An essay on the diseases of the internal ear

Front matter

m Hi 1

H in

H H

Introduction

Among the diseases which afflict the human species, those of the internal ear require, on the part of the profession, newefforts and new researches. The works of Duverney, Valsalva, Morgagni, &c. &c. have, it is true, thrown some light upon this subject, but what topic is there on which there is left nothing more to be desired ?

More recently those distinguished men, Cotunnus, Meckel, Scarpa and Compared, have enriched the science with their valuable discoveries — the first, by demonstrating that the labyrinth is filled with a thin fluid, instead of air supposed to be contained in it — the second, by giving a more true and definite description of the" parts which line the labyrinth, and especially of the semicircular canals.

Mr. Cooper, the celebrated English surgeon, has shown, by experiment and observation, that by the perforation of the membrana tympani, we may, in certain cases of deafness, restore hearing.

Before the writings of Cotunnus and Meckel, we had no correct theory of the perception of sounds. Our notions in relation to the diseases of the organ of hearing and their treatment were still more erroneous.

Notwithstanding these new discoveries, the pathology and treatment of the diseases of the internal ear are yet very far from having attained to that degree of improvement of which they are susceptible. Certain powerful causes have opposed obstacles to that improvement. 3

1st. The structure of the auditory apparatus is extremely complicated; the parts which constitute its structure are so deeply hidden, that its diseases are concealed from view; and hence the uncertainty of their diagnosis.

2d. The belief that congenital deafness always depends upon some fault of original conformation. In consequence of such belief, that species of deafness is regarded as irremediable, so that no one presumes to employ the least remedial means. Nevertheless, there are means which we can conveniently use, and frequently with much benefit. I had an instance of this in the person of young Briguet. Congenital deafness, and that which occurs soon after birth, often depends merely upon inspissated mucus which obstructs the eustachian tube and the cavity of the drum. Nevertheless, I do not pretend to call in question the defect of early conformation, which often presents itself in the structure of the internal ear, such as we discover in other parts of the body; but it is only in this case that deafness is incurable.

3d. The difficulty of applying remedies immediately to the part affected, is another reason which has opposed the progress of the treatment of the diseases of the ear. That difficulty is removed, as regards the affections of the eustachian tube, the cavity of the tympanum, and the mastoid cells. The instruments which I have invented fulfil, in that respect, the end desired; for, by means of them, we can convey into those cavities the liquors which we judge proper. By their means many causes of deafness will be removed and hearing restored. Of this I am convinced by experiment and observation.

I do not propose to give a complete treatise on deafness, but only to throw some degree of light upon the etiology and treatment of that disease, and to furnish some further means of overcoming it. Indeed, by considering the diseases which affect the different parts of the internal ear, as being the cau-

M ses which may give rise to deafness; by displaying each of those diseases; by seeking to ascertain their seats — the causes which produce and the symptoms which characterize them, the judgment and prognosis, in relation to the nature of deafness, will be less conjectural, the treatment more rational, and consequently more certain.

Before entering on the details which each disease may present, we will glance at deafness generally, and first will give a clear and concise definition of the disease. We shall avoid equivocal terms, or those which are employed with ambiguity. We shall reduce the divisions to as small a number as possible.

Definition. — Deafness is a total loss, or a considerable diminution of the sense of hearing.

Varieties. — We may reduce the varieties of deafness to the four following.

1st. If an infant has the defect at birth, it is called congenital

2d. If it occur some time after birth, as the result of disease, it is denominated accidental.

3d. If it be the advance of age which gives rise to it, we give it the appellation of senile.

4th. Finally, when deafness attacks only one ear, it is termed incomplete, and complete when both ears are affected.

These four varieties of deafness will be embraced under two denominations.

When deafness is incipient and hearing is merely difficult, we shall term the disease (Dysecee) difficult hearing.

When deafness is complete and absolute, we shall, with most nosologists, denominate it (Cophose) complete deafness.

I shall not introduce, in this division, another defect of hearing, to which some have given the name of Paracousie, or false-hearing. Of those who are affected with it, some hear indistinctly words spoken with a loud voice, whilst the perception of feeble sounds is distinct. Others hear ordinary k sounds when aided by a loud noise which accompanies them; others hear all sounds double. I shall say nothing more of this variety of disease.

