CHAPTER XII. CHRONIC NON-SUPPURATIVE INFLAMMATION OP THE (Part 1)

CHAPTER XII. CHRONIC NON-SUPPURATIVE INFLAMMATION OP THE MIDDLE EAR. Both in the ranks of the laitj and the profession, the treatment of aural diseases has of old been stigmatized as unsuccessful and unsatisfactory. Carefully madte observations of the results of rational and scientific practice, in a large number of cases, have shown that this reproach can only with justice, if at all, be applied to two classes of the affections of the ear. Nearly all the others are singularly tractable when their course is properly regulated. By these two classes, I mean chronic non-suppurative inflammation of the middle ear, and the affections of the labyrinth, or internal ear. In recent times the generic term, .chronic catarrhal inflammation of the middle ear, is usually employed to designate the former variety of disease. I shall soon find fault with the indiscriminate use of this name, but for the present we may allow it to stand, as giving a pretty clear idea of the affections arranged under it. Statis- tics show that, of every thousand cases of aural disease, that present themselves in private practice, a little more than one- half are chronic non-suppurative inflammations of the middle ear.* The disease is called chronic because, when it first comes to professional notice, it has usually already existed for months and years, and because, if unchecked, it advances with des tractive progress as long as life lasts. Although the dis- ease often does its work of impairing or destroying the func- tion of hearing, with but few of the subjective evidences of * New York Medical Journal, August, 1869. Transactions Medical Society- State of New York, 1871. CHRONIC NON-SUPPURATTVE INFLAMMATION. 259 what is called inflammation — there may be no heat, redness, or pain — we find many of the other marks of diseased action, in swelling, thickening, adhesions, which entitle it to be placed under this head. It has also been called a catarrhal inflam- mation, because the cavity, air-chamber, and tube, which form its seat, are lined by mucous membrane. We say middle ear, because these parts form the anatomical centre of the organ of hearing. It is the same disease which Sir William Wilde understood, but which, as it seems to me, he inappropriately called chronic myringitis, or inflammation of the drum-head. But the drum-head is only one of other parts that is affected in this disease, and may, perhaps, be scarcely at all injured, while the most important changes in structure and function have occurred in other parts of the middle ear. In common speech — and I do not mean by this, among the laity, but in the profession — many of the forms of chronic catarrh of the middle ear have been, from time immemorial, classified as nervous. The great author whom I have just quoted, did much to combat this error — an error which not only kept back the growth of the science of otology, because it retarded the conception of a successful plan of treatment, but which also assisted to deepen the reproach which for centuries has rendered aural disease the bele noir of medical practice. The reason for this classification of these affections as ner- vous is found in the fact that the poor means of diagnosis, which were in the hands of the profession until a few years since, the absence of a simple otoscope, and the want of knowledge of the value of the Eustachian catheter, and the tuning-fork, did not allow of the appreciation of the delicate changes which make up what the Germans call the " Kranh- keitsbild" — the picture of the disease. There was another reason in the fact that the poor, distressed patient, having gone in vain to his usual consolers, if not curers — the regular practitioners — often resorted to the charlatan. Under his wonderful but distressing treatment, added to the trial of the horrible tinnitus aurium, and impairment of hearing, he became so utterly worn out and so distrustful of each new adviser, that the so-called nervousness was very apparent. The common idea of nervous deafness is that it occurs 260 CHRONIC NON-SUPPURATIVE INFLAMMATION. chiefly amoug the weak and sensitive ; but this notion has no basis in pathology — so-called nervous people are not apt to be deaf, nor does their sensitive or nervous organism have much effect upon their hearing power, unless it is already im- paired from an inflammatory cause. As yet this class of cases comes as a rule to the notice of the practitioner of modern otology only when the disease is far advanced. The following table shows this : Cases of Chronic Nonsuppurative Inflammation. — Whole number, 525. No. of cases of 80 years' standing over 40 years' standing . over 20 " " . between 10 and 20 years' standing 5 and 10 " 3 and 5 " 1 and 3 one year .... less tban one year . Whole number .... 40 133 141 75 74 42 13 525 These are the cases of this disease that I have recorded, in private practice. It will be seen that by far the larger number, more than fifty per centum, had observed some loss of function for more than five years, while about eight per cent, had been affected for more than twenty years. Every person has, so to speak, a superfluous amount of hearing, which he may lose before his hearing is sufficiently impaired to annoy him in the common affairs of life. People who spend many hours of the day in noisy places, such as boiler-shops, on board steamships, in the stock-board of Wall Street, as I have seen by frequent examples, may lose very much of their hearing power before they are at all aware of it. Then, again, the lower classes, who labor hard all day in the open air with their fellows, and who live at night in small and noisy rooms, where the demands upon the hearing power are very slight, hardly consider its impairment as a loss of function. These causes have conspired, with the general ignorance of the pathology and treatment of non-suppurative aural disease, NOMENCLATURE. 