bad mishandling, there is likely to belit tle difficulty in washing out the intruder.
Should there be firm impaction in the bony canal or such swelling of the soft parts as to defy this procedure, it is best to use the water hotter still to reduce the inflammation and then to wait until the conditions are more favorable. Ur gent symptoms may forbid this delay; then if vigorous syringing is unavailing, other instruments, such as a fine loop of wire or a blunt hook, may be tried in skillful hands, usually under general anesthesia, unless the patient is in per fect control. All but specially adapted forceps are commonly worse than useless and apt to force the body deeper. The agglutination-method may suit those who fear to use water lest it swell some bodies and cause seeds to germinate be fore they can be removed; but hours can rarely be spent over such matters. If the body really needs removal it is safer to lay the soft parts forward by a free incision behind the auricle, and in the shorter and wider naked canal to use efficient leverage or bold chiseling to free and extract the mass. The injury thus surgically inflicted should be healed in a week; what will be done in blindly groping in the depths of the ear may never be repaired, and the life as well as the hearing may be sacrificed by such "conservatism." If after syringing vainly an impacted seed it is decided to wait for reduced in flammation, a few drops of carbolated glycerin will serve as a sedative astrin gent and will dehydrate the seed as much as hours of syringing could swell it. So the science of those who syringe with substitutes for water is as wasted as that which floated up leaden shot with mercury instead of turning the ear down to let them fall out. Gravity can often be utilized in thus inclining the head, and gentle rotary rubbing in front of the ear will often coax out the foreign body. An air-douche with the Politzer bag or other means will sometimes best remove light substances, proving as efficacious as the old-fashioned, but reprehensible, "box on the ear" which has sent many a cherry-stone or pebble flying out across the room. The ear should be directed downward, drawn straight and relieved of any pressure of the jaw-condyle by opening the mouth.