Causes.-— The causes of deafness are so numerous, most of them so obscure, and some so singular, that it is difficult to give a complete enumeration, or a precise classification of them; nevertheless, we shall arrange them in the following order.

1st. Defects of original conformation in some part of the auditory apparatus,* or the absence of the acoustic nerve, may be a cause (a rare one indeed, but ascertained by port-mortem examination,) of congenital deafness.

2nd. Deafness is sometimes hereditary, like many other diseases, of which, at birth, we receive the germ, or if the expression be preferred, the predisposition. Trukaf was consulted by a man thirty years of age, who had become deaf at the age of fourteen years, and whose father, mother, and three brothers, or sisters, all suffered the same disease. I know a man who became deaf at the age of forty years; he has told me that his paternal uncle, his father, and two of his brothers have, at the same age, experienced the same infirmity.

A physician who had resided a long time at Marseilles, communicated to me a very singular phenomenon. He informed me of a family in that city, consisting of six children, the first

* Imperfections of the external passages are very rare; I have had occasion to witness one instance, with Dr. Repiguet, Chirurgien-major des Jlntiquailles. The two passages were closed by continuity of the skin, the porches of the ears were very imperfect; nevertheless deafness was not complete. The application of caustic potash on the place where the auditory passage should have been, has already so far improved his hearing, that the young patient hears almost as well, as if he had never had the defect, so little is it necessary to approach him.

J of whom is deaf from birth; the second hears very well; the third is deaf, and so on alternately. Deafness cannot be regarded as hereditary with these children, since the father and mother enjoy their hearing in a very perfect state*

3d. In the interior of the cranium, any thing which may compress the auditory nerve, at its origin or along its course, and thus obstruct the influence of the nerve upon the auditory apparatus, may be regarded as a cause of deafness.

4th. Deafness, like gutta serena, is sometimes produced by inordinate seminal discharges. Sylvatius cites a remarkable instance of deafness supervening upon excessive indulgence in venereal pleasures.

5th. Lauzani speaks of a woman who became deaf whenever she was pregnant, and did not recover her hearing till after her confinement. She became pregnant four times, and

* To the above account we may add that of a family at Aix, in Savoy, consisting of seven children. The oldest is deaf and dumb, the second hears perfectly, the third is deaf and dumb, the fourth is as fortunate as the second; the fifth, sixth, and last are perfectly deaf. The eldest of the family, a male, is paralytic in his inferior extremities. He is now at Lyons, as is also one of his sisters, at the Institution of the Deaf and Dumb, conducted by M. Comberry. The last, but one, of these children, is an idiot. It should be remarked, that the father and mother enjoy very good health, and have none of the infirmities of that numerous and unhappy family. There are also in the Institution of which we speak, many pupils who have, among their brothers and sisters, one or more deaf and dumb, and whose parents are exempt from that affection.

The town of Bessenay, in the department of the Rhone, furnishes an instance of the same kind. In a family composed of eight children, four are deaf and dumb, and, as in the preceding instances, they alternate with those that enjoy the sense of hearing.

These observations might be still further extended, but I think it will be difficult to give a satisfactory explanation, or to form a theory from such data. Nevertheless these facts ought to be preserved in the march of science, were they useful merely to indicate its proper limits. Th. P.

Ik as often experienced this inconvenience. The same author relates the case of the wife of a peasant, who, during gestation, besides deafness, was subject to sciatic pains and to ulcers of the legs. All these evils disappeared immediately after her delivery.

6th. Worms in the stomach and intestines also produce deafness.

7th. Hypocondriacs, whose digestion is impaired, and who often suffer gastric derangements, are subject to become deaf. Must we believe, with Etmeller, that deafness, in such cases, consists in a spasmodic tension of the tympanum, or other membranes of the ear? This much is certain, that many cases of deafness have been cured by merely the repeated employment of purgative medicines.

8th. Deafness is a frequent symptom of adynamic and ataxic fevers. It is generally regarded as a favourable symptom when it happens on a critical day.