261 to render the results of treatment unsatisfactory, as well as to cause patients to consult a physician at a very late stage of their trouble. Be all this as it may, we now have tolerably accurate means of diagnosticating, and fairly successful means of treating those affections, and it is in the light of these recent advances that we are now able to speak. First, as to the nomenclature. I have never been fully satisfied with the nomenclature of Yon Troltsch, vast improve- ment as it was on those classifications which had preceded it. Some of them were crude, others fanciful and altogether too refined. Yon Troltsch classified all non-suppurative disease as catarrhal, and then separated those in which the catarrhal symptom — excess of secretion — was not very marked, by plac- ing them under the head of sclerosis or hardening or rigidity of the mucous membrane. After looking at many ears, in which there was no trace, either in the pharynx, Eustachian tube, or cavity of the tympanum, of an excess of secretion from the mucous membrane, but in which there were marked changes in the way of increase, hypertrophy or proliferation of tissue, and in others where the catarrhal symptoms were very much in the background, although they existed, I felt that aural catarrh was a meagre and incorrect name with which to describe such a state of things. The very name " catarrh," as applied to a sunken drum-head, immovable chain of bones, dry pharynx, easily permeable Eustachian tubes, is repugnant to all our notions of scientific nomenclature. Whatever may have been the origin or exciting cause of such cases, they cannot be called catarrhal, when their examination shows such a state of things as this. Chr uber has made a division in his text-book, and describes an otitis media hypertrophica, or plastic inflammation : but I think his own description of the pathology of the disease shows that he is discussing not what has hitherto been com- prehended under the head of sclerosis, but an extension of a suppurative process, such as causes the formation of granula- tions or polypi. The nomenclature of the author is founded on his own clinical experience, and upon the reports of the pathology of this class of cases that have been made by Toynbee and others. 262 CATARRHAL AND PROLIFEROUS INFLAMMATION. Chronic non-suppurative inflammations of the middle ear may be divided into two great classes, Catarrhal, Proliferous. I choose the translation of the German word Wucherung as furnishing the best adjective to describe the changes in the middle ear, of which I am to speak ; and in what I have to say I shall attempt to be guided by these divisions. Some authors and practitioners would admit another clas- sification, based upon the parts involved, and speak of chronic myringitis, or chronic inflammation of the membrana tympani, and of chronic catarrh of the Eustachian tube. Whatever we may believe of acute inflammation of these parts, I can scarcely accept the idea of one that has existed for any considerable space of time without involving either the cavity of the tym- panum or the mastoid cells, or both. The nomenclature, tubal catarrh, also leads, as I believe, to incorrect notions as to the therapeutic value of the Eustachian catheter, and of Politzer's method of inflating the drum cavity. These methods of treat- ment are useful, not so much for what they do to the tube, but for their effect upon the cavities into which it opens. When air-bubbles are crackling in the cavity of the tym- panum, as in catarrhal inflammation, or when the tube is greatly narrowed by the hypertrophy of its lining membranes, but at the same time we have, as we always do, in the latter case, a sunken drum-head, an altered light spot, signs of proliferous inflammation of many of the structures making up the middle ear, I do not see how we can with propriety speak of a tubal affection, even if its symptoms are predominant, and even if treatment of, and through, the lining membrane of the tube, does place things in such a condition that Nature will com- plete the cure. No time need be spent upon this question, which may, perhaps, seem to some a comparatively unim- portant one, had not incorrect notions in the past led to an incorrect style of treatment. In former times, the membrana tympani, under the assumption that such an affection as an independent chronic myringitis existed, was vigorously treated by instillations of various fluids, and by perforation, and of late, under the idea that we have a great deal of tubal catarrh SYMPTOMS OF CHRONIC CATARRH. 203 without further progress in the morbid action, undue stress is sometimes laid upon applications to the mouth of the tub' • ; Politzer's method is substituted for the catheter, when its true place, valuable and indispensable as it is, except in the case of very young children, is as an adjuvant to that instrument. SUBJECTIVE SYMPTOMS OF CHRONIC CATAREHAL INFLAM- MATION. I think we may assume, from the history of cases, that this form of disease is either a consequent of frequent attacks of acute catarrh of the middle ear, or that it occurs in people who have what we may call a catarrhal diathesis. The dis- ease is, therefore, unlike its companion, proliferous inflamma- tion, not at all insidious in its approach. The patient suffer- ing from this disease, who consults us about his hearing, is usually aware that there is an excess of secretion in his pharynx, and that for years he has been annoyed and troubled by being obliged to use a handkerchief xery freely, and by feelings