9th. Deafness has been known to follow a violent paroxysm of sneezing. Vagner relates, in the Memoirs of Natural Curiosities, that a literary man, having made use of some sternutatory powder, became incurably deaf in the right ear.

1 Oth. A violent and long-continued cough may produce the same effect. In the course of this work I cite an instance of this cause of deafness, from my own observation.

11th. Washing the head with cold water is a frequent cause of deafness. Cutting the hair, at a particular period of life, has produced the same infirmity.

12th. Chronic issues, suddenly suppressed by topical astringents, have also given rise to deafness.

13th. A violent and unexpected sound sometimes surprises the organ of hearing, so as to strike it deaf. To this cause we must refer the deafness of soldiers of artillery. They may experience a real disorganization of the ear. Richter, in his

Bibliotbeque Chirurgicale, says, that they are not only liable, to become deaf, but even to hemorrhage from the ears.

14th. Deafness is sometimes produced by blows and falls on the head. Authors are replete with observations relative to children becoming deaf from cuffs received at school.

15th. Every thing which may impede the free entrance of air into the eustachian tube, such as excessive swellings of the tonsils, of the parotid glands; polypus in the posterior nares, closure of the expanded orifice of the tube by ulceration of the fauces, or merely by inspissated and tenacious mucus, which adheres to the posterior nares, are so many causes of deafness.

This disease may depend upon morbid changes in the external parts of the auditory apparatus. The causes of this variety are numerous, but it is not my design to speak of them here.

The diagnosis of deafness is difficult, in the same degree that the cause is hidden and obscure; thus, injury of the cavity of the tympanum and the parts contained therein; the affections of the labyrinth, and those of the acoustic nerve, are still concealed from us by a veil of obscurity.

The prognosis is attended with the same difficulties. We cannot pronounce it, in a case under consideration, but in a conjectural manner. It is true, however, that I have observed in many persons affected with difficulty of hearing, and even with deafness, (of which the cause was unknown to me,) that after the buzzing noise has ceased, the organ of hearing recovered completely, or in a great degree, the faculty of hearing. Generally, hearing is restored in proportion as the buzzing noise diminishes; but sometimes the latter ceases whilst the deafness persists in the same degree, although, after some time, hearing may be restored and become established, even in persons advanced in life.

If the causes and symptoms of deafness are so little understood, we ought chiefly to ascribe the fact to want of knowledge of this morbid anatomy, which is only to be acquired by dissection. It is to be desired that physicians to institutions of deaf-mutes should practice the dissection of the ear in all the deaf-and-dumb who die in those establishments; and that they should semi-annually give the greatest possible publicity to their researches. Till then there can be nothing but uncertainty in our acquaintance with the causes, and nothing but obscurity in the symptoms of the diseases of the internal ear, consequently, improvement in their treatment will be slow and laborious.

The ancient physicians treated deafness with topical remedies and with powerful purgatives. Celsus and his cotemporaries employed the juice of the wild cucumber, the tincture of myrrh, frankincense dissolved in woman's milk, poppy juice, rose-water, tincture of castor, &c. &c., which they dropped into the external auditory passage. They made use of purgatives, highly drastic, such as elaterium, hellebore, &c.

Modern medicine employs modes of treatment much more varied, but it is not much more successful. It prescribes musk, camphor, introduced into the external auditory passage. Some introduce, through the same passage, the oils of sweet and bitter almonds, those of the kernels of the peach, and of rue; oil in which ants have been infused; water which distils from the green branches of the ash; injections of the mineral water of Balaruc — of Bagneres — of Barege, &c. &c. Some establish issues, as those of the seton, caustic, blisters, &c.

A Bavarian bath-keeper, mentioned by Sckinkius, devised a singular method of curing deafness. He plunged the patient into a warm bath, to produce turgescence of the little veins which run behind the ear. When these were sufficiently apparent he opened them with the point of a lancet and drew a considerable quantity of blood, to the great relief of the patients on whom he practised the evacuation. This remedy may have some success in cases of sanguineous plethora of the organ of hearing.

Purgatives are remedies eminently useful in some cases of deafness; so much so that, according to Truka, they ought to be employed in all cases, except those of debility.

Penot and Lazare prescribed fomentions, to be applied to the head, with warm mineral sulphur-water, the latter also recommended aromatic fomentations to the same part.

Pierre Castro, first physician to the Duke of Mantua, employed a mode of treatment which he devised for cases of complete deafness. I shall speak particularly of it when I shall come to treat of lesions of the acoustic nerves.

Within about thirty years anatomy has made considerable progress. By giving a more particular and exact description of the parts which enter into the structure of the internal ear, it has thrown light upon the mechanism and functions of each of these parts, and has suggested, for the cure of deafness, the following modes.

Riolan has proposed the perforation of the mastoid process for the purpose of introducing medicines into the interior of the ear. M. Jasser was the first who practised it.

In 1724, M. Guyot, maitrc des postes, at Versailles, contrived an instrument with which he thought he could inject liquids into the eustachian tube, by introducing the instrument through the mouth,

In 1732, Messrs. Wathen and Cleland, English surgeons, presented to the Royal Society of London, a flexible and hollow sound by means of which they introduced medicines into the interior of the ear, conveying the instrument through the nasal fossae, nnd thence into the expansion of the eustachian lube 1

The celebrated Sabatier also invented an instrument for the same purpose, but he confessed that he had never tried it on the living subject.

In 1811, 1 devised certain instruments proper for sounding the eustachian tube, by the way of the nares. By means of those instruments I convey into the ear certain liquids, the nature of which varies according to the exigency of the case.

Natural philosophy, as well as anatomy, also furnishes us with certain means for the treatment of deafness — such as electricity, galvanism, mineral and animal magnetism. The two first have been too much magnified, by encomiums on their utility. As to the last, they have had but an ephemeral reputation.

We shall still comprehend, in the class of remedies which natural philosophy has furnished, the perforation of the membrana tympani; because that operation tends to re-establish the equilibrium of the air contained in the cavity of the tympanum, with the column of atmospheric air which enters into the meatus auditorius — an equilibrium interrupted by obstruction of the eustachian tube. Mr. Cooper was the first who performed that operation.

All the modes of procedure which I propose to offer, will be described and discussed in the course of this work.

ESSAY

DISEASES OF THE INTERNAL EAR.

For the sake of arrangement, in treating the subject with which we are to be occupied, I have thought it expedient to classify the diseases which affect the internal ear, and which may become causes of deafness. I name them in the following order.

First. Diseases of the membrana tympani.

Second. Diseases of the cavity of the tympanum — of the muscles and small bones which are found there.

Third. Affections of the interior of the eustachian tube.

Fourth. Diseases which affect organs adjacent to the tube.

Fifth. Diseases of the labarynth.

Sixth, and last. Diseases of the auditory nerve.

Each of the above classes will be the subject of a distinct section.

Section I. Diseases Of The Membrana Tympani

This septum may be, on the side of the auditory passage, overspread by a fungous pellicle — may become thickened by some degree of inflammation, or by a polypus attaching itself to the external surface. It may be relaxed and protruded either into the meatus auditoiius externus, or into the cavity of the tympanum. Sometimes it is too tense; inflamed, ulcerated, ossified, cartilaginous, or perhaps it is altogether or partially wanting.

"It is but a short time," says Rosenthal, "since I had occasion to examine, at Breslau, the body of a deaf-mute whose deafness had occurred in consequence of small-pox. I found the membrane of the tympanum relaxed and thicker than usual — the auditory nerve also appeared to be harder than common. In other respects all the parts of the internal ear were perfectly well organized."

Chapter I

On the fungous membrane which covers the memhrana tympani.

"The membrana tympani, in new-born infants," says Leschevin "is overspread, on the side of the meatus auditorius externus, by a very thick fungous membrane, which soon disappears in consequence of suppuration. Whenever it happens that this membrane remains adherent to that of the drum, instead of being separated from it, as commonly happens, it will necessarily occasion deafness."*

May not this have been the case with the deaf-mute of Chartres, whose history is reported in the Royal Academy of Sciences of Paris, 1703, and who began to hear at the age of twenty-four years after the occurrence of suppuration in both ears? The deaf-mute of whom Riolan speaks, who recovered his hearing after perforation of the membrane with a tooth-pick, was undoubtedly in the same condition.