of fulness referred to the frontal sinus and tympanic cavities There is often, also, at times, a sound in the ear like the crack- ling of air-bubbles. The voices of Mends appear muffled ; and it is hard, for the victims of chronic aural catarrh, when the dis- ease is advancing, not to believe that every one is speaking in a much lower tone than is usual for them. Such patients often complain bitterly on this subject, and will scarcely admit that- their hearing is at all impaired, or, if so, they stoutly assert that it is one ear only, when the fact is, that, with one perfect ear, it is only under peculiar circumstances, certainly not in ordinary conversation, in front of the patient, will a person be observed to be at all hard of hearing. There is a feeling about this that is different from that expressed about diseases of the eye at least, and I believe, in most maladies, patients will express their feelings, and often with an exaggeration, rather than with an extenuation of the symptoms ; but, however much patients with chronic inflam- mation of the middle ear may suffer from impairment of hear- ing, they will often insist that they are hardly affected, or that they have a very little trouble in that way, when they 264 VERTIGO IN CATAEEHAL INFLAMMATION. can scarcely hear loud conversation addressed specially to them. Patients affected with chronic catarrh of the middle ear also complain, as a rule, of tinnitus aurium, and a sense of ful- ness in the ears. The ears feel as if the auditory canals were stopped up. They often ask very anxiously if there is not something in the ear, and seem incredulous when the negative answer is given. Vertigo is another symptom of which these patients speak, and it is often considered as undoubted evi- dence that there is disease of the brain. Vertigo is a symp- tom by no means peculiar to catarrhal inflammation. It also occurs in impacted cerumen, and still more frequently in pro- liferous inflammation, as well as in cerebral disease. When vertigo occurs in aural disease, it is a consequence of increased pressure upon the labyrinth through the fenestra ovalis. It is by no means a serious symptom, when the cause is to be found in the middle ear, for it is usually relieved by a mechanical treatment through the Eustachian catheter. There are many cases in my note-book which illustrate this, but none more striking than the following : A physician consulted me last winter on account of impair- ment of hearing in one ear, accompanied by a tendency to topple over on that side, which he said was a consequence of being thrown from his sleigh some months before, when he suffered a concussion of the brain. He was quite disposed to regard the tendency to fall over as a cerebral lesion, but the use of the Eustachian catheter, and Politzer's method of inflat- ing the ear, not only improved the hearing, but took away the unpleasant sensation. Physician as he was, he was at first disposed to smile at the idea of using local means to ameliorate this brain-symptom ; but he has continued to be perfectly relieved from his cerebral malady up to this time, nearly a year since he consulted me. I have often heard patients describe the feeling of fulness in the ears as a sensation as if the ears were plugged with some foreign substance ; it is almost impossible for them to avoid the impression that the auditory canals are plugged with cerumen. Very many times, after I have examined a patient suffering from chronic disease of the middle ear, I have been INSANITY FROM AURAL DISEASE. 26& asked to look again to see whether I could not find some hard- ened wax ; and on one occasion a poor fellow, who I suppose was, to a certain extent, insane, grew very angry and called me hard names, because I would not remove wax which he knew was in his ear. Yon Troltsch* relates a case, from Meyer, of Hamburg, where a melancholic person was relieved of a sound in the ear, seeming to him to be the cry of a child, by the removal of a plug of cerumen, which caused deafness on one side. The patient made a rapid and complete recovery from the mental affection, after the cerumen was removed. It is the opinion of Schwartze,t of Halle, a very careful and competent ob- server, that subjective aural sensations, which are caused by demonstrable affections of the ear, may, in predisposed per- sons, especially when there is any hereditary tendency to men- tal disease, become the direct cause of aural hallucinations, that may accelerate the outbreak of a disease of the brain. He mentions a case where, in his opinion, and in that of one of the physicians of the Insane Asylum at Halle, a threatened attack of brain disease was prevented by treatment of the ear. In some cases insane persons who suffer from aural disease distinguish its tinnitus from these illusions or hallucinations. Dr. Koppe confirms this view, and shows that in some cases hallucinations disappear after treatment of the ear. I have elsewhere reported:!: a case of the suicide of a pro- fessor in one of our educational institutions, who consulted me on account of impairment of hearing, but more especially on account of tinnitus aurium. He said, on leaving the consult- ing-room, that, if he felt sure that I was correct in my opinion (that he would not get great relief from this very trying symp- tom, tinnitus), he would put an end to his existence ; which he did a few months after, by blowing out his brains. During this last summer, a gentleman, a public-school teacher, con- sulted my associate, Dr. Charles S. Bull, in regard to a sup- puration of the ear, which caused considerable impairment of hearing and great tinnitus. He was exceedingly depressed * Test-book, second American edition, p. 531. •f Loc. cit., p. 5i2. % New York