M. Le Bouvyers Desmortiers cites an instance very similar to the two preceding. "At Nantes, (year 7,)" says that

* Prix de V Academie royale de chirurgie, torn, iv, in 4to. pp.

author, "there was a man deaf and dumb from birth, aged twenty-eight years, who then heard and spoke very well, without having been treated with any remedies. Here is then a second phenomenon, equal to that of the young man of Chartres. We should be glad to know whether there are not many others that have escaped our notice, for want of witnesses capable of making them known to us?"*

M. Le Docteur Portal raises doubts in regard to the existence of this membrane. "It is not possible," says he, "to ascertain the fact in infancy. The suppuration is said to be very imperceptible. I can also state another reason. When suppuration occurs the pus blends itself with the cerumen of the ear, and hence it is difficult to distinguish it. It is necessary, in order to remove all doubt in relation to the subject, that the child should never be from under the observation of the physician or surgeon, and that they should examine the whole auditory passage, and the nature of the wax, which, during suppuration, is changed in its natural colour, and has a strong odour, as well as the auditory passage; but'" adds the author, "all these observations are difficult to make," (he might say impossible,) "because of the number of circumstances that are often opposed. It is necessary to wait for a more advanced period, that is, when the child can make known to us that it hears or not."f

It is certain that this fungous membrane may, in some subjects, exist at the time of birth, as the membrana pupilaris is found to exist in some others.

Granting that this be a cause of deafness, it cannot be difficult to recognise it. By exposing the ear to a strong light, and directing the rays of the sun into the meatus auditorius,

* Considerations on congenital deaf-mutes. t Precis de Chirurg. part. p. 477 et 478.

the bottom of the meatus will be very easily seen, where the false membrane adheres to that of the tympanum. If the bottom of the meatus be of a pearly white, smooth, and very sensible to the touch of the probe, we may be certain that the membrane is covered by no obstruction. But if it appears red, fungous, but little, or not at all, sensible to the probe, we may be assured that the false membrane exists.

Leschevin proposes two modes of destroying it. One consists in causing it to suppurate, by irritating the part with acrid medicaments; the other, in causing the false membrane to wither and to separate by desquammation, by touching it with mild corrosives, of dry consistence, as the kali purum, applied cautiously. Leschevin gives the preference to the latter method, as it appears to him to be attended with least inconvenience.

Both appear to me to be equally dangerous, inasmuch as these, irritating substances may give rise to a considerable degree of inflammation, which the surgeon is not always able to arrest, nor even to restrain; hence may arise a deep suppuration, which may destroy the membrana tympani, reach the drum, and produce the most serious results. At other times, these means, if they affect the false membrane but slightly, will prove ineffectual; for, instead of causing the separation of that kind of foreign substance, either by suppuration or desquammation, they confer upon it a greater degree of thickness and consistence. At least this happens (if we may reason from analogy,) to those false membranes which form upon the globe of the eye, when we treat them with similar means.

Two facts, derived from Frabricius of Hildanus, prove how dangerous it is to introduce irritating substances into the auditory passages.

I

A child, eight years of age, had a discharge from the ears — she was placed in the hands of an empyric, who injected into them an oily fluid, which produced intolerable pains. These pains rapidly increased — inflammation, fever, and delirium soon supervened. A physician allayed these symptoms by the employment of suitable means, but deafness made rapid progress, and at the age of twenty-four years the young person was insensible to the loudest sound *

Another child six years of age, introduced into her left ear a glass bead, of the size of a pea. Many fruitless attempts were made to extract it. From that time the patient was tormented with continual pains in the ear — these abated, but were occasionally increased by cold and moisture.

At length the child experienced a slight degree of numbness, which gradually increased, first in the left arm, then in the hand, next in the leg, and finally in the whole side. A dry cough persisted after this occurrence. The patient suffered attacks of epilepsy, and the arm became atrophied. All these symptoms immediately ceased on the extraction of the bead.f

The accidents mentioned in the above cases, although they were not the result of caustic, applied for the removal of the fungous membrane adherent to the membrana tympani, are nevertheless conclusive, in regard to my opinion; for it is difficult, not to say impossible, to introduce any caustic, so as to excite irritation in the false membrane, without communicating irritation to the meatus auditorius — to the membrana tympani, and thence to the interior of the ear.

From these considerations, I shall give preference to perforation of the tympanum over the method proposed by Leschevin, because it appears to me less dangerous, and because

* Fabricc de Hilden, cent. 5, observation 5. j Ouvrage cite, it restores the patients hearing more promptly than other me= thods, as is proved by experience and observation. To prevent the closing of the aperture, a small portion of gum elastic sound should be introduced, which operation must for a time be repeated every day.

Chapter II

On polypus growing upon the external surface of the membrana tympani.

The auditory passage, like all cavities which are lined by a mucous membrane, is subject to polypus excrescences. Hence the membrana tympani is subject to the same, because its external surface is overspread by the mucous membrane of the same passage. Authors make frequent mention of polypi which grow upon the walls of the external auditory passage, but no one, so far as I know, speaks of polypus arising from the membrana tympani, and which increases to such a degree as to obstruct the passage and produce deafness.

The causes which may produce these excrescences are very numerous. Every thing, which irritates and produces inflammation and ulceration of the mucous membrane, may give rise to polypus. Thus it is that an ear-pick, introduced frequently and rudely into the auditory passage; scabies, scrofula, measles, scarlatina, small-pox and syphilis, give rise to inflammation, ulceration, and by consequence, polypus.

M. Alibert, in his Therapeutique Medicale, speaks of a young man who had become deaf from excrescences which had been produced by syphilis. The author does not say whether these excrescences were of a polypus kind,

Adynamic and ataxic fevers often terminate in deafness, which is sometimes accompanied by long and obstinate suppuration; hence arises polypus. The following case confirms what I assert.

M. M** # , twenty-two years of age, came to consult me, May 1st, 1817; he was affected w r ith deafness of the left ear, of which the immediate cause was a polypus, also with difficulty of hearing in the right ear. These disorders were accompanied with suppuration and a buzzing sound in one or the other ear. They supervened on an adynamic fever, which the young man had suffered at the age of twelve years. Injections of eau de Balaruc, thrown into the auditory passage caused the polypus to drop off.

The substance had the form, colour, and consistence of a strawberry, and it was attached to the membrana tympani by a very slender pedicle. On examining that membrane I discovered near the middle a reddish point of the size of a small lentil, where I was persuaded that the pedicle of the polypus had been attached.

The separation of the excrescence was followed by a slight hemorrhage which spontaneously ceased, without the necessity of my employing any means to suppress it. The suppuration and the buzzing sounds have ceased, and the hearing of that ear is completely re-established. All this was simultaneous with the removal of the polypus from the meatus auditorius.

The symptoms of this form of disease are easily ascertained; a single examination is sufficient to determine the existence of the polypus in the auditory passage. But it is not thus easy to ascertain the precise point where it is attached.

Nevertheless, whatever may be the point at which the polypus is attached, that circumstance need not influence the treatment, which consists in the employment of the following means: — twisting it off; removing it with the ligature, cutting k

I instrument, actual cautery, or caustic. All these means are useful; each being preferable under particular circumstances.

We find in Scultet* the history of a polypus of the ear which had caused deafness by completely filling the auditory passage, and which was, in part, cured by tearing it away, and in part by the application of the actual cautery.

M. Leschevinf has seen a young girl suffering from a similar excrescence, implanted very deeply in the auditory passage, and which issued from it more than half an inch. This excrescence, which Leschevin regards as a true polypus, was fungous, and gave out a fetid purulent discharge from its surface. The author removed it by laceration and saw no more of the patient.

CHAPTER III. On relaxation of the membrana tympani

This affection varies in correspondence with the causes which produce it; these causes are very numerous, — such as humidity, together with a south wind; catarrh of the meatus externus and of the cavity of the drum; damp air; water dashed upon the membrane; a serous efflux from the ear. Plater, Langet and Scarpa, witnessed these abundant discharges, and regarded them